The influence of perceptions of community norms on current contraceptive use among men and women in Ethiopia and Kenya

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.

Collective norms and modern contraceptive use in men and women: A multilevel analysis of DHS Program data in Nigeria and Zambia

Background: Social norms have long been understood as essential for demographic preferences, intentions and behavior, despite a lack of consistent definitions and measures in the field. Recent work has more clearly defined these norms, both at the individual and community/collective levels. However, past research on the effect of social norms on contraceptive use has focused mainly on the influence of individual-level norms, largely among women only, contributing to mixed findings. Methods: This study addresses this gap through the use of multilevel models to identify associations between collective gender, fertility, and family planning norms and individual use of modern contraceptives for both men and women, using recent Demographic and Health Survey (DHS) data from Nigeria and Zambia. Multiple measures of variation, including community-level random effects and the intraclass correlation, are calculated, providing evidence of the general effect of community factors on behavior. Results: Our findings support the importance of social, demographic and economic context on how collective gender, fertility, and family planning norms relate to modern contraceptive use. Different social norms are associated with use in the two countries, and, even within the same country, men and women’s use are influenced by different norms. Among the examined norms, only collective fertility norms were associated with use for all the groups examined, consistently associated with lower use of modern contraception. Overall, clustering at the community level explained a larger proportion of variance in individual use in men compared to women, suggesting that men’s behavior was more consistently associated with the measured social norms than women’s. Conclusions: These findings suggest that careful attention should be paid to understanding and measuring social norms when considering programs or policy around the provision of modern contraception and that these should not assume that social norms influence men and women’s behaviors in the same way.

The role of social norms on adolescent family planning in rural Kilifi county, Kenya

PURPOSE

Despite Kenya's encouraging progress in increasing access to modern contraception among youth, several barriers remain preventing large-scale efforts to reduce demand-side unmet need for family planning. Shifting social norms around the use and acceptability of modern contraception may represent a potent target for future interventions. However, the structure of normative influence on individual modern contraceptive use among youth needs to be determined. Therefore, our aim was to estimate the influence of individual and group-level normative influence on modern contraceptive use among adolescents from two villages in rural Kenya.

METHODS

Trained enumerators collected data from individuals aged 15-24 who provided oral informed consent, or parental informed consent, in two villages in rural Kilifi county. Participants completed a questionnaire related to modern contraceptive use and were asked to nominate one to five people (referents) with whom they spend free time. The enumerators photographed each individual who nominated at least one referent using Android phones and matched them with their nominated referents. Using this social network data, we estimated group-level normative influence by taking an average of referents' modern contraception use. We then explored associations between descriptive norms, injunctive norms, and network modern contraceptive use on individual modern contraceptive use, controlling for known confounders using logistic regression models. We also conducted sensitivity analyses to test a pattern of differential referent influence on individual modern contraceptive use.

RESULTS

There was a positive association between pro-modern contraception descriptive and injunctive norms and individual modern contraception use (adjusted Odds Ratio (aOR) = 1.29, 95% confidence interval (CI) = 1.05-1.6, and aOR = 1.31, CI = 1.06-1.62, respectively). Network modern contraceptive use was associated with individual use in the bivariate model (aOR = 2.57, CI = 1.6-4.12), but not in the multivariable model (aOR = 1.67, CI = 0.98-2.87). When stratified by sex and marital status, network modern contraceptive use was associated with individual modern contraceptive use among female participants (aOR = 2.9, CI = 1.31-6.42), and unmarried female participants (aOR = 5.26, CI = 1.34-20.69), but not among males. No interactive effects between norms variables were detected. Sensitivity analyses with a different estimate of network modern contraceptive use showed similar results.

CONCLUSIONS

Social norms are multilevel phenomena that influence youth modern contraceptive use, especially among young women in rural Kenya. Unmarried women with modern contraceptive users in their social network may feel less stigma to use contraception themselves. This may reflect gendered differences in norms and social influence effects for modern contraceptive use. Future research should investigate group-level normative influence in relation to family planning behaviors.

Mediating effects of inequitable gender norms on intimate partner violence and contraceptive use in a cluster randomized control trial in Niger: A causal inference mediation analysis

Background

Gender inequity, a deeply-rooted driver of poor health globally, is expressed in society through gender norms, the unspoken rules that govern gender-related roles and behavior. The development of public health interventions focused on promoting equitable gender norms are gaining momentum internationally, but there remain critical gaps in the evidence about how these interventions are working to change behavioral outcomes.

Methods

A four-arm cluster randomized control trial (cRCT) was conducted to evaluate the effects of the Reaching Married Adolescents in Niger (RMA) intervention on modern contraceptive use and intimate partner violence (IPV) among married adolescent girls and their husbands in Dosso, Niger (T1: 1042 dyads; 24 mos. follow-up: 737 dyads, 2016-2019). This study seeks to understand if changes in perceived inequitable gender norms among husbands are the mechanism behind effects on modern contraceptive use and IPV. We estimated natural direct and indirect effects via these gender norms using inverse odds ratio weighting. An intention-to-treat approach and a difference-in-differences estimator in a hierarchical linear probability model was used to estimate prevalence differences, along with bootstrapping to estimate confidence intervals.

Results

The total effects of the RMA small group intervention (Arm 2) is estimated to be an 8% reduction in prevalence of IPV [95% CI: -0.18, 0.01]. For this arm, the natural indirect effect through gender inequitable social norms is associated with a 2% decrease (95% CI: -0.07, 0.12), accounting for 22.3% of this total effect, and the natural direct effect with a 6% decrease (95% CI: -0.20, -0.02) in IPV. Of the total effect of the RMA household visit intervention (Arm 1) on contraceptive use (20% increase), indirect effects via inequitable gender norms were associated with an 11% decrease (95% CI: -0.18, -0.01) and direct effects with a 32% increase (95% CI: 0.13, 0.44) in contraceptive use. For the combination arm, of the total effects on contraceptive use (19% increase), indirect effects were associated with a 9% decrease (95% CI: -0.20, 0.02) and direct effects with a 28% increase (95% CI: 0.12, 0.46).

Conclusion

The present study contributes experimental evidence that the small group RMA intervention reduced IPV partially via reductions in perceived inequitable gender norms among husbands. Evidence also suggests that increases in perceived inequitable gender norms resulted in decreased contraceptive use among those receiving the household visit intervention component. Not only do these results open the "black box" around how the RMA small group intervention may create behavior change to help inform its future use, they provide evidence supporting behavior change theories and frameworks that postulate the importance of changing underlying social norms in order to reduce IPV and increase modern contraceptive use.

Acceptability of an intravaginal ring for simultaneously preventing HIV infection and pregnancy: Qualitative findings of the Kisumu Combined Ring Study, 2019

Multipurpose prevention technology intravaginal rings (MPT IVRs) may offer a promising solution for addressing women's multiple sexual and reproductive health needs. We describe MPT IVR acceptability perspectives and examine user experiences of 25 cisgender women aged 18-34 years enrolled in a phase IIa randomized, partially blinded, placebo-controlled evaluation of tenofovir-based IVRs with and without contraceptive co-formulation. All took part in an individual, audio-recorded, semi-structured qualitative interview. A thematic analysis of transcribed interviews was completed in MaxQDA. Participants shared little to no knowledge of or experience with IVRs prior to joining the study. Four MPT IVR themes were identified: physical well-being, method reliability, personal management, and societal endorsement. Commonly cited of concern, but less described as being experienced, were physical discomforts (e.g., painful insertion/removal; inability to carry out daily activities/chores; foreign body sensation; expulsion; sexual interference, or debilitating side effects). Uncertainty regarding efficacy influenced perspectives about intended prevention benefits. Personal choices in managing reproduction and sexual behaviors had to be congruent with sociocultural values and norms for acceptance beyond the individual user level. Participants viewed broader community acceptance as likely to be mixed given community opposition to the use of modern family planning methods. They also shared concerns that IVR use could lead to infertility, especially among nulliparous women, or that it would encourage premarital sex or high-risk sexual behaviors among adolescent and young women. While a MPT IVR may not be suitable for all women, first-hand testimonials could help influence collective receptivity. Additional community acceptability research is needed. Clinical Trial Registration The study is registered at http://ClinicalTrials.gov under the identifier NCT03762382.

Using structural equation modeling to examine the influence of family planning social norms on modern contraceptive use in Nigeria

Despite high knowledge of family planning (FP) among Nigerian women, use of modern contraceptives remains low. While FP investments in Nigeria have been ongoing for decades, relatively little emphasis on contextual and structural factors may have contributed to low demand for and use of contraception. From 2009 to 2014, the Bill & Melinda Gates Foundation (BMGF) supported the Nigerian Urban Reproductive Health Initiative (NURHI) with the aim of increasing voluntary use of contraceptives among women ages 15-49 years in six Nigerian cities. A subsequent phase of NURHI was implemented in three states for the next 3 to 5 years. Using cross-sectional survey data from three cities (two exposed to NURHI, one not exposed), this study examines whether social norms around FP were related to women's use of modern contraception, and whether the relationship differed by varying levels of exposure to the program (i.e., by city). We identified three distinct FP social norms through factor analysis: norms around delaying first pregnancy; spacing or limiting pregnancies; and using contraception when the husband disagrees. Using structural equation modeling, we found that FP social norms are related to use of modern contraceptive methods, and the relationship varies by city and norm type. The observed differences suggest that this relationship depends on numerous factors at the individual, interpersonal and societal level, and this may include malleable factors influenced by the NURHI program.

Beyond "toxic bodies": Multiplied rationalities of women's reproductive health in a high-risk environmental area (Taranto, Italy)

This study investigates women's reproductive health concerns in Taranto, a steel town and a "high-risk environmental area" in Italy. It draws on participatory ethnographic research (body mapping, interviews and fieldnotes) and analyses political and social aspects of women's reproductive health in relation to pollution. I argue that in highly polluted environments, both political rationalities and women's health concerns over their bodies are multiplied, extending beyond a focus on their bodies as shaped by toxic exposure. Women make sense of knowledge about their reproductive health and questions of responsibility in relation not only to societal norms, but also through reference to the wider polluted environment and the political-economic structures they inhabit. By focusing on women's own experiences, the study contributes to our understanding of women's agency over their environment-health relations and seeks to complicate women's role as environmental subjects beyond "toxic bodies".

A vignette-based approach to understanding social norms around family planning in three Nigerian cities

Understanding the mechanisms through which social norms shape contraceptive use can help prevent unintended pregnancies in low-income countries. The Nigerian Urban Reproductive Health Initiative (NURHI) aimed to increase contraceptive uptake through advocacy, service delivery, and demand generation. Using data from focus group discussions, we examined whether social norms around family planning (FP), and specifically use of modern contraception (MC), varied among women and girls of reproductive age exposed to varying levels of the programme in three Nigerian cities. Injunctive social norms were generally unfavourable of unmarried adolescent girls' use of MC, though participants often shared exceptions for certain types of adolescents whose use of MC would be acceptable. There was greater acceptability for MC use by women who wanted to space or limit pregnancies. Participants reported that norms around FP and MC use have become more accepting in their communities over time. Normative differences between cities were identified. Participants' perceptions of religious leaders' support for FP use may have contributed to positively influencing social norms.

Validation and Assessment of a Tool to Measure Psychosocial Readiness to Use Modern Contraceptives among Women in Tigray, Ethiopia

Social norms, beliefs, and attitudes around modern contraception (MC) use can influence the decision to take up a method, but susceptibility to these factors varies between individuals. The effect of psychosocial readiness to use MC at the individual level is not established for women in Ethiopia. Data from 349 women were used for validity and reliability testing of a 12-item MC psychosocial readiness scale. A rating-scale Rasch model tested for unidimensionality, rating scale functioning, and construct and content validity. Multiple linear regression assessed the effect of respondent characteristics on MC psychosocial readiness scores. The psychometric properties of the univariate MC psychosocial readiness scale were satisfactory after the stepwise removal of two items. Prior MC use, socioeconomic status, geographic zone, and education were significantly associated with increased endorsement of MC psychosocial readiness. The 10-item scale measures the extent of endorsement of MC psychosocial readiness for childbearing women in Tigray, Ethiopia. Further research should qualitatively explore the identified influence of education on MC psychosocial readiness.

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

Background

Prior research has established that an individual’s social environment may influence his or her reproductive behaviors, yet less is known about peer influence on contraceptive use among young people (ages 15–24). In Kenya, the site of this study, 15% of adolescents ages 15–19 have begun childbearing and 45% of sexually active young women report current use of a modern contraceptive method. This highlights the need to better understand what factors influence young people to use contraception. The objective of this study is to explore the relationship between the perception of peers’ use of contraceptives and contraceptive use and method choice among young men and women in Kenya.

Methods

This study utilizes a nationally representative sample of women and men aged 15–24 years from the 2018 and 2019 cross sectional Shujaaz State of the Kenyan Youth annual surveys. Among the sample of sexually experienced young people (59%), multivariable multinomial logistic regression was used to explore the association between the perception of peers’ use of contraceptives and the respondent’s contraceptive method choice: non-user, condom use or use of any other modern method. Results are presented separately for young men and young women.

Results

Our results show that sexually experienced young men and women who perceive that their peers are using contraceptives are more likely to report current use of condoms compared to being a nonuser (RRR = 2.12, p < 0.001, RRR = 2.59, p < 0.001, respectively); they are also more likely to use condoms than another modern method of contraception (RRR = 2.13, p = 0.034, RRR = 1.71, p = 0.014, respectively). Young women are more likely to use another modern method (not including condoms) than be a nonuser when they perceive that their peers’ use contraceptives (RRR = 1.51, p = 0.020).

Conclusions

The results of this study highlight the important role of peer influence on young people’s contraceptive choices. These findings can be used to develop programs that encourage behavior change communication activities in Kenya that focus on normalizing use of a full range of contraceptive methods among peer groups of sexually experienced young people.

In Kenya, about 15% of women age 15–19 have already had a birth and approximately one third of these women did not want to have a child at that time. Yet about 45% of sexually active women ages 15–24 report that they currently use family planning (FP). Among young people, friends and peers are an important influence on behaviors.

This study focused on a representative sample from Kenya of female and male youth (ages 15–24) who ever had sex. Men and women were asked questions about use of FP, if they think their peers use FP and about characteristics such as age and education.

The results showed that young women and men who believed their peers use FP were more likely to use FP themselves. Also, young men and women who believed that peers use FP were more likely to use condoms than not use any FP and more likely to use condoms than to use another modern method of FP. Young women who thought their peers use were more likely to use another modern method (not including condoms) than to be a nonuser of FP.

Programs targeting young people should include information on a range of FP methods and aim to include groups of peers and encourage open discussion.

Associations between adverse childhood experiences and contraceptive use among young adults in Honduras

OBJECTIVE

Research on adverse childhood experiences (ACEs) and use of modern contraception is limited in Honduras. The government has made substantial gains in promoting modern contraception. Young adults experience high rates of violence. The aim of this study was to assess the relationship between ACEs and contraceptive behaviors among young women and men.

METHODS

We used data from 810 women and 753 men aged 18-24 years from the 2017 Honduras Violence against Children Survey, a cross-sectional, nationally representative household survey of childhood adversity. We assessed associations between ACEs and three contraceptive use outcomes: use versus nonuse of modern contraceptives; use of methods requiring medium/high or low programmatic support among current contraceptive users; and frequent versus infrequent condom use.

FINDINGS

Exposure to physical or emotional abuse and witnessing violence in the home was not significantly associated with the three contraceptive use outcomes for men or women. Sexual abuse and parental separation reduced odds of contraceptive use among women (Odds Ratio (OR) < 0.60) but not among men. In contrast, orphan status increased odds of modern contraception use among men (OR 1.93) and frequent condom use among women (OR 2.22).

CONCLUSION

The inconsistent direction and magnitude of associations between ACEs and modern contraceptive use among young men and women suggests divergent relationships between ACEs and sexual and reproductive health behaviors. Results may highlight the strength of norms around contraceptive use and/or widespread access to community-based family planning programs and comprehensive sexuality education, irrespective of exposure to ACEs in Honduras.

Social and provider networks and women's contraceptive use: Evidence from Madagascar

OBJECTIVES

Women may differ by whether they rely on health providers and/or social ties for seeking information and advice about family planning. It is unknown whether these differences matter for contraceptive outcomes. This study assessed the association between women's family planning (FP) network (social and/or provider ties) and contraceptive use.

STUDY DESIGN

This cross-sectional, egocentric network study was conducted among reproductive-age women (n = 193) in rural Madagascar. Data included socio-demographics and contraceptive use. Respondents listed who they relied on for contraceptive information, advice or guidance and provided ties' gender, age, relationship, and perceived support of contraceptive use. The primary outcome was current contraceptive use. Predictors included having a FP network (0/1) and FP network composition (no network, social ties only, provider ties only, both provider and social ties), respectively. Analyses were conducted using a generalized linear model specifying a Poisson distribution, with covariate adjustment and cluster robust standard errors.

RESULTS

Having a network of individuals to turn to for contraceptive information compared to having no FP network was positively associated with contraceptive use (adjusted relative risk [aRR] 4.4, 95% confidence interval [CI] 2.00-9.87). Having a social network, a provider network, or a combination of social and provider network were all positively associated with contraceptive use (aRR 4.30 [CI 1.92-9.66], aRR 4.46 [CI 2.04-9.75], aRR 4.72 [CI 1.93-11.50], respectively), compared to having no FP network.

CONCLUSIONS

Contraceptive use was higher among women who relied on social ties, provider ties or both for contraceptive information and advice, compared to women with no FP network. These findings suggest that FP interventions should use a multicomponent approach taking into account both social and provider networks.

IMPLICATIONS

It is unknown whether differences in whether women rely on social ties (friends, partner, family members) vs. providers for contraceptive information and advice affect contraceptive outcomes. Women are just as likely to use contraception whether they rely on social ties, provider ties, or both for contraceptive information and advice.

"As a woman who watches how my family is… I take the difficult decisions": a qualitative study on integrated family planning and childhood immunisation services in five African countries

Background

Family planning (FP) has the potential to improve maternal and child health outcomes and to reduce poverty in sub-Saharan Africa. However, substantial unmet need for modern contraceptive methods (MCMs) persists in this region. Current literature highlights multi-level barriers, including socio-cultural norms that discourage the use of MCMs. This paper explores women’s choices and decision-making around MCM use and examines whether integrating FP services with childhood immunisations influenced women’s perceptions of, and decision to use, an MCM.

Methods

94 semi-structured interviews and 21 focus group discussions with women, health providers, and community members (N = 253) were conducted in health facilities and outreach clinics where an intervention was delivering integrated FP and childhood immunisation services in Benin, Ethiopia, Kenya, Malawi and Uganda. Data were coded using Nvivo software and an analytical framework was developed to support interpretative and thematic analyses on women’s decision-making about MCM use.

Results

Most women shared the reproductive desire to space or limit births because of the perceived benefits of improved health and welfare for themselves and for their children, including the economic advantages. For some, choices about MCM use were restricted because of wider societal influences. Women’s decision to use MCMs was driven by their reproductive desires, but for some that was stymied by fears of side effects, community stigma, and disapproving husbands, which led to clandestine MCM use. Health providers acknowledged that women understood the benefits of using MCMs, but highlighted that the wider socio-cultural norms of their community often contributed to a reluctance to use them. Integration of FP and childhood immunisation services provided repeat opportunities for health providers to counter misinformation and it improved access to MCMs, including for women who needed to use them covertly.

Conclusions

Some women chose to use MCMs without the approval of their husbands, and/or despite cultural norms, because of the perceived health and economic benefits for themselves and for their families, and because they lived with the consequences of short birth intervals and large families. Integrated FP and childhood immunisation services expanded women’s choices about MCM use and created opportunities for women to make decisions autonomously.

The association between men's family planning networks and contraceptive use among their female partners: an egocentric network study in Madagascar

Background

Ensuring women have information, support and access to family planning (FP) services will allow women to exercise their reproductive autonomy and reduce maternal mortality, which remains high in countries such as Madagascar. Research shows that women’s social networks - their ties with partners, family members, friends, and providers - affect their contraceptive use. Few studies have considered the role of men’s social networks on women’s contraceptive use. Insofar as women’s contraceptive use may be influenced by their male partners, women’s contraceptive use may also be affected by their partner’s social networks. Men may differ by the types of ties they rely on for information and advice about FP. It is unknown whether differences in the composition of men’s FP networks matter for couples’ contraceptive use. This study assessed the association between men’s FP networks and couples’ contraceptive use.

Methods

This egocentric network study was conducted among married/partnered men (n = 178) in rural Madagascar. Study participants listed who they relied on for FP information and advice, including health providers and social ties. They provided ties’ gender, age, relationship, and perceived support of contraceptive use. The primary outcome was couples’ contraceptive use, and explanatory variables included FP networks and their composition (no FP network, social-only network, provider-only network, and mixed network of social and provider ties). Analyses used generalized linear models specifying a Poisson distribution, with covariate adjustment and cluster robust standard errors.

Results

Men who had FP networks were 1.9 times more likely to use modern contraception as a couple compared to men with no FP network (95% confidence interval [CI] 1.64–2.52; p ≤ 0.001). Compared to men with no FP network, men were more likely to use modern contraception if they had a social-only network, relative risk (RR) = 2.10 (95% CI, 1.65–2.68; p ≤ 0.001); a provider-only network, RR = 1.80 (95% CI, 1.54–2.11; p ≤ 0.001); or a mixed network, RR = 2.35 (95% CI, 1.97–2.80; p ≤ 0.001).

Conclusions

Whether men have a FP network, be it provider or social ties, distinguishes if couples are using contraception. Interventions should focus on reaching men not only through providers but also through their social ties to foster communication and support for contraceptive use.

Positive deviance in infection prevention and control: A systematic literature review

BACKGROUND

Healthcare-associated infections (HAIs) remain a major challenge. Various strategies have been tried to prevent or control HAIs. Positive deviance, a strategy that has been used in the last decade, is based on the observation that a few at-risk individuals follow uncommon, useful practices and that, consequently, they experience better outcomes than their peers who share similar risks. We performed a systematic literature review to measure the impact of positive deviance in controlling HAIs.

METHODS

A systematic search strategy was used to search PubMed, CINAHL, Scopus, and Embase through May 2020 for studies evaluating positive deviance as a single intervention or as part of an initiative to prevent or control healthcare-associated infections. The risk of bias was evaluated using the Downs and Black score.

RESULTS

Of 542 articles potentially eligible for review, 14 articles were included for further analysis. All studies were observational, quasi-experimental (before-and-after intervention) studies. Hand hygiene was the outcome in 8 studies (57%), and an improvement was observed in association with implementation of positive deviance as a single intervention in all of them. Overall HAI rates were measured in 5 studies (36%), and positive deviance was associated with an observed reduction in 4 (80%) of them. Methicillin-resistant Staphylococcus aureus infections were evaluated in 5 studies (36%), and positive deviance containing bundles were successful in all of them.

CONCLUSIONS

Positive deviance may be an effective strategy to improve hand hygiene and control HAIs. Further studies are needed to confirm this effect.

Individual and community-level factors associated with modern contraceptive use among adolescent girls and young women in Mali: a mixed effects multilevel analysis of the 2018 Mali demographic and health survey

Background

Unintended pregnancy constitutes a significant public health challenge in sub-Saharan Africa and particularly among young people, who are more likely to closely space births and experience adverse obstetric outcomes. Studies on modern contraceptive use have mostly focused on women of reproductive age in general with limited attention to factors associated with modern contraceptive use among adolescents and young women (aged 15–24) in Mali. We examined the individual and community-level factors associated with modern contraceptive use among this age cohort using the 2018 Mali demographic and health survey data.

Methods

We analyzed data from 2639 adolescent girls and young women, and our outcome of interest was current use of modern contraceptives. We performed descriptive analysis using frequencies and percentages and inferential analysis using mixed-effects multilevel logistic regression. The results of the mixed-effects multilevel logistic regression were presented as adjusted odds ratios with their corresponding 95% confidence intervals.

Results

The prevalence of modern contraceptive use among adolescent girls and young women in Mali was 17.1% [95% CI, 15–19%]. Adolescent girls and young women who were married [aOR = 0.20, CI = 0.09–0.41], had no formal education [aOR = 0.43, CI = 0.32–0.59], in the poorest wealth quintile [aOR = 0.38, CI = 0.19–0.79] and had no children [aOR = 0.38, CI = 0.27–0.53] were less likely to use modern contraceptives. Similarly, those who had low knowledge of modern contraception [aOR = 0.60, CI = 0.42–0.85] and whose ideal number of children was six or more [aOR = 0.66, CI = 0.43–0.99] were less likely to use modern contraceptives. However, those with four or more births were more likely to use modern contraceptives [aOR = 1.85, CI = 1.24–2.77].

Conclusion

Modern contraceptive use among adolescent girls and young women in Mali has improved slightly relative to the prevalence of 2012, though the prevalence is still low, compared to the prevalence in other sub-Saharan African countries and the prevalence globally. Individual-level factors such as marital status, educational level, wealth quintile, parity, ethnicity and ideal number of children were associated with the use of modern contraceptive among adolescent girls and young women in Mali. Community knowledge of modern contraceptives was found as a community-level factor associated with modern contraceptive use among adolescent girls and young women. Therefore, Mali’s Ministry of Health and Public Hygiene's Health Promotion and Education unit should prioritise and intensify contraceptive education to increase coverage of modern contraceptive use and address disparities in the use of modern contraceptives. Such education should be done, taking into consideration factors at the individual and community-level of the target population.

Adoption of outgroup norms provides evidence for social transmission in perinatal care practices among rural Namibian women

Background and objectives

How do new ideas spread in social groups? We apply the framework of cultural evolution theory to examine what drives change in perinatal care norms among Himba women in the Kunene region of Namibia. Access to formal medical care is on the rise in this region, and medical workers regularly visit communities to promote WHO-recommended perinatal care practices. This study investigates how various forms of social transmission affect women's uptake of medical recommendations concerning perinatal care.

Methodology

Based on interviews with one hundred Himba mothers, we used Bayesian multi-level logistical regression models to examine how perceptions of group preferences, prestige ascribed to outgroup conformers, interaction with the outgroup and access to resources affect norm adoption.

Results

Women who perceive medical recommendations as common in their group prefer, plan and practice these recommendations more often themselves. We observed a shift toward medical recommendations regarding birth location and contraception use that was in line with conformity bias predictions. Practices that serve as cultural identity markers persist in the population.

Conclusions and implications

Norm changes, and the cultural evolutionary processes that can lead to them, are not uniform, either in process or pace. Empirical studies like this one provide important examples of how these changes reflect local culture and circumstance and are critical for better understanding the models that currently predominate in cultural evolution work. These cases can also help bridge the gap between evolutionary anthropology and public health by demonstrating where promotion and prevention campaigns might be most effective.

Lay Summary

The recent promotion of WHO-recommended perinatal care practices in Namibia provides an opportunity to empirically study norm change using a cultural evolution framework. We found women adopt medical recommendations when they believe these are common in their social group. Local norms that were not discouraged persisted in the study group.

The influence of health facility-level access measures on modern contraceptive use in Kinshasa, DRC

Expanding access to family planning (FP) is a principal objective of global family planning efforts and has been a driving force of national family planning programs in recent years. Many country programs are working alongside with the international family planning community to expand access to modern contraceptives. However, there is a challenging need for measuring all aspects of access. Measuring access usually requires linking information from multiple sources (e.g., individual women and facilities). To assess the influence of access to family planning services on modern contraceptive use among women, we link four rounds of individual women and service delivery points survey data from PMA2020 in Kinshasa. Multilevel logistics regression on pooled data is performed to test the influence of facility-level access factors on individual-level contraceptive use. We add variables tailored from a conceptual framework to cover elements of access to family planning: administrative access, geographic or physical access, economic access or affordability, cognitive access, service quality, and psychological access. We find that the effect of community and facility-level access factors varies extensively but having fewer stocked-out facilities and more facilities with long-acting permanent methods (LAPM) increases the odds of using modern contraceptives among women in Kinshasa. Our study shows that reliable supply chain with a broad array of method mix will increase the odds of modern contraceptive use at community level among women in Kinshasa. Using to community-oriented practices and service delivery along with empowering women to make health-related decisions should become a priority of family planning programs and international stakeholders in the country.

Trends and determinants of contraceptive use among female adolescents in Ghana: Analysis of 2003-2014 Demographic and Health Surveys

INTRODUCTION

Thirty percent (30%) of all deliveries in 2014 were recorded among adolescents in Ghana, whom contraceptive use has been found to be low. Our study, therefore, aimed to retrospectively look at the trends and determinants of contraceptive use (modern and traditional) among female adolescents in Ghana.

MATERIALS AND METHODS

We used data from the 2003, 2008 and 2014 Ghana Demographic and Health Surveys. The sample for this study comprised sexually active female adolescents aged 15-19 for each of the rounds thereby resulting in a sample of 426 in 2003, 389 in 2008 and 726 in 2014. We calculated the proportion of adolescents using contraceptives (either traditional or modern) for each of the three surveys. We computed the use of contraceptives among adolescents and the type of contraceptives used with respect to their socio-demographic characteristics. Multinomial Logistic Regression was used to assess the determinants of contraceptive use at 95% confidence interval and Odds Ratios (OR) and p-values were reported.

RESULTS

Contraceptive use declined from 22.1% in 2003 to 20.4% in 2014. Adolescents who were married had lower odds [OR = 0.09, 95% CI = 0.03-0.96] of using traditional methods of contraception compared to those who were not married. Those who read newspapers at least once a week were more likely to utilize modern contraceptives [OR=1.84, CI = 1.05-4.78] compared to adolescents who did not read newspapers at all. Similarly, those who watched television at least once a week were more likely to use modern contraceptives than those who did not watch television at all [OR = 2.25, CI = 1.06-4.78].

CONCLUSION

These findings imply that intensifying educational messages on contraceptive use among adolescents using various newspapers and television stations to convey the messages and emphasizing the importance of using modern contraceptive is worthwhile.

Social networks and their effects on the choice of contraceptive use and method in Bangladesh

Purpose

The purpose of this paper is to examine the effects of social networks on contraceptive adoption in Bangladesh.

Design/methodology/approach

Data were collected from 430 couples; the age of men was between 15 and 49 years. χ2 test was applied to test the association between independent variables and current contraceptive use. Binary logistic regression was applied to examine the effects of social network on contraceptive use, and multinomial logistic regression was applied to examine the effect of social network on the choice of method.

Findings

Results from binary logistic regression reveal that social networks of both men (OR=2.71, 95% CI=1.371−5.354) and women (OR= 3.597, 95% CI=1.754−7.380) had a strong positive effect on current contraceptive use. The result from multinomial logistic regression also shows that men’s social network (OR= 2.74, 95% CI= 1.356−5.548) and women’s social network (OR=4.165,95% CI=1.958−8.860) were also associated with choosing a modern contraceptive method.

Originality/value

Social networks have a significant effect on current contraceptive use and modern method choice in Bangladesh. A social network approach should be included in family planning program in Bangladesh.

Individual, community and service environment factors associated with modern contraceptive use in five Sub-Saharan African countries: A multilevel, multinomial analysis using geographically linked data from PMA2020

The importance of the family planning service environment and community-level factors on contraceptive use has long been studied. Few studies, however, have been able to link individual and health facility data from surveys that are nationally representative, concurrently fielded, and geographically linked. Data from Performance Monitoring and Accountability 2020 address these limitations. To assess the relative influences of the service delivery environment and community, household, and individual factors on a woman's likelihood of using a modern contraceptive in five geographically and culturally diverse sub-Saharan African countries. Nationally representative, cross-sectional data from PMA2020 were linked at the household and service delivery level. Country-specific and pooled multilevel multinomial logistic models, comparing non-users, short- and long-acting method users were used. The variables elected for inclusion in our multivariate analyses were guided by the conceptual framework to profile the different levels of influences on individual use of modern contraception. Average marginal effects were calculated to improve interpretability. We find that the effect of contextual factors varies widely but that being visited by a health worker who spoke about family planning in the past 12 months was consistently and positively associated with individual use of short-acting and long-acting contraception. Characteristics of the nearest health facility did not generally exercise their own independent influences on a woman's use of contraception, except in the case of Burkina Faso, where the average distance between individuals and the nearest family planning provider was significantly greater than other countries. Inclusion of country fixed effects in the pooled models and the relevance of covariates at different levels in the country-specific models demonstrate that there is significant variation across countries in how community, individual, and service delivery environment factors influence contraceptive use and method choice. Context must be taken into account when designing family planning programs.

Prevalence and predictors of unmet contraceptive need in HIV-positive female sex workers in Mombasa, Kenya

OBJECTIVES

Female sex workers (FSWs) in sub-Saharan Africa are a key population for HIV prevention and treatment interventions, but less attention is given to their family planning needs. We evaluated the prevalence and predictors of unmet contraceptive need in HIV-positive FSWs.

STUDY DESIGN

This cross-sectional analysis used data from an existing longitudinal study of FSWs in Mombasa, Kenya. This analysis included women who were HIV positive, age ≥18 years, pre-menopausal, not currently pregnant or desiring pregnancy, and reported exchanging sex for cash or in-kind payment at the time of enrollment. Unmet contraceptive need was defined as non-use of modern non-barrier contraceptives and not currently trying to become pregnant. Poisson regression was used to identify factors independently associated with unmet contraceptive need.

RESULTS

Among 346 HIV-positive FSWs, 125 (36.1%) reported modern non-barrier contraceptive use, leaving 221 (63.9%, 95%CI 58.8-68.9%) with unmet contraceptive need. Condom use was the only form of contraception for 129 (37.3%) participants. In unadjusted analyses, unmet contraceptive need was associated with physical abuse in the past year by someone other than a regular partner (PR 1.2, 95%CI 1.0-1.5), desire for (more) children (PR 1.3, 95%CI 1.1-1.5), and having 2-3 previous pregnancies compared to 0-1 prior pregnancies (PR 0.8, 95%CI 0.6-0.9). In adjusted analyses, lower number of previous pregnancies and having desire for future children remained significantly associated with a higher prevalence of unmet contraceptive need.

CONCLUSIONS

Unmet need for modern non-barrier contraception was found in two-thirds of HIV-positive FSWs who reported that they were not currently trying to become pregnant, and was higher in women with the lowest number of prior pregnancies (0-1 prior pregnancies) and in those reporting desire for (more) children in the future. These findings highlight the need for concerted efforts to identify and eliminate barriers to contraceptive use in FSWs living with HIV.

Applying a deviance framework to understand modern contraceptive use in sub-Saharan Africa

Increasing modern contraceptive use is important for improving maternal and child health and achieving economic growth and development goals. However, pervasive high unmet need for modern contraceptives in sub-Saharan Africa warrants new understandings of the drivers of modern contraceptive use. A deviance approach (i.e., examining how women's experiences/characteristics differ from other women in their community) provides an innovative framework for capturing heterogeneity among women in a community. This framework can inform public health programming by both exploring how women avoid adverse health outcomes and understanding the needs of harder-to-reach populations who may experience health risks, despite living in communities where others do not experience vulnerability. Using data from Demographic and Health Surveys from 29 sub-Saharan African countries, we examine how a woman's deviation from community norms around socioeconomic characteristics and gender and fertility norms and behaviors is associated with modern contraceptive use. Random-effects logistic regression models were fitted for each country to examine relationships between modern contraceptive use and deviance. Some deviance factors were associated with modern contraceptive use in only a few countries, while others were significant across many countries. Cross-country consistency in the direction of the relationship between deviance and modern contraceptive use varied by the specific deviance factor, with some relationships being consistent across countries, and other relationships being more varied. For example, having more education than the community norm was associated with increased modern contraceptive use across countries; however, marrying older than other women in the community was associated with an increase in modern contraceptive use in some countries and a decrease in others. More work is needed to understand the role of deviance on modern contraceptive use; however, this study suggests that using context-specific deviance approaches may be important for further elucidating experiences of modern contraceptive use.

Contraception in adolescence: the influence of parity and marital status on contraceptive use in 73 low-and middle-income countries

Background

There is still a large gap in relation to effectively meet the contraceptive needs and family planning goals of adolescents. Our aim was to describe how having a partner and children impact on contraceptive behavior of sexually active female adolescents from low and middle-income countries (LMICs).

Methods

Analyses were based on the most recent Demographic and Health Surveys and Multiple Indicator Surveys carried out since 2005 in 73 LMICs with available data for sexually active women aged 15–19 years. Modern contraceptive prevalence and demand for family planning satisfied with modern methods of contraception (mDFPS) were estimated among three subgroups of adolescents considering their parity and marital status- not married, married without children, and married with children – at national and regional levels.

Results

Female adolescents who were married with no children presented the lowest median modern contraceptive prevalence in all world regions, ranging from 2.9% in West & Central Africa to 29.0% in Latin America & Caribbean. Regarding mDFPS, the lowest coverage for married adolescents without children was found in West & Central Africa (12.6%), whereas Latin America & Caribbean presented the highest (50.4%). In East Asia & Pacific, not married adolescents were the group with the lowest mDFPS (17.1%). In 12 countries, mDFPS was below 10% among married adolescents without children: Angola, Chad, Congo, Congo DR, Guinea, Mozambique, Niger, Nigeria, and Senegal in Africa, Philippines and Timor-Leste in Asia and Guyana in Latin America & Caribbean.

Conclusions

In most countries, modern contraceptive prevalence and mDFPS were particularly low among married female adolescents without children, which should be considered a priority group for intervention. The findings suggest that social norms regarding marriage and fertility expectations and other cultural barriers have a role at least as relevant as contraceptive availability. All these aspects need to be considered in the design of family planning strategies to effectively increase modern contraceptive use among adolescents everywhere, particularly in conservative contexts.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0686-9) contains supplementary material, which is available to authorized users.

The prevalence of modern contraceptive use and its associated socio-economic factors in Ghana: evidence from a demographic and health survey of Ghanaian men

OBJECTIVE

This study estimated the prevalence of modern contraceptive use (MCU) and the sociodemographic factors associated with MCU among sexually active men in Ghana. The study is informed by the Health Belief Model, which is used as a conceptual framework for understanding MCU.

STUDY DESIGN

This was a cross-sectional study of 2014 Ghana Demographic and Health Survey data.

METHODS

Analysis was limited to 3373 men who reported being sexually active within the 24-months prior to the survey data collection. Descriptive statistics, Chi-squared test, and multivariable logistic regression analyses were used to estimate the prevalence of MCU and the associated factors affecting contraception use.

RESULTS

The sexually active men ranged in age from 15 to 59 years of whom 26.20% used modern contraceptives. Men who had discussed family planning with a health worker were more likely to use contraceptives compared with men who did not (adjusted odds ratio [AOR] = 1.54; 95% confidence interval [CI] = 1.14-2.08). Men who were undecided about having additional children were more likely to be using modern contraception compared with men who wanted more children (AOR = 1.85; 95% CI = 1.06-3.22). Men with at least a primary education were more likely to use contraception compared with men with no education (AOR = 1.80; 95% CI = 1.23-2.63). Finally, men with multiple sexual partners were more likely to use contraception compared with men with a single sexual partner (AOR = 1.42; 95% CI = 1.09-1.85).

CONCLUSION

There was a low prevalence of MCU among sexually active Ghanaian men. MCU was associated with factors such as education and age.

Gender norms and modern contraceptive use in urban Nigeria: a multilevel longitudinal study

Background

Evidence suggests that gender equality positively influences family planning. However, the evidence from urban Africa is sparse. This study aimed to examine the association between changes in gender norms and modern contraceptive use over time among women in urban Nigeria.

Methods

Data were collected in 2010/2011 from 16,118 women aged 15–49 living in six cities in Nigeria (Abuja, Benin, Ibadan, Ilorin, Kaduna, and Zaria) and again in 2014 from 10,672 of the same women (34% attrition rate). The analytical sample included 9933 women living in 480 neighborhoods. A four-category outcome variable measured their change in modern contraceptive use within the study period. The exposure variables measured the changes in the level of gender-equitable attitudes towards: a) wife beating; b) household decision-making; c) couples’ family planning decisions; and d) family planning self-efficacy. Multilevel multinomial logistic regression models estimated the associations between the exposure variables at the individual and neighborhood levels and modern contraceptive use controlling for the women’s age, education, marital status, religion, parity, household wealth, and city of residence.

Results

The proportion of women who reported current use of modern contraceptive methods increased from 21 to 32% during the four-year study period. At both surveys, 58% of the women did not report using modern contraceptives while 11% reported using modern contraceptives; 21% did not use in 2010/2011 but started using by 2014 while 10% used in 2010/2011 but discontinued use by 2014. A positive change in the gender-equitable attitudes towards household decision-making, couples’ family planning decisions, and family planning self-efficacy at the individual and neighborhood levels were associated with increased relative probability of modern contraceptive use (adoption and continued use) and decreased relative probability of modern contraceptive discontinuation by 2014. No such associations were found between the individual and neighborhood attitudes towards wife beating and modern contraceptive use. Accounting for the individual and neighborhood gender-equitable attitudes and controlling for the women’s demographic characteristics accounted for 55–61% of the variation between neighborhoods in the change in modern contraceptive use during the study period.

Conclusion

Interventions that promote gender equality have the potential to increase modern contraceptive use in Nigerian cities.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0664-3) contains supplementary material, which is available to authorized users.

Factors influencing the use of contraceptives through the lens of teenage women: a qualitative study in Iran

BACKGROUND

One out of seven teenage girls in developing countries marries before the age of 15. While the fertility rate of teenage girls is high, the rate of contraceptive use remains low; therefore, this group of teenagers needs reproductive healthcare. This study was undertaken to explore factors influencing the use of contraceptives from the perspective of teenage women living in the city of Ardabil in Iran.

METHODS

This qualitative study was conducted with 14 married women aged 13-19 years who attended in urban-rural healthcare centers in Ardabil. Eligible women were recruited using purposive sampling and were invited to take part in individual in-depth semi-structured interviews. The duration of the interviews varied from 45 to 90 min with an average of 55 min. Sampling continued until data saturation was reached and no new data was collected. Each interview was tape-recorded after obtaining the participant's permission, transcribed verbatim and analyzed for identifying categories and themes using conventional content analysis.

RESULTS

Three themes and eight subthemes were developed. The themes were as follows: "insufficient familiarity with contraceptive methods", "pressure to become pregnant" and "misconceptions".

CONCLUSION

Despite the high prevalence of early marriage in Iranian society, teenage women are not empowered or prepared for marriage and birth control. Sexual and reproductive healthcare services to teenage women should be improved to meet their needs.

How the Community Shapes Unmet Need for Modern Contraception: An Analysis of 44 Demographic and Health Surveys

Unmet need for modern contraception is a major public health concern in resource-constrained countries. Recent research supports the application of social-ecological theories to explain how characteristics of a woman's community shape modern contraception use. However, this research focuses largely on individual countries and uses a limited number of community-level effects. We fitted three random-effects logistic regression models to examine associations between 13 community-level variables and the odds of reporting unmet need, unmet need for spacing, and unmet need for limiting for all parous, female respondents in 44 DHS surveys collected in 2010-2015 (n=528,101). Community variables explain significant variance in unmet need between communities. Associations between community variables and unmet need differ by urban and rural residence. The results highlight several commonalities in how the community shapes unmet need across resource-constrained settings and may help in designing structural-level interventions.

Determinants of modern contraceptive use among sexually active men in Kenya

Background

Research in Kenya has focussed on family planning from women’s perspectives, with the aim of helping reduce the burden of unintended pregnancies. As such, the determinants of modern contraceptive use among sexually active women are well documented. However, the perspectives of men should be considered not only as women’s partners, but also as individuals with distinct reproductive histories and desires of their own. This study seeks to understand the determinants of modern contraceptive use among sexually active men, by exploring factors that are correlated with modern contraceptive use.

Methods

The data source is the nationally representative 2014 Kenya Demographic and Health Survey (DHS) of men aged 15–54 years. The analysis is restricted to 9,514 men who reported being sexually active in the past 12 months prior to the survey, as they were likely to report either doing something or not to avoid or delay pregnancy. We use bivariate and multinomial logistic regression to assess factors that influence modern contraceptive use among sexually active men.

Results

Findings from the bivariate and multinomial logistic regression indicate that region of residence, marital status, religion, wealth, interaction with a health care provider, fertility preference, number of sexual partners and access to media were all significantly associated with modern contraceptive use among sexually active men.

Conclusion

Provider-client interaction as well as dissemination of information through mass media has the potential to increase knowledge and uptake of modern contraceptives. Similar efforts targeting segments of the population where contraceptive uptake is low are recommended.

Modern contraceptive utilization and associated factors among married pastoralist women in Bale eco-region, Bale Zone, South East Ethiopia

Background

Women who live in remote rural areas encounter different challenges against contraception and often deny the use of modern contraceptive methods. The predictors of modern contraceptive utilization by pastoralist women in the Bale eco-region could be specific and are not well known. Therefore, this study aims to assess modern contraceptive utilization and its determinants among married pastoralist women in Bale eco-region, Oromia regional state, South East Ethiopia.

Methods

A community-based cross-sectional study was conducted from 20th November 2015 to 30th February 2016. A structured questionnaire was used to interview 549 married pastoralist women who were selected by multistage sampling technique. The data were analyzed by SPSS - 21 software, multivariate logistic regression analysis was used to identify predictors of modern contraceptive use at (P-value <0.05), and odds ratios with 95% confidence interval were used to assess the strength of associations between variables.

Results

The current modern contraceptive method use by married pastoralist women was (20.8%). Among the total users, (78.1%) use the injectable method. The common reasons for non-use of modern contraceptive methods includes: religious-opposition (55.9%), desire for more children (28.3%), fear of side effects (25.5%), and husband’s opposition (17.5%). Couple discussion (AOR = 4.63, 95%CI: 2.15, 9.98), perceived husband’s approval (AOR = 8.00, 95% CI: 3.52, 18.19), discussion with health extension worker (AOR = 5.99, 95% CI: 1.81, 19.85), and perceived cultural acceptability (AOR = 2.10, 95% CI: 1.09, 4.03) were the independent predictors of modern contraceptive use by married pastoralist women in Bale eco-region.

Conclusion

The study identified lower modern contraceptive method utilization by pastoralist women, and the majority of the contraceptive users rely on short- acting contraceptive methods. The uncomplimentary perceptions towards religious and cultural acceptability of modern contraceptive method were among the major reasons for lesser utilization of the methods. Family planning programs should be tailored to actively involve pastoralist women, husbands, and religious leaders in pastoralist communities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2115-5) contains supplementary material, which is available to authorized users.

Are men well served by family planning programs?

Although the range of contraceptives includes methods for men, namely condoms, vasectomy and withdrawal that men use directly, and the Standard Days Method (SDM) that requires their participation, family planning programming has primarily focused on women. What is known about reaching men as contraceptive users? This paper draws from a review of 47 interventions that reached men and proposes 10 key considerations for strengthening programming for men as contraceptive users. A review of programming shows that men and boys are not particularly well served by programs. Most programs operate from the perspective that women are contraceptive users and that men should support their partners, with insufficient attention to reaching men as contraceptive users in their own right. The notion that family planning is women’s business only is outdated. There is sufficient evidence demonstrating men’s desire for information and services, as well as men’s positive response to existing programming to warrant further programming for men as FP users. The key considerations focus on getting information and services where men and boys need it; addressing gender norms that affect men’s attitudes and use while respecting women’s autonomy; reaching adolescent boys; including men as users in policies and guidelines; scaling up successful programming; filling gaps with implementation research and monitoring & evaluation; and creating more contraceptive options for men.

DO THE SEX COMPOSITION OF LIVING CHILDREN AND THE DESIRE FOR ADDITIONAL CHILDREN AFFECT FUTURE INTENTION TO USE CONTRACEPTION IN ETHIOPIA?

Information on future intention to use contraceptives is a potential programme indicator for family planning services. Using three consecutive rounds of Ethiopian Demographic and Health Survey (EDHS) data collected in 2000, 2005 and 2011, this study examined whether the sex composition of living children and future desire for additional children were associated with the intention to use contraceptives among Ethiopian women aged 15-49 years who were not using any method of contraception at the time of the survey. The pooled multivariate binary logistic regression analysis indicated that between 2000 and 2011, the intentions of non-users to use contraceptives in the future increased significantly. Women who had at least one child (with an equal number of boys and girls, more boys than girls or more girls than boys) who did not want any more children, and those who were unsure about their desire for additional children, showed an increased intention to use contraceptives in the future, compared with those with an equal number of boys and girls who expressed a desire for additional children. Women with no children and who did not want children, or those who were unclear about their future desire, showed a lower intention to use contraceptives, compared with women with an equal number of boys and girls who wanted a child in the future.

Factors influencing contraceptive use and non-use among women of advanced reproductive age in Nigeria

BACKGROUND

Factors influencing contraceptive use and non-use among women of advanced reproductive age have been insufficiently researched in Nigeria. This study examines factors influencing contraceptive use and non-use among women of advanced reproductive age in Nigeria.

METHODS

Secondary data were pooled and extracted from 2008 and 2013 Nigeria Demographic and Health Surveys (NDHS). The weighted sample size was 14,450 women of advanced reproductive age. The dependent variable was current contraceptive use. The explanatory variables were selected socio-demographic characteristics and three control variables. Analyses were performed using Stata version 12. Multinomial logistic regression was applied in four models.

RESULTS

Majority of the respondents are not using any method of contraceptive; the expected risk of using modern contraceptive relative to traditional method reduces by a factor of 0.676 for multiparous women (rrr = 0.676; CI: 0.464-0.985); the expected risk of using modern contraceptive relative to traditional method reduces by a factor of 0.611 for women who want more children (rrr = 0.611; CI: 0.493-0.757); the relative risk for using modern contraceptive relative to traditional method increases by a factor of 1.637 as maternal education reaches secondary education (rrr = 1.637; CI: 1.173-2.285); the relative risk for using modern contraceptive relative to traditional method increases by a factor of 1.726 for women in richest households (rrr = 1.726; CI: 1.038-2.871); and the expected risk of using modern contraceptive relative to traditional method increases by a factor of 1.250 for southern women (rrr = 1.250; CI: 1.200-1.818).

CONCLUSIONS

Socio-demographic characteristics exert more influence on non-use than modern contraceptive use. The scope, content and coverage of existing BCC messages should be extended to cover the contraceptive needs and challenges of women of advanced reproductive age in the country.

Son Preference in Pakistan; A Myth or Reality

OBJECTIVE

To analyze desire for sons/daughters among ladies of Peshawar, Pakistan, with a view to rule out son preference and to study impact of various demographic characteristics on the subject.

METHODS

Cross-sectional descriptive study conducted at Combined Military Hospital, Peshawar, from August 2015 - January 2016; sampling technique was random/probability/non-purposive. Self-designed questionnaire was utilized; carrying questions pertinent to desire for sons/daughters during marital life, and demographic details. Data analyzed via descriptive analysis (SPSS-21), expressed as frequencies/percentages and mean ± standard deviation(minimum/maximum). Sons and daughters desired (dependent variables) were cross-tabulated with independent variables.

RESULTS

Response rate was 63.25% (n-506). Data revealed following: Sons desired 3.05±2.061(1/12); Daughters desired 1.15±0.767(0/4); 6.1%(n-31) and 0.6%(n-3) desired infinite number of sons and daughters respectively, 18.2%(n-92) did not desire to have even one daughter, while 2.2%(n-11) considered it immaterial to have daughters or sons. There was a significant relation between sons desired and client's education (p<0.001), husband's education (p<0.001) and socioeconomic class (p<0.001). There was no significant impact of religion (p-0.142) on desire for sons. Impact of independent variables on daughters desired was similar but less pronounced.

CONCLUSION

There was candid son preference among the respondents. Gender discrimination can be attenuated by adequately addressing son preference at all tiers.

Characteristics of women screened for a contraceptive intravaginal ring study in Kisumu, Kenya, 2014

BACKGROUND

HIV antiretroviral-based intravaginal rings with and without co-formulated contraception hold promise for increasing HIV prevention options for women. Acceptance of and ability to correctly and consistently use this technology may create challenges for future ring-based microbicide trials in settings where this technology has not been introduced. We examined baseline factors associated with enrolling in a contraceptive intravaginal ring study in Kisumu, Kenya and describe notional acceptability (willingness to switch to a contraceptive ring based solely on information received about it).

METHODS

Demographic, psychosocial, and behavioral eligibility screening of women 18-34 years was undertaken. Testing for pregnancy, HIV, and other sexually transmitted infections (STIs) was also conducted. We compared enrollment status across groups of categorical predictors using prevalence ratios (PR) and 95% confidence interval (CI) estimates obtained from a log-binomial regression model.

RESULTS

Out of 692 women pre-screened April to November 2014, 463 completed screening, and 302 women were enrolled. Approximately 97% of pre-screened women were willing to switch from their current contraceptive method to use the intravaginal ring exclusively for the 6-month intervention period. Pregnancy, HIV, and STI prevalence were 1.7%, 14.5%, and 70.4% respectively for the 463 women screened. Women 18-24 (PR=1.47, CI 1.15-1.88) were more likely to be enrolled than those 30-34 years of age, as were married/cohabitating women (PR=1.62, CI 1.22-2.16) compared to those separated, divorced, or widowed. In adjusted analyses, sexual debut at less than 17 years of age, one lifetime sexual partner, abnormal vaginal bleeding in the past 12 months, condomless vaginal or anal sex in the past 3 months, and not having a sexual partner of unknown HIV status in the past 3 months were predictive of enrollment.

CONCLUSION

High notional acceptability suggests feasibility for contraceptive intravaginal ring use. Factors associated with ring use initiation and 6-month use will need to be assessed.

Contraceptive service delivery in Kenya: A qualitative study to identify barriers and preferences among female sex workers and health care providers

OBJECTIVE

Female sex workers (FSWs) need access to contraceptive services, yet programs often focus on HIV prevention and less on the broader sexual and reproductive health needs of FSWs. We aimed to identify barriers to accessing contraceptive services among FSWs and preferences for contraceptive service delivery options among FSWs and health care providers (HCPs) in order to inform a service delivery intervention to enhance access to and use of contraceptives for FSWs in Kenya.

STUDY DESIGN

Twenty focus group discussions were conducted with FSWs and HCPs in central Kenya.

RESULTS

Three barriers were identified that limited the ability of FSWs to access contraceptive services: (1) an unsupportive clinic infrastructure, which consisted of obstructive factors such as long wait times, fees, inconvenient operating hours and perceived compulsory HIV testing; (2) discriminatory provider-client interactions, where participants believed negative and differential treatment from female and male staff members impacted FSWs' willingness to seek medical services; and (3) negative partner influences, including both nonpaying and paying partners. Drop-in centers followed by peer educators and health care facilities were identified as preferred service delivery options.

CONCLUSIONS

FSWs may not be able to regularly access contraceptive services until interpersonal (male partners) and structural (facilities and providers) barriers are addressed. Alternative delivery options, such as drop-in centers coupled with peer educators, may be an approach worth evaluating.

IMPLICATIONS STATEMENT

An unsupportive clinic infrastructure, discriminatory provider-client interactions and negative partner influences are barriers to FSWs accessing the contraception services they need. Alternative service delivery options, such integrating contraceptive service delivery at drop-in centers designed for FSWs and information delivery through peer educators, might provide improved access and better service quality to FSWs seeking contraception.

Community Influences on Married Women's Safer Sex Negotiation Attitudes in Bangladesh: A Multilevel Analysis

The influence of disadvantaged or deprived community on individuals' health risk-behaviors is increasingly being documented in a growing body of literature. However, little is known about the effects of community characteristics on women's sexual attitudes and behaviors. To examine community effects on married women's safer sex negotiation attitudes, we analyzed cross-sectional data from the 2011 Bangladesh Demographic and Health Surveys on a sample of 15,134 married women in 600 communities. We estimated two multilevel logistic regression models. Model 1, which included only individual-level variables, showed that women's autonomy/empowerment, age, and HIV knowledge had significant associations with their safer sex negotiation attitudes. We did not find any socioeconomic status gradient in safer sex negotiation attitudes at the individual level. Adding community-level variables in Model 2 significantly improved the fit of the model. Strikingly, we found that higher community-level poverty was associated with greater positive safer sex negotiation attitudes. Prevailing gender norms and overall women's empowerment in the community also had significant effects. While research on community influences calls for focusing on disadvantaged communities, our research highlights the importance of not underestimating the challenges that married women in economically privileged communities may face in negotiating safer sex. To have sufficient and equitable impact on married women's sexual and reproductive health, sexual and reproductive health promotion policies and programs need to be directed to women in wealthier communities as well.

Men's Perspectives on Their Role in Family Planning in Nyanza Province, Kenya

Research has indicated that gender dynamics-and in particular men's disapproval of family planning-have had an influence on the low levels of contraceptive use in sub-Saharan Africa. Limited evidence exists, however, on effective strategies to increase male approval. We conducted 12 focus group discussions with married men aged 20-66 (N = 106) in Kenya to explore FP perceptions. Men's disapproval of FP was associated with anxieties regarding male identity and gender roles. Men often distrusted FP information provided by their wives because they suspected infidelity or feared being viewed as "herded." Men also feared that providers might pressure them into vasectomies or into disclosing extramarital sexual activity or HIV diagnoses to their wives. Suggested strategies include programs targeting couples jointly and FP education for men provided by male outreach workers. To encourage men's acceptance, community-based programs directly targeting men are needed to reduce stigma and misconceptions and to increase awareness of the benefits of FP.

The Role of Quality Health Services and Discussion about Birth Spacing in Postpartum Contraceptive Use in Sindh, Pakistan: A Multilevel Analysis

INTRODUCTION

Rapid population growth, stagnant contraceptive prevalence, and high unmet need for family planning present significant challenges for meeting Pakistan's national and international development goals. Although health behaviors are shaped by multiple social and environmental factors, research on contraceptive uptake in Pakistan has focused on individual and household determinants, and little attention has been given to community characteristics that may affect access to services and reproductive behavior.

METHODS

Individual and community determinants of contraceptive use were identified using multivariable multilevel logistic regression to analyze data from a 2014 cross-sectional survey of 6,200 mothers in 503 communities in Sindh, Pakistan.

RESULTS

Only 27% of women who had given birth in the two years before the study reported using contraceptives. After adjusting for individual and community characteristics, there was no difference in the odds of contraceptive use between urban and rural women. Women who had delivered at a health facility had 1.4 times higher odds of contraceptive use than women who delivered at home. Those who received information about birth spacing from a doctor or relatives/friends had 1.81 and 1.38 times higher odds of contraceptive use, respectively, than those who did not. Living in a community where a higher proportion of women received quality antenatal care and where discussion of birth spacing was more common was significantly associated with contraceptive use. Community-wide poverty lowered contraceptive use.

CONCLUSIONS

Quality of care at the community level has strong effects on contraceptive use, independent of the characteristics of individual households or women. These findings suggest that powerful gains in contraceptive use may be realized by improving the quality of antenatal care in Pakistan. Community health workers should focus on generating discussion of birth spacing in the community. Outreach efforts should target communities where the demand for contraception appears to be depressed due to high levels of poverty.

Married Women's Justification of Intimate Partner Violence in Bangladesh: Examining Community Norm and Individual-Level Risk Factors

One-third of the women worldwide experience intimate partner violence (IPV) that increases their vulnerability to both short- and long-term physical, sexual, reproductive, and mental health problems. Surprisingly, IPV is justified by many women globally. Although the IPV literature to date is mostly focused on risk factors associated with actual occurrences, little is known on attitudinal acceptance of such violence. Also, despite the growing scholarship of community influence and health link, IPV research has relatively overlooked the effects of norms at the community level. Using a representative national sample of 13,611 married women in Bangladesh, this study examined the association of community attitudes and women's individual attitudes toward wife beating. The results revealed that women living in communities with permissive attitudes toward wife beating were more likely to justify husbands' beating (OR=4.5). Women married at a younger age, who had less than primary-level education, lived in households categorized as poor or middle class, and did not consume media appeared to be at higher risk for justifying wife beating. This research adds to a growing research body on community influences on health by examining IPV attitudes and community norms link.

State variations in women's socioeconomic status and use of modern contraceptives in Nigeria

BACKGROUND

According to the 2014 World Population Data Sheet, Nigeria has one of the highest fertility and lowest contraceptive prevalence rates around the world. However, research suggests that national contraceptive prevalence rate overshadows enormous spatial variations in reproductive behavior in the country.

OBJECTIVE

I examined the variations in women's socioeconomic status and modern contraceptive use across states in Nigeria.

METHODS

Using the 2013 Nigeria Demographic and Health Survey data (n = 18,910), I estimated the odds of modern contraceptive use among sexually active married and cohabiting women in a series of multilevel logistic regression models.

RESULTS

The share of sexually active, married and cohabiting women using modern contraceptives widely varied, from less than one percent in Kano, Yobe, and Jigawa states, to 40 percent in Osun state. Most of the states with low contraceptive prevalence rates also ranked low on women's socioeconomic attributes. Results of multilevel logistic regression analyses showed that women residing in states with greater shares of women with secondary or higher education, higher female labor force participation rates, and more women with health care decision-making power, had significantly higher odds of using modern contraceptives. Differences in women's participation in health care decisions across states remained significantly associated with modern contraceptive use, net of individual-level socioeconomic status and other covariates of modern contraceptive use.

CONCLUSION

Understanding of state variations in contraceptive use is crucial to the design and implementation of family planning programs. The findings reinforce the need for state-specific family planning programs in Nigeria.

Social network- and community-level influences on contraceptive use: evidence from rural Poland

The diffusion of 'modern' contraceptives-as a proxy for the spread of low-fertility norms-has long interested researchers wishing to understand global fertility decline. A fundamental question is how local cultural norms and other people's behaviour influence the probability of contraceptive use, independent of women's socioeconomic and life-history characteristics. However, few studies have combined data at individual, social network and community levels to simultaneously capture multiple levels of influence. Fewer still have tested if the same predictors matter for different contraceptive types. Here, we use new data from 22 high-fertility communities in Poland to compare predictors of the use of (i) any contraceptives-a proxy for the decision to control fertility-with those of (ii) 'artificial' contraceptives-a subset of more culturally taboo methods. We find that the contraceptive behaviour of friends and family is more influential than are women's own characteristics and that community level characteristics additionally influence contraceptive use. Highly educated neighbours accelerate women's contraceptive use overall, but not their artificial method use. Highly religious neighbours slow women's artificial method use, but not their contraceptive use overall. Our results highlight different dimensions of sociocultural influence on contraceptive diffusion and suggest that these may be more influential than are individual characteristics. A comparative multilevel framework is needed to understand these dynamics.

Motivations and Constraints to Family Planning: A Qualitative Study in Rwanda's Southern Kayonza District

Community members and health workers recognized the value of spacing and limiting births but a variety of traditional and gender norms constrain their use of contraception. Limited method choice, persistent side effects, transportation fees, stock-outs, long wait times, and hidden service costs also inhibit contraceptive use.

Background:

While Rwanda has achieved impressive gains in contraceptive coverage, unmet need for family planning is high, and barriers to accessing quality reproductive health services remain. Few studies in Rwanda have qualitatively investigated factors that contribute to family planning use, barriers to care, and quality of services from the community perspective.

Methods:

We undertook a qualitative study of community perceptions of reproductive health and family planning in Rwanda’s southern Kayonza district, which has the country’s highest total fertility rate. From October 2011 to December 2012, we conducted interviews with randomly selected male and female community members (n = 96), community health workers (n = 48), and health facility nurses (n = 15), representing all 8 health centers’ catchment areas in the overall catchment area of the district’s Rwinkwavu Hospital. We then carried out a directed content analysis to identify key themes and triangulate findings across methods and informant groups.

Results:

Key themes emerged across interviews surrounding: (1) fertility beliefs: participants recognized the benefits of family planning but often desired larger families for cultural and historical reasons; (2) social pressures and gender roles: young and unmarried women faced significant stigma and husbands exerted decision-making power, but many husbands did not have a good understanding of family planning because they perceived it as a woman’s matter; (3) barriers to accessing high-quality services: out-of-pocket costs, stock-outs, limited method choice, and long waiting times but short consultations at facilities were common complaints; (4) side effects: poor management and rumors and fears of side effects affected contraceptive use. These themes recurred throughout many participant narratives and influenced reproductive health decision making, including enrollment and retention in family planning programs.

Conclusions:

As Rwanda continues to refine its family planning policies and programs, it will be critical to address community perceptions around fertility and desired family size, health worker shortages, and stock-outs, as well as to engage men and boys, improve training and mentorship of health workers to provide quality services, and clarify and enforce national policies about payment for services at the local level.

Barriers to modern contraceptive methods uptake among young women in Kenya: a qualitative study

Background

Young women in Kenya experience a higher risk of mistimed and unwanted pregnancy compared to older women. However, contraceptive use among youth remains low. Known barriers to uptake include side effects, access to commodities and partner approval.

Methods

To inform a youth focussed behaviour change communication campaign, Population Services Kenya developed a qualitative study to better understand these barriers among young women. The study was carried out in Nyanza, Coast, and Central regions. Within these regions, urban or peri-urban districts were purposively selected based on having contraceptive prevalence rate close to the regional average and having a population with low socioeconomic profiles. In depth interviews were conducted with a sample of sexually active women aged 15–24, both users and non-users, that were drawn from randomly selected households.

Results

All the respondents in the study were familiar with modern methods of contraception and most could describe their general mechanisms of action. Condoms were not considered as contraception by many users. Contraception was also associated with promiscuity and straying. Fear of side effects and adverse reactions were a major barrier to use. The biggest fear was that a particular method would cause infertility. Many fears were based on myths and misconceptions. Young women learn about both true side effects and myths from their social networks.

Conclusion

Findings from this research confirm that awareness and knowledge of contraception do not necessarily translate to use. The main barriers to modern contraceptive uptake among young women are myths and misconceptions. The findings stress the influence of social network approval on the use of family planning, beyond the individual’s beliefs. In such settings, family planning programming should engage with the wider community through mass and peer campaign strategies. As an outcome from this study, Population Services Kenya developed a mass media campaign to address key myths and misconceptions among youth.

Social networks and female reproductive choices in the developing world: a systematized review

Continuing high global maternal mortality and morbidity rates in developing countries have resulted in an increasing push to improve reproductive health services for women. Seeking innovative ways for assessing how positive health knowledge and behaviors spread to this vulnerable population has increased the use of social network theories and analysis in health promotion research. Despite the increased research on social networks and health, no overarching review on social networks and maternal health literature in developing countries has been conducted. This paper attempts to synthesize this literature by identifying both published and unpublished studies in major databases on social networks and maternal and child health. This review examined a range of study types for inclusion, including experimental and non-experimental study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, cohort studies, case control studies, longitudinal studies, and cross-sectional observational studies. Only those that occurred in developing countries were included in the review. Eighteen eligible articles were identified; these were published between 1997 and 2012. The findings indicated that the most common social network mechanisms studied within the literature were social learning and social influence. The main outcomes studied were contraceptive use and fertility decisions. Findings suggest the need for continuing research on social networks and maternal health, particularly through the examination of the range of social mechanisms through which networks may influence health behaviors and knowledge, and the analysis of a larger variety of reproductive outcomes.

Community influences on contraceptive use in Mozambique

Fertility in sub-Saharan Africa remains the highest in the world. Yet, the average contraceptive prevalence in Africa is the lowest in major world regions and there is limited understanding of the mechanisms through which community context shapes contraceptive use in the region. Using data from the 2011 Mozambique Demographic and Health Survey, we examine the mechanisms through which community context influences women's use of modern methods of contraception in Mozambique. We find that community context influences the use of modern methods of contraception by shaping the environment in which women live.

The social context of adolescent women's use of modern contraceptives in Zimbabwe: a multilevel analysis

BACKGROUND

Efforts aimed at reducing maternal mortality as per the Millennium Development Goal 5 (MDG 5) include reducing early childbearing through increased adolescent contraceptive use. Despite a substantial attempt to study factors influencing adolescent contraceptive use in Sub-Saharan Africa (SSA), few studies have explored the role of community level characteristics on adolescent modern contraceptive use. This study examines the influence of both individual, household and community variables in influencing adolescent contraceptive use in Zimbabwe. This study posits that community characteristics are more critical predictors of adolescent contraceptive use in Zimbabwe than other individual and household characteristics.

METHODS

Data from the 2010/11 Zimbabwe Demographic Health Survey (ZDHS), supplemented by additional data from the Measure DHS consultants were used. A total weighted sample of 457 non-pregnant adolescent women aged 15 to 19 years who had their last sex within 12 months preceding the 2010/11 ZDHS was analysed. Univariate, bivariate and multilevel binary logistic regression analysis were performed using generalized linear mixed models (GLMM).

RESULTS

The odds of contraceptive use were higher for adolescent women with one or more children ever born (Odds Ratio (OR), 13.6) and for those ever married (OR, 2.5). Having medium and high access to media also increased the odds of using contraceptives (OR, 1.8; 2.1 respectively). At community level, the odds of modern contraceptive use decreased with an increase in the mean number of children ever borne per woman (OR, 0.071), an increase in the mean number of school years per women (OR, 0.4) and an increase in the proportion of women with at least secondary education (OR, 0.5). It however increased with an increase in the proportion of women experiencing at least one problem accessing health care (OR, 2.0). Individual and community level variables considered successfully explained the variation of adolescent contraceptive use across provinces.

CONCLUSIONS

Both individual and community characteristics were important predictors of adolescent contraceptive use in Zimbabwe. Reproductive program interventions aimed at increasing adolescent contraceptive use should take into account both individual and community factors. There is need for further research that examines other community characteristics influences that include political and cultural factors.

Partner approval and intention to use contraception among Zanzibari women presenting for post-abortion care

OBJECTIVE

We examined the effect of partner approval of contraception on intention to use contraception among women obtaining post-abortion care in Zanzibar.

STUDY DESIGN

Our data source was a 2010 survey of 193 women obtaining post-abortion care at a large public hospital in Zanzibar. We used multivariable logistic regression analysis to assess associations between partner approval and intention to use contraception.

RESULTS

Overall, 23% of participants had used a contraceptive method in the past, and 66% reported intending to use contraception in the future. We found that partner approval of contraception and ever having used contraception in the past were each associated with intending to use contraception in the future. In the multivariable model, adjusting for past contraception use, partner approval of contraception was associated with 20 times the odds of intending to use contraception (odds ratio, 20.25; 95% confidence interval, 8.45-48.56).

CONCLUSIONS

We found a strong association between partner approval and intention to use contraception. Efforts to support contraceptive use must include both male and female partners.

IMPLICATIONS

Public health and educational efforts to increase contraceptive use must include men and be targeted to both male and female partners. Given that male partners are often not present when women obtain health care, creative efforts will be required to meet men in community settings.

Determinants of family planning use among Turkish married men who live in South East Turkey

This study assesses the determinants of family planning methods use by Turkish married men in South East Anatolia. A descriptive and cross-sectional survey research design was used among 1,352 men aged 20 to 52 years who lived in South East Turkey. A pilot-tested questionnaire was used to collect data. Descriptive statistics, chi-square, and multivariate regression analysis were used. The rate of nonusage of contraceptive methods among the participants was 60.4%. Within the nonusers, 34.9% reported a religious prohibition and 9.4% had misconceptions about family planning. Chi-square analysis determined four factors that were significantly related to the men's usage of contraception. These factors are the following: the men's age, educational level, number of existing children, and their perception of their household income level. These four factors were also subjected to multivariate regression analysis, the results of which were used to compute odds ratios for each value of each factor indicating the likelihood for using contraception by men within each group. Male-specific family planning programs can make an important contribution to the overall efforts to improve the usage of contraceptives by men. It is important to note that family planning services and education programs related to family planning should be appropriate for men.