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

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.

Keywords: Context-acceptability theory; Family planning; Realist evaluation.

Fig. 1

Analytical framework

Fig. 2

Context-acceptability cascade. Using the example of religious leaders in Kenya: in an initial prevailing context of strong religious beliefs and powerful religious leaders (C₁), examination of religious text for alignment with FP (I₁) with religious leaders (A₁) triggers recognition that FP aligns with religious values (M₁), leading to acceptance of FP (O₁). The recognition that FP aligns with religious values is a new context (C₂) which may itself or with advocacy activities of religious leaders (I₂) trigger recognition of alignment of religious text and FP (M₁) in men (A₂) leading to acceptance of FP (O₁). Similarly, the acceptance of FP by religious leaders leads to a new context (C₃) with initiation of a similar process as that initiated by (C₂). Generally, project/programme conditions represent a number of differing prevailing contexts (Cxn), which in the presence or absence of an intervention/s (Ixn) trigger mechanisms (Mxn) in different actors (Ax) and lead to a number of potential outcomes (Oxn). Using empirical data to elucidate and describe these context-acceptability cascades enables deeper understanding of the fluidity of the interplay between context, interventions, mechanisms, and outcomes

Fig. 3

Adapted TFA constructs. Source: Sekhon et al. [17]; adaptation = shaded constructs