Abstract
BackgroundFamily planning (FP) can lengthen birth intervals and potentially reduce the risk of foetal death, low birthweight, prematurity, and being small for gestational age. Effective FP is most easily achieved through access to and acceptability of modern contraceptive methods (MCMs). This study aimed to identify mechanisms of acceptability and the contexts in which they are triggered and to generate theories to improve the selection and implementation of effective interventions by studying an intervention integrating FP with childhood immunisation services.MethodsQualitative interpretative synthesis of findings from realist evaluations of FP interventions in five African countries was guided by an analytical framework. Empirical mechanisms of acceptability were identified from semi-structured interviews and focus group discussions with key stakeholders (N = 253). The context in which these mechanisms were triggered was also defined. Empirical mechanisms of acceptability were matched to constructs of a theoretical framework of acceptability. Context-acceptability theories (CATs) were developed, which summarised constructs of acceptability triggered for specific actors in specified contexts. Examples of interventions that may be used to trigger acceptability for these actors were described.ResultsSeven CATs were developed for contexts with strong beliefs in religious values and with powerful religious leaders, a traditional desire for large families, stigmatisation of MCM use, male partners who are non-accepting of FP, and rumours or experiences of MCM side effects. Acceptability mechanisms included alignment with values and beliefs without requiring compromise, actors’ certainty about their ability to avoid harm and make the intervention work, and understanding the intervention and how it works. Additionally, acceptability by one group of actors was found to alter the context, triggering acceptability mechanisms amongst others.ConclusionsThis study demonstrated the value of embedding realist approaches within implementation research. CATs are transferable theories that answer the question: given the context, what construct of acceptability does an intervention need to trigger, or more simply, what intervention do we need to apply here to achieve our outcomes? CATs facilitate transfer of interventions across geographies within defined contexts.
Highlights
Planning (FP) can lengthen birth intervals and potentially reduce the risk of foetal death, low birthweight, prematurity, and being small for gestational age
Acceptability is key to the successful implementation of interventions, and interventions work in some contexts but not in others
We demonstrate how different contexts trigger mechanisms of acceptability, and we explain the influence of actors and interventions on this relationship
Summary
Planning (FP) can lengthen birth intervals and potentially reduce the risk of foetal death, low birthweight, prematurity, and being small for gestational age. A child born to a woman less than 18 months after the birth of her previous child has an increased risk of foetal death, low birthweight, prematurity, and being small for gestational age [1, 2]. Planning (FP) studies have explored the acceptability of specific MCMs such as intrauterine devices (IUDs) [5], female condom [6], male condom shape [7], self-injections [8], and contraceptive vaginal rings [9, 10] as well as behaviour change methods to increase FP uptake including mobile FP decision aids [11] and mobile phone behavioural interventions [12]. Acceptability is rarely defined in these studies despite commonly being implied through the measurement of quantitative outcomes or through the interrogation of qualitative themes
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