Postpartum Green Star family planning decision aid for pregnant adolescents in Tanzania: a qualitative feasibility study

Background: The use of a decision aid in clinical settings has been beneficial. It informs and educates patients about the available treatment options that can help them reduce decision-making conflicts related to feeling uninformed compared with routine care. There is a scarcity of published data about using a decision aid during family planning counseling with postpartum women focusing on long-acting reversible contraception in Tanzania. Therefore, we developed a “postpartum Green Star family planning decision aid” and assessed its feasibility. The study outcomes were practicality, usefulness, and acceptability perceived by pregnant adolescents and nurses/midwives. Methods: We used an exploratory qualitative in-depth interview involving six nurses/midwives with three or more years of experience in family planning services and 12 pregnant adolescents aged 15–19 years. Purposive sampling was used to select the participants, and selection relied on the saturation principle of data collection. We used a semi-structured interview guide translated into the Kiswahili language. Data were transcribed and analyzed following inductive content analysis. Results: The amount of information presented was just right, with the time of reading the data ranging from 20 min to 1 h. The study participants perceived the flow of information to be good, with small significant changes suggested. Kiswahili language was used and reported to be appropriate and well elaborated. However, a few words were told to be rephrased to reduce ambiguity. The nurses/midwives said that the decision aid included most of the vital information the participants wanted to know during their family planning counseling. Pregnant adolescents stated that the decision aid improved their knowledge and provided new details on the long-acting reversible contraception methods (intrauterine copper devices and implants) offered immediately after childbirth. The participants stated that the decision aid addressed long-acting reversible contraception methods’ benefits and side effects and dispelled myths and misconceptions. The study participants considered the decision aid helpful in complementing the family planning counseling offered and improving pregnant adolescents’ knowledge. Conclusion: The postpartum Green Star family planning decision aid was practical, useful, and acceptable in enhancing the objectivity of counseling about long-acting reversible contraception methods. It improved the knowledge of pregnant adolescents in Tanzania about the available contraception methods (i.e., the use of intrauterine copper devices and implants), which can be immediately used postpartum. Further research is needed to assess the effects of the decision aid on long-acting reversible contraception postpartum uptake among pregnant adolescents in Tanzania.

The study used an exploratory qualitative research design. In August 2020, we conducted 18 in-depth interviews that involved healthcare providers and pregnant adolescents from Amana District Hospital in Dar es Salaam. Although the decision aid was designed for pregnant adolescents, we included healthcare providers because we wanted to hear their opinions about the decision aid. We believe that the family planning counseling experiences of the healthcare providers would provide significant and well-informed comments to improve the contents of the decision aid and the intervention process. The study population consisted of six healthcare providers and 12 pregnant adolescents. The healthcare providers were nurses/midwives with three or more years of experience in family planning services. The pregnant adolescents were 15–19 years of age who could read and communicate in the Kiswahili language and consented to participate in the study. The study’s principal investigator and the person in charge of the maternity clinic were responsible for recruiting the study participants who were purposively selected to best answer the research questions. The interviews lasted for 40–50 min and were led by two moderators: one who asked the questions and another who assisted and recorded the interview and took notes. A semi-structured interview guide with five questions in the Kiswahili language was used to collect information from pregnant adolescents and healthcare providers. In the interview, participants were asked the following questions: “What do you think about the information presented in the decision aid?”, “How do you feel about the use of a decision aid for deciding postpartum family planning?”, “What do you think about the usefulness of the decision aid?”, “Will you recommend its use in the clinic?” and several follow-up questions. We obtained ethical approval from St. Luke’s International University, Muhimbili University of Health and Allied Sciences, and the National Institute of Medical Research. Permission to conduct the study was obtained from the regional medical officer and the medical officer-in-charge of Amana District Hospital. The interviews were conducted in a private room within the hospital to ensure convenient access and privacy. The principal investigator informed the participants about the study’s purpose, scope, and importance at the beginning of each discussion. The study participants were informed of their rights to participate and withdraw during the interview whenever they felt like it. Written informed consent was obtained from each participant for participating and recording the interview. The principal investigator requested the participants to feel free and be open when responding to questions and assured them that there was no right or wrong answer. The principal investigator and a research assistant conducted the interviews. Experience in conducting interviews, experience in using recorders, having knowledge, and experience in family planning were the criteria used for selecting the research assistant. A one-day training was conducted for the research assistant to comprehensively understand the purpose of the study, what questions to ask, how to ask, and probe and when to obtain written informed consent from the participants not to influence data collection. The P.I. uploaded the audio files into a secured computer with a passcode immediately after all interviews each day. The interviews were transcribed verbatim in the Kiswahili language, and the data was analyzed while in the Kiswahili language. We conducted thematic analysis following the steps outlined by Braun and Clarke [24]. An iterative inductive-deductive, the team-based coding approach was employed to code and analyze the data [25]. The P.I. and R.A. who conducted the in-depth interviews undertook the coding process and analysis. Individual codes were then organized into subcategories and categories. study participants’ quotes illustrated the key findings. Using a team-based approach, we developed the codebook [25] after re-reading all the transcripts (familiarization with data). The P.I. and R.A. had several meetings where codebooks and memos were presented, codes updated, and any existing disagreement was resolved. Next, the P.I. and R.A. generated themes that involved open-ended coding of several transcripts with no predetermined codes or categories. Coding was done directly onto the hard copies of the transcripts during multiple readings of the interviews. Independent from each other, the P.I. and R.A. coded interviews question by question and then shared and compared their coding findings to reconcile differences, if any. The P.I. and R.A. applied the codes from the codebook to all 18 transcripts. Codes were refined, reduced, and expanded during this period. Finally, the P.I. and R.A. generated categories and subcategories based on the findings of the initial coding. Codes were grouped under categories and subcategories. The author identified the gap, target population, and objectives to address the research problem. We mainly focused on previously published studies to determine the objectives to be addressed [21, 23, 26–28]. There are limited publications that described the use of decision aids in reducing decision-making conflicts on the utilization of long-acting reversible contraception methods. We then identified the individual needs of the participating pregnant adolescents by reviewing a previous study that looked at barriers to the utilization of family planning among female youths in Dar es Salaam, Tanzania [11]. The individual needs of the participants included inadequate knowledge, especially of long-acting reversible contraception methods. We found female teens to have several misbeliefs about the methods and how to participate in decision-making. Most female teens could not decide on their own without involving their sexual partners (Fig. 1). Flow diagram showing the process of developing the final postpartum Green Star family planning decision aid (version 1) The content, design, and arrangement of the “developed prototype decision aid were grounded in the Ottawa Patient Decision Aid Development eTraining [29], International Patient Decision Aid Standards Collaboration checklist [30], Theory of Planned Behavior [31], Health Belief Model [32], Social Cognitive Theory [33], current clinical guides for family planning counseling for providers [1, 34], and findings from previous studies on the benefits and side effects of the options, satisfaction and continuation rates, and fertility return [35–41]. The prototype decision aid has four components based on the Ottawa Patient Decision Aid development guide: (1) know how to make a decision with conviction; (2) understand the characteristics of the decision; (3) clarify what is important to you, and (4) make the decision (Figs. ​(Figs.2,2, ​,3,3, ​,4,4, ​,5).5). The author shared a prototype decision aid with three experts that involved a research supervisor and two midwives, all with several years of experience in maternal and child health and developing decision aids. The aim of sharing the prototype decision aid with these experts was to receive comments on the comprehensibility and usefulness of the prototype decision aid, which we incorporated to modify and improve the decision aid. The final decision aid version 1 was given to six healthcare providers and 12 pregnant adolescents to assess its practicality, usefulness, and acceptability (Fig. 1). Four steps involved in developing the decision aid based on the Ottawa Patient Decision Aids development Contents in steps 1 and 2 of the decision aid Contents in step 2 of the decision aid: understand the characteristics of the options Contents in steps 3 and 4 of the decision aid

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