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Table 2 Major contextual factors and context-actor-mechanism-outcome configurations

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

Context CAMO Acceptability construct
Strong belief in religious values CAMO 1: Strong belief in religious values (C) such that the community (A) consider FP to be out of line with religious principles or forbidden (M) and do not accept FP (O) Ethicality
 Respondent (R): ‘They say that if you die and the implant is still within you then it is against the Muslim religion, as you are not supposed to be buried with any foreign object inside you. They also say preventing a baby is forbidden’. Ethiopia Nurse_23
 R: ‘Am a Catholic by faith so before when….I was growing as a child I was told and heard about family planning as a bad thing’. Kenya Religious leader_10
Traditional desire for large family and belief that FP aims to limit family size CAMO 2: Traditional desire for large family and belief that FP aims to limit family size (C) such that the community (A) rejects FP as being against their traditional values (M) and FP is not accepted by the community (O) Ethicality
 R: ‘Within the community, family planning is stigmatised in the way it was introduced before. They say family planning is to have few number of children which the people don’t want that. You are trying to control the number because our people say people is wealth. You have big wealth when you have more people…’ Kenya Health administrator19
 R: ‘And then also polygamy, when a man has many women, they compete to have children, you know to own a man. They think that you win a man by overproducing’. Uganda Midwife_7
MCM use is stigmatised CAMO 3: Stigmatisation of MCM use and belief that it is linked to prostitution (C) lead men (A) to fear their wives will be seen as prostitutes (M) and to their non-acceptance of MCM use (O) Unintended consequences
 R: ‘It is bad in the context of certain women getting the family planning method, making use of the protection that the planning gives them, to take up prostitution. That is where we as men start being reluctant’. Benin Men’s FGD_15
 R: ‘The women do not want the men to know that they have done the family planning because the men think that a woman who has agreed to family planning is more likely to become a prostitute. Therefore, for men, a woman who is using family planning can prostitute herself and cannot be controlled’. Benin Midwife_5
Male partners are non-accepting of FP or MCM use CAMO 4: Male partners are non-accepting of FP or MCM use (C) and women (A) feel that they cannot use MCMs or that they have to hide their MCMs (M) so women do not openly accept MCMs (O) Self-efficacy
 R: ‘Most people say…. men do not allow their wives to go for family planning. Some even hide their health passports so that their husbands should not know that they are on family planning. Some wait for their husbands to go to work so that they should go to the clinic and access family planning’. Malawi Woman FP user_14
 R: ‘Most of them use the injectable one because of the husbands. For example if they use implants that means husband will discover – then problem. If they take pill then the same, husbands will discover – problems...’. Malawi Nurse/FP trainer_22
Experience or rumours of side effects of MCMs CAMO 5: Women have experience with or hear rumours of side effects of MCMs (C) such that women (A) are afraid of side effects (M) and do not accept MCMs (O) Unintended consequences
 R: ‘some of the challenges we get in the village are that when one person using family planning develop side effects and maybe that person was sick and so many others will see family planning as bad’. Kenya CHV FGD_15
 R: ‘The women in the village refuse because they say family planning blocks stomachs and it makes you barren hence you can’t produce again. That family planning removes feelings for sleeping with your husband. That a woman who practices family planning will become a prostitute’. Uganda Women’s empowerment group member_18