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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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