Community attitudes and gendered influences on decision making around contraceptive implant use in rural Papua New Guinea

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Study Justification:
– Despite efforts to improve contraceptive implant acceptability and uptake in rural Papua New Guinea (PNG), usage remains limited.
– Previous literature suggests that community attitudes and decision-making processes may negatively impact implant uptake.
– This study aims to explore community attitudes towards the contraceptive implant and the pathways to decision making around its use in a rural community on Karkar Island, PNG.
Highlights:
– Men in the community are supportive of their wives using family planning, but there is a lack of familiarity with the contraceptive implant, leading to low uptake.
– Men play a strong role in the decision-making process around method use, despite perceiving family planning as “women’s business.”
– Younger men are more receptive to biomedical information and more likely to want to use implants, while older men prefer guidance from prominent community members.
– Engaging with groups reluctant to connect with health information and those influential in the decision-making process will have the greatest impact on increasing implant acceptability and uptake.
Recommendations:
– Target future healthcare interventions by understanding the relational dynamics affecting the decision-making unit in communities where gendered roles and social perceptions strongly influence the decision to use the contraceptive implant.
– Engage with groups who are hesitant to access health information and those who have significant influence in the decision-making process.
Key Role Players:
– Community leaders
– Religious leaders (Catholic and non-Catholic)
– Health workers (nurses, midwives, doctors, community health workers)
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare workers
– Community engagement and awareness campaigns
– Development and dissemination of educational materials
– Support for community leaders and religious leaders in promoting contraceptive implant use
– Monitoring and evaluation of interventions
Please note that the cost items provided are general suggestions and may vary depending on the specific context and resources available.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides a detailed description of the study design, methods, and findings. However, it does not provide specific statistical data or quantitative measures of the community attitudes and gendered influences on decision making around contraceptive implant use. To improve the evidence, the authors could consider including quantitative data on the prevalence of low uptake of contraceptive implants, the percentage of men and women supportive of family planning, and the differences in attitudes and decision-making processes between age groups. Additionally, providing specific examples or quotes from the focus group discussions and in-depth interviews would further strengthen the evidence.

Background: Despite targeted interventions to improve contraceptive implant acceptability and uptake in rural Papua New Guinea (PNG), ongoing use of this method remains limited. Previous literature has suggested community attitudes and intrinsic factors within the decision-making process may be negatively impacting on implant uptake, however these elements have not previously been studied in detail in this context. We set out to explore community attitudes towards the contraceptive implant and the pathways to decision making around implant use in a rural community on Karkar Island, PNG. Methods: We conducted 10 focus-group (FGD) and 23 in-depth interviews (IDI) using semi-structured topic guides. Key sampling characteristics included age, exposure or non-exposure to implants, marital status, education and willingness to participate in discussion. Four FGDs were held with women, four with men and two with mixed gender. IDIs were carried out with five women (current implant users, former implant users, implant never users), five men, five religious leaders (Catholic and non-Catholic), four village leaders and four health workers. Two in-depth interviews (four participants) were analysed as dyads and the remaining participant responses were analysed individually. Results: Men were supportive of their wives using family planning but there was a community-wide lack of familiarity about the contraceptive implant which influenced its low uptake. Men perceived family planning to be ‘women’s business’ but remained strongly influential in the decision making processes around method use. Young men were more receptive to biomedical information than older men and had a greater tendency towards wanting to use implants. Older men preferred to be guided by prominent community members for decisions concerning implants whilst young men were more likely to engage with health services directly. Conclusions: In communities where a couple’s decision to use the contraceptive implant is strongly coloured by gendered roles and social perceptions, having a detailed understanding of the relational dynamics affecting the decision-making unit is useful in targeting future healthcare interventions. Engaging groups who are reluctant to connect with health information, as well as those who are most influential in the decision making process, will have the greatest impact on increasing implant acceptability and uptake.

Karkar Island is a rural community off the coast of Madang town, Madang Province on the north coast of PNG, and is a two hour boat ride from the mainland. In 2016 the population was estimated at 60,000 with 31,200 females (52%), of whom 51% were in the reproductive age range of 15—49 years [11, 23]. Less than one in three (29%) of women of reproductive aged were using modern contraceptives in 2016 [11, 12]. Amongst those using a modern method, 40% were using implants, 31% were using injectables, 31% were using the oral contraceptive pill and the remainder were using condoms, had had a tubal ligation or their husband had had a vasectomy [11, 12].. Implant uptake amongst women on the island since 2016 has been minimal [23]. There are 52 villages on the island of which 41 (79%) are along the island’s 84 km coastline [11, 23]. Villages are connected by a continuous road which is subject to flooding. The island is serviced by one district hospital, two major health centres and 23 peripheral aid posts which are all accessible by road. The hospital and health centres are continuously staffed by nurses, midwives, doctors and community health workers whilst staffing at aid posts is inconstant. Family planning counselling and services should theoretically be available from all sites [23]. The socio-demographic make-up of Karkar Island is similar to other rural communities throughout Papua New Guinea because there is a high proportion of reproductive aged women, an increasing number of adolescents, a strong religious presence in the community, the majority of families rely on subsistence income and population literacy rates are low [11, 16]. However the unique geography of the island means that women have greater access by road to the major health facilities; because of this engagement with antenatal services and the number of supervised birth rates on Karkar is between 15—30% higher than the rural national average [11]. The population of Karkar Island is also relatively isolated from the mainland which minimizes the effect of shifting populations on the location’s health profile. Each village on Karkar Island is headed by one or two leaders, a church representative and four to five family elders, all of who are typically men [11, 23]. Social ranking is determined by age, gender and land asset with village heads responsible for maintaining order within and between villages, including resolving family and marital disputes where necessary [11, 12]. There is little in the way of formal employment on Karkar Island with almost all men and women reliant on subsistence agriculture or informal markets for their livelihoods [11, 12]. The data used in this paper was drawn from a sub-set of a larger mixed methods study on the impacts of contraceptive implants on maternal and neonatal health [16, 23]. As part of the qualitative study, focus group discussions (FGD) and in-depth interviews (IDI) with community members and healthcare workers were used. The purpose of the qualitative sub-study was to explore community attitudes towards the contraceptive implant and the pathways to decision making around the use of the implant. Twelve coastal and four inland villages were randomly selected for sampling using a computer-generated ballot. The research team liaised with the leaders in each village and together they invited participants to partake in FGDs. Snowball sampling was then used to invite men and women to partake in IDIs (Table 1). Key sampling characteristics for participants included age, exposure or non-exposure to implants, marital status, education and willingness to participate in discussion. We classified young people as those persons under 25 years of age according to the World Health Organisation definition [24]. We used a dyadic approach with the two couples who agreed to be interviewed separately and were aware that their accounts would be analysed alongside their partner’s to directly compare the two perspectives within the same couple unit. Interviews for members of each couple unit were unable to be carried out simultaneously but were carried out successively without opportunity for them to convene and discuss with one another [25]. Focus-group discussion and in-depth interview participant groupings A semi-structured topic guide was used to guide the FGDs and explored the following areas: role of family; family planning knowledge; family planning perceptions; experience with the implant; decision making around implant use; and potential enablers and barriers towards implant use. Prior to conducting the FGDs the topic guide was informed by formative work with the research team to ensure its contextual suitability. The development of the topic guides for IDIs was informed by iterative interim analysis of FGD data. IDIs explored the decision-making processes around implant use and non-use in detail including: why implants are used or not, who plays a role in the decision making process, who provides advice to women, who provides advice to men, what actual experience of implant use has been, why women stop or discontinue implant use and what personal and community attitudes are towards unintended and teenage pregnancy. All FGDs and IDIs were audio-recorded with participant consent and later transcribed and translated from Tok Pisin to English by independent researchers. IDIs lasted an average of 55 min. Not conversant in Tok Pisin, the lead author recruited a Papua New Guinean researcher trained in qualitative research to conduct the IDIs and FGDs. The Papua New Guinean researcher was provided training by the lead author on the research tool and the aim of the study. The lead author met with all participants and thanked them for their involvement but was only present in the FGDs and only participated in and ad-hoc manner in IDIs as the lead interviewer shared information in English. A male health care worker known to the community supported the lead interviewer to ensure men were comfortable being interviewed by a Papua New Guinean woman. Written transcripts were analysed using thematic analysis following the models described by Neuman and Silverman [26, 27] whereby transcripts were read and re-read in a process of familiarisation. They were then open-coded using techniques outlined by Strauss and Corbin [28]. A coding framework was then developed and applied to the data. Analytical memos drawing on coded material supported the process of charting to cluster coded data into groups and categories to develop the main themes which described and characterised the primary findings from the transcripts. We used methods of triangulation to compare findings from within the same couple unit, across gender and age within the interview and FGD data and then cross-validated these findings with community leaders to enhance the richness of the data and to be able to account for variation in perspectives [29, 30].

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Based on the provided description, here are some potential innovations that could improve access to maternal health in rural Papua New Guinea:

1. Community education and awareness programs: Implementing targeted educational programs to increase community knowledge and awareness about contraceptive implants and their benefits. This could involve conducting workshops, community meetings, and distributing informational materials in local languages.

2. Male involvement in family planning: Recognizing the influence of men in the decision-making process around contraceptive use, it is important to engage and educate men about family planning methods, including contraceptive implants. This could be done through men’s health forums, outreach programs, and involving male community leaders in promoting family planning.

3. Training healthcare workers: Providing comprehensive training to healthcare workers, including nurses, midwives, and doctors, on contraceptive methods, including implants. This would ensure that healthcare providers have the necessary knowledge and skills to counsel women and provide accurate information about contraceptive options.

4. Strengthening healthcare infrastructure: Improving the availability and accessibility of family planning services by ensuring that health facilities, including district hospitals, health centers, and peripheral aid posts, are adequately staffed and equipped to provide contraceptive services, including implant insertion and removal.

5. Addressing cultural and social barriers: Recognizing and addressing cultural and social factors that may influence contraceptive decision-making, such as gender roles and community attitudes. This could involve working with community leaders, religious leaders, and influential individuals to promote positive attitudes towards family planning and contraceptive use.

6. Mobile health (mHealth) interventions: Utilizing mobile technology, such as text messaging and mobile applications, to provide information and reminders about contraceptive methods, including implants. This could help overcome barriers related to distance and limited access to healthcare facilities.

7. Community-based distribution programs: Implementing community-based distribution programs where trained community health workers or volunteers can provide contraceptive services, including implant insertion and removal, within the community. This would increase access to services, particularly in remote areas.

These innovations, if implemented effectively, could help improve access to maternal health and increase the acceptability and uptake of contraceptive implants in rural Papua New Guinea.
AI Innovations Description
The recommendation to improve access to maternal health based on the study is to target future healthcare interventions by having a detailed understanding of the relational dynamics affecting the decision-making unit in communities where a couple’s decision to use the contraceptive implant is strongly influenced by gendered roles and social perceptions. This includes engaging with groups who are reluctant to connect with health information, as well as those who are most influential in the decision-making process. By addressing community attitudes and intrinsic factors within the decision-making process, interventions can be tailored to increase acceptability and uptake of the contraceptive implant, ultimately improving access to maternal health services.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health in rural Papua New Guinea:

1. Increase awareness and education: Develop targeted campaigns and programs to raise awareness about maternal health, including the benefits and availability of contraceptive implants. This can be done through community engagement, workshops, and educational materials.

2. Engage community leaders: Work closely with village leaders, religious leaders, and other influential community members to promote the importance of maternal health and contraceptive use. Their support and endorsement can help change community attitudes and encourage acceptance of contraceptive methods.

3. Improve access to healthcare services: Strengthen the healthcare infrastructure on Karkar Island by ensuring consistent staffing at aid posts and providing training for healthcare workers on family planning counseling and services. This will ensure that women have access to accurate information and quality care.

4. Address gendered influences: Recognize and address the gendered influences on decision-making around contraceptive use. Engage men in discussions about family planning and challenge the perception that it is solely a women’s responsibility. Promote gender equality and encourage men to be supportive partners in maternal health.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline data collection: Gather information on the current state of maternal health, contraceptive use, and community attitudes through surveys, interviews, and focus groups.

2. Define indicators: Identify specific indicators that will measure the impact of the recommendations, such as contraceptive uptake rates, knowledge levels, and attitudes towards family planning.

3. Implement interventions: Roll out the recommended interventions, such as awareness campaigns, community engagement programs, and healthcare improvements.

4. Monitor and evaluate: Continuously collect data on the selected indicators to assess the progress and effectiveness of the interventions. This can be done through surveys, interviews, and monitoring of healthcare service utilization.

5. Analyze and interpret data: Analyze the collected data to determine the impact of the interventions on improving access to maternal health. Compare the baseline data with the post-intervention data to identify any changes or improvements.

6. Adjust and refine interventions: Based on the findings from the data analysis, make adjustments and refinements to the interventions as needed. This could involve scaling up successful strategies or addressing any challenges or gaps identified.

7. Repeat evaluation: Continuously monitor and evaluate the impact of the interventions over time to ensure sustained improvements in access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health in rural Papua New Guinea and make informed decisions on future healthcare interventions.

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