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      Context-acceptability theories: example of family planning interventions in five African countries

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          Abstract

          Background

          Family 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.

          Methods

          Qualitative 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.

          Results

          Seven 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.

          Conclusions

          This 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.

          Supplementary Information

          The online version contains supplementary material available at 10.1186/s13012-020-01074-z.

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          Most cited references43

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          Standards for reporting qualitative research: a synthesis of recommendations.

          Standards for reporting exist for many types of quantitative research, but currently none exist for the broad spectrum of qualitative research. The purpose of the present study was to formulate and define standards for reporting qualitative research while preserving the requisite flexibility to accommodate various paradigms, approaches, and methods.
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            Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework

            Background It is increasingly acknowledged that ‘acceptability’ should be considered when designing, evaluating and implementing healthcare interventions. However, the published literature offers little guidance on how to define or assess acceptability. The purpose of this study was to develop a multi-construct theoretical framework of acceptability of healthcare interventions that can be applied to assess prospective (i.e. anticipated) and retrospective (i.e. experienced) acceptability from the perspective of intervention delivers and recipients. Methods Two methods were used to select the component constructs of acceptability. 1) An overview of reviews was conducted to identify systematic reviews that claim to define, theorise or measure acceptability of healthcare interventions. 2) Principles of inductive and deductive reasoning were applied to theorise the concept of acceptability and develop a theoretical framework. Steps included (1) defining acceptability; (2) describing its properties and scope and (3) identifying component constructs and empirical indicators. Results From the 43 reviews included in the overview, none explicitly theorised or defined acceptability. Measures used to assess acceptability focused on behaviour (e.g. dropout rates) (23 reviews), affect (i.e. feelings) (5 reviews), cognition (i.e. perceptions) (7 reviews) or a combination of these (8 reviews). From the methods described above we propose a definition: Acceptability is a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention. The theoretical framework of acceptability (TFA) consists of seven component constructs: affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy. Conclusion Despite frequent claims that healthcare interventions have assessed acceptability, it is evident that acceptability research could be more robust. The proposed definition of acceptability and the TFA can inform assessment tools and evaluations of the acceptability of new or existing interventions. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2031-8) contains supplementary material, which is available to authorized users.
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              Family planning: the unfinished agenda.

              Promotion of family planning in countries with high birth rates has the potential to reduce poverty and hunger and avert 32% of all maternal deaths and nearly 10% of childhood deaths. It would also contribute substantially to women's empowerment, achievement of universal primary schooling, and long-term environmental sustainability. In the past 40 years, family-planning programmes have played a major part in raising the prevalence of contraceptive practice from less than 10% to 60% and reducing fertility in developing countries from six to about three births per woman. However, in half the 75 larger low-income and lower-middle income countries (mainly in Africa), contraceptive practice remains low and fertility, population growth, and unmet need for family planning are high. The cross-cutting contribution to the achievement of the Millennium Development Goals makes greater investment in family planning in these countries compelling. Despite the size of this unfinished agenda, international funding and promotion of family planning has waned in the past decade. A revitalisation of the agenda is urgently needed. Historically, the USA has taken the lead but other governments or agencies are now needed as champions. Based on the sizeable experience of past decades, the key features of effective programmes are clearly established. Most governments of poor countries already have appropriate population and family-planning policies but are receiving too little international encouragement and funding to implement them with vigour. What is currently missing is political willingness to incorporate family planning into the development arena.
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                Author and article information

                Contributors
                Jayne.webster@lshtm.ac.uk
                Journal
                Implement Sci
                Implement Sci
                Implementation Science : IS
                BioMed Central (London )
                1748-5908
                12 January 2021
                12 January 2021
                2021
                : 16
                : 12
                Affiliations
                [1 ]GRID grid.8991.9, ISNI 0000 0004 0425 469X, Disease Control Department, , London School of Hygiene and Tropical Medicine, ; London, UK
                [2 ]GRID grid.477359.b, International Rescue Committee Ethiopia Programme, ; Addis Ababa, Ethiopia
                [3 ]GRID grid.420433.2, ISNI 0000 0000 8728 7745, International Rescue Committee US, ; New York, USA
                [4 ]Save the Children Malawi Country Office, Blantyre, Malawi
                [5 ]Save the Children US, Washington, DC USA
                [6 ]World Vision International, Nairobi, Kenya
                [7 ]World Vision US, Monrovia, CA USA
                [8 ]CARE Benin, Cotonou, Benin
                [9 ]GRID grid.423462.5, ISNI 0000 0001 2234 1613, CARE USA, ; Atlanta, USA
                Author information
                http://orcid.org/0000-0002-0498-8883
                Article
                1074
                10.1186/s13012-020-01074-z
                7805098
                33435959
                8db45091-e22a-4602-8807-9dd1bfdf4b2a
                © The Author(s) 2021

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 12 August 2020
                : 10 December 2020
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100008648, Pfizer Foundation;
                Categories
                Research
                Custom metadata
                © The Author(s) 2021

                Medicine
                context-acceptability theory,realist evaluation,family planning
                Medicine
                context-acceptability theory, realist evaluation, family planning

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