Decision-making pathways for contraceptive use among refugee and host populations in Adjumani district, Uganda. 

Abstract Introduction Contraceptive use is known to have a positive impact on maternal and child health outcomes, but it is still low especially in low-income countries. Contraceptive use is even lower among people in humanitarian situations. This study explored the decision-making processes towards use or non-use of contraceptives by people in humanitarian situations to inform program design for uptake. Methods A qualitative exploratory study was conducted among women of reproductive age (15-49 years) living in any of the three refugee settlements of Pagirinya, Nyumanzi, and Mirieyi and the surrounding host communities in Adjumani district, Uganda. Data were collected using 49 in-depth interviews (IDIs), 11 Key Informant Interviews (KIIs,) and 20 Focus Group Discussions (FGDs). Inductive thematic analysis was done with the aid of Atlas ti. Version 14. Results This study found that the decision-making processes entailed linear and nonlinear internalized cognitive and contextual processes involving four dynamic pathways. While following the linear pathway, participants reported starting with 1) idea inception, then followed through to 2) cognitive processing, 3) consultation, and 4) decision-making to either use or not use contraception. Complex linear pathway happened when participants did not go through consultation but straight to decision making. However, participants who followed non-linear pathway continuously went back to cognitive processing. Some women after consultation, or those already using and those not using contraceptives, decided to go back to cognitive processing to reconsider their current positions. This study found that some women who started off not using contraceptives ended up using, while some who started off using contraception ended up dropping out. There were also events that defied established pathway where women were forced to get off contraception by their spouses. Conclusions This study showed dynamic decision-making processes involving both internal and external environments as triggers to decision-making for contraceptive use. Interventions to increase contraceptive use should target both users and significant others who influence the decision for use particularly among refugees.