Perfect- and typical-use effectiveness of the Dot fertility app over 13 cycles: results from a prospective contraceptive effectiveness trial.

OBJECTIVE: Dynamic Optimal Timing (Dot) is a smartphone application (app) that estimates the menstrual cycle fertile window based on the user's menstrual period start dates. Dot uses machine learning to adapt to cycles over time and informs users of 'low' and 'high' fertility days. We investigated Dot's effectiveness, calculating perfect- and typical-use failure rates. METHODS: This prospective, 13 cycle observational study (ClinicalTrials.gov NCT02833922) followed 718 women who were using Dot to prevent pregnancy. Participants contributed 6616 cycles between February 2017 and October 2018, providing data on menstrual period start dates, daily sexual activity and prospective intent to prevent pregnancy. We determined pregnancy through participant-administered urine pregnancy tests and/or written or verbal confirmation. We calculated perfect- and typical-use failure rates using multi-censoring, single-decrement life-table analysis, and conducted sensitivity, attrition and survival analyses. RESULTS: The perfect-use failure rate was calculated to be 1.0% (95% confidence interval [CI]: 0.9%, 2.9%) and the typical-use failure rate was 5.0% (95% CI: 3.4%, 6.6%) for women aged 18-39 (n = 718). Survival analyses identified no significant differences among age or racial/ethnic groups or women in different types of relationships. Attrition analyses revealed no significant sociodemographic differences, except in age, between women completing 13 cycles and those exiting the study earlier. CONCLUSION: Dot's effectiveness is within the range of other user-initiated contraceptive methods.

Understanding your body matters: Effects of an entertainment-education serial radio drama on fertility awareness in Rwanda.

Given widespread misunderstanding of pregnancy risk, awareness of one's fertility has the potential to influence sexual and reproductive health behaviors. This mixed-methods study examined the impact of a serial radio drama in Rwanda, Impano n'Impamba, on fertility awareness and other factors related to family planning uptake by comparing listeners and non-listeners in a nationally representative household survey (n = 1477) and analyzing in-depth interviews with 32 listeners. Listeners had higher fertility awareness than non-listeners for key concepts, including the menstrual cycle, onset of fertility, and postpartum pregnancy risk. Qualitative interviews suggest discussion groups provided an invaluable opportunity to ask questions to a knowledgeable facilitator and clarify the fertility awareness information. No significant differences in modern family planning use or intention to use were found between listeners and non-listeners, but listeners reported greater supportive norms, self-efficacy, and discussion of family planning. Qualitative interviews suggest that increased discussion about family planning occurred because the drama emboldened people to talk about uncomfortable and taboo topics. Post-broadcast, listeners of Impano n'Impamba had greater fertility awareness then non-listeners and were more likely to experience intermediate outcomes related to family planning such as perception of positive family planning norms, a feeling of self-efficacy, and increased communication with others related to family planning. The study provides lessons for future interventions with the aim of increasing fertility awareness to improve sexual and reproductive health.

Correlates of postpartum common mental disorders: results from a population-based study in Amhara region, Ethiopia.

Postpartum common mental disorders are prevalent among women in Ethiopia. Data on associated factors are limited. This population-based study assessed mental health among 1294 nonpregnant, postpartum women in Amhara region. Poor health of the last delivered child and inequitable gender attitudes were associated with poor mental health among other factors. Social support from female friends was strongly protective. Community mental health services could strengthen social support between female friends with education and support group facilitation by health extension workers.

The role of relationship types on condom use among urban men with concurrent partners in Ghana and Tanzania.

Multiple concurrent partnerships are hypothesized to be important drivers of HIV transmission. Despite the demonstrated importance of relationship type (i.e., wife, girlfriend, casual partner, sex worker) on condom use, research on concurrency has not examined how different combinations of relationship types might affect condom use. We address this gap, using survey data from a sample of men from Ghana (GH: n = 807) and Tanzania (TZ: n = 800) who have at least three sexual partners in the past three months. We found that approximately two-thirds of men's reported relationships were classified as a girlfriend. Men were more likely to use a condom with a girlfriend if their other partner was a wife compared to if their other partner was a sex worker (GH: OR 3.10, 95% CI, 1.40, 6.86; TZ: OR 2.34, 95% CI 1.35, 4.06). These findings underscore the importance of considering relationship type when designing HIV prevention strategies in these settings.

Vasectomy provider decision-making balancing autonomy and non-maleficence: qualitative interviews with providers.

Background: Male sterilization, or vasectomy, is 99.9% effective at preventing pregnancy with less than a 2% risk of complications. Despite the high efficacy, low risk, low cost, and gender equity benefits of vasectomy, just 2% of women reported that they and their partners relied on vasectomy as their contraceptive method globally in 2019. Health care providers can be both a facilitator and a barrier in men's health generally, and may be in vasectomy provision as well. This study sought to describe the decision-making rationales of experienced vasectomy providers when evaluating patient candidacy in complex cases. Methods: Fifteen vasectomy providers belonging to the global Vasectomy Network google group from seven countries participated in online interviews using a semi-structured in-depth interview guide. Providers were asked about their vasectomy training, their reasons for vasectomy provision, challenging cases they have faced, and approaches used to manage challenging cases. Vignettes were used to further elicit decision-making rationale. Thematic analysis was conducted using MAXQDA20. Results: Provider decision-making was predicated on ensuring patients were well-informed, able to consent, and certain about their choice to have a vasectomy. Once those foundational conditions were met, providers filtered patient characteristics through their training, laws and policies, sociocultural norms, experience, and peer influence to produce a cost-benefit breakdown. Based on the cost-benefit analysis, providers determined whether to weigh autonomy or non-maleficence more heavily when determining vasectomy patient candidacy. Conclusions: Despite clinical best practices that promote prioritizing patient autonomy over non-maleficence, some providers continued to weigh non-maleficence over autonomy in vasectomy patient candidacy evaluations. Non-maleficence was particularly prioritized in cases providers deemed to be at higher risk of regret. The findings of this study suggest vasectomy provider training should emphasize evidence-based best practices in shared decision-making and patient-centered care to facilitate vasectomy provision that honors patient autonomy and rights.

Changes in couples' communication as a result of a male-involvement family planning intervention.

Research suggests that spousal communication and male involvement in decision making can positively influence family-planning use and continuation. However, few existing studies explore the dynamics of this communication and how they factor into family-planning decision making. Building upon a recent evaluation of a theory-based male-involvement intervention in Malawi, this study aimed to fill this gap by examining the role of communication in the intervention's success, through semi-structured in-depth interviews with male participants and female partners of study participants. Results support the idea that communication is an integral component of successful interventions to increase male involvement in family planning. Participants reported improvements in spousal communication, increased frequency of communication, and an increase in shared decision making as a result of the study, which directly contributed to their family-planning use. This effect was often mediated through increased knowledge or reduced male opposition to family planning. Further analysis of communication and decision-making dynamics revealed shifts in gendered communication norms, leading to improvements in spousal relationships in addition to contraceptive uptake. This study shows that interventions can and should encourage spousal communication and shared decision making, and it provides an effective model for involving men in family-planning use.

COVID-19 vaccine acceptance among Bangladeshi adults: Understanding predictors of vaccine intention to inform vaccine policy.

OBJECTIVES: The purpose of this study was to identify predictors of COVID-19 vaccine intention among Bangladeshi adults. METHODS: Secondary data from the COVID-19 Beliefs, Behaviors & Norms Survey conducted by the Massachusetts Institute of Technology (MIT) and Facebook were analyzed. Data were collected from 2,669 adult Facebook users in Bangladesh and was collected between February 15 and February 28, 2021. Binomial logistic regression examined the relationship between COVID-19 vaccination intent and demographic variables, risk perception, preventive behaviors, COVID-19 knowledge, and likelihood of future actions. RESULTS: Seventy-nine percent of respondents reported intent to get the COVID-19 vaccine when it becomes available. Intent to get vaccinated was highest among females, adults aged 71-80, individuals with college or graduate-level degrees, city dwellers, and individuals who perceived that they were in excellent health. Results of the binomial logistic regression indicated that predictors of vaccination intent include age (OR = 1.39), high risk perception of COVID-19 (OR = 1.47), and intent to practice social distancing (OR = 1.22). DISCUSSION: Findings suggest that age, perceived COVID-19 risk, and non-pharmaceutical COVID-19 interventions may predict COVID-19 vaccination intent among Bangladeshi adults. Findings can be used to create targeted messaging to increase demand for and uptake of COVID-19 vaccines in Bangladesh.

Global survey on COVID-19 beliefs, behaviours and norms.

Policy and communication responses to COVID-19 can benefit from better understanding of people's baseline and resulting beliefs, behaviours and norms. From July 2020 to March 2021, we fielded a global survey on these topics in 67 countries yielding over 2 million responses. This paper provides an overview of the motivation behind the survey design, details the sampling and weighting designed to make the results representative of populations of interest and presents some insights learned from the survey. Several studies have already used the survey data to analyse risk perception, attitudes towards mask wearing and other preventive behaviours, as well as trust in information sources across communities worldwide. This resource can open new areas of enquiry in public health, communication and economic policy by leveraging large-scale, rich survey datasets on beliefs, behaviours and norms during a global pandemic.

Encouraging contraceptive uptake by motivating men to communicate about family planning: the Malawi Male Motivator project.

OBJECTIVES: We examined the effect of a peer-delivered educational intervention, the Malawi Male Motivator intervention, on couples' contraceptive uptake. We based the intervention design on the information-motivation-behavioral skills (IMB) model. METHODS: In 2008 we recruited 400 men from Malawi's Mangochi province who reported not using any method of contraception. We randomized them into an intervention arm and a control arm, and administered surveys on contraceptive use at baseline and after the intervention. We also conducted in-depth interviews with a subset of intervention participants. RESULTS: After the intervention, contraceptive use increased significantly within both arms (P < .01), and this increase was significantly greater in the intervention arm than it was in the control arm (P < .01). Quantitative and qualitative data indicated that increased ease and frequency of communication within couples were the only significant predictors of uptake (P < .01). CONCLUSIONS: Our findings indicate that men facilitated contraceptive use for their partners. Although the IMB model does not fully explain our findings, our results show that the intervention's content and its training in communication skills are essential mechanisms for successfully enabling men to help couples use a contraceptive.

Trends in handwashing behaviours for COVID-19 prevention: Longitudinal evidence from online surveys in 10 sub-Saharan African countries.

Handwashing is essential for respiratory virus prevention, but uptake of handwashing in the context of the SARS-CoV-2 pandemic remains under-explored. This study examines trends in and determinants of handwashing practices for COVID-19 prevention in 10 countries in West, East, and Southern Africa. Data are derived from an online global Facebook survey assessing COVID-19 knowledge, attitudes, and practices, fielded in July (Round 1) and November 2020 (Round 2). Adults ≥18 years (N = 29,964) were asked if they practiced handwashing with soap and water in the past week to prevent COVID-19. Design-corrected F-statistics compared knowledge and practice of handwashing, at country and regional levels, between survey rounds. A country-level fixed-effects logistic regression model then identified socio-demographic and ideational correlates of handwashing at Round 2. Most participants were >30 years-old, men, post-secondary educated, and urban residents. Between survey rounds, handwashing prevalence declined significantly across regions and in each country, from a 14% decline (Δ84%-70%) in Tanzania to a 3% decline (Δ92%-89%) in South Africa. Handwashing was higher among participants aged >30 years (Adjusted Odds Ratio [aOR] = 1.25, 95% confidence interval [95%CI]: 1.15-1.35) and with post-secondary education (aOR = 1.62, 95%CI: 1.49-1.77) but lower among men (aOR = 0.71, 95%CI: 0.64-0.78). Ideational factors associated with handwashing included perceived effectiveness of handwashing (aOR = 2.17, 95%CI: 2.00-2.36), knowing someone diagnosed with COVID-19 (aOR = 1.28, 95%CI: 1.18-1.40), and perceived importance of personal action for COVID-19 prevention (aOR = 2.93; 95%CI: 2.60-3.31). Adjusting for socio-demographic and ideational factors, country-level marginal probabilities of handwashing ranged from 67% in Tanzania to 91% in South Africa in Round 2. COVID-19 prevention messages should stress the importance of handwashing, coupled with mask use and physical distancing, for mitigating respiratory disease transmission. Behaviour change communications should be sensitive to resource heterogeneities in African countries, which shape opportunities for sustainable handwashing behaviours.

Men and COVID-19: Adding a gender lens.

In this commentary, the authors point out that there are important gender determinants to both men's and women's vulnerabilities to COVID-19, and call on the global health community to unpack and address these early in the COVID-19 pandemic response. They point to best practices and tools from two decades of engaging men in research and programming in the sexual and reproductive health field.

Estimating six-cycle efficacy of the Dot app for pregnancy prevention.

OBJECTIVE: To assess six-cycle perfect and typical use efficacy of Dynamic Optimal Timing (Dot), an algorithm-based fertility app that identifies the fertile window of the menstrual cycle using a woman's period start date and provides guidance on when to avoid unprotected sex to prevent pregnancy. STUDY DESIGN: We are conducting a prospective efficacy study following a cohort of women using Dot for up to 13 cycles. Study enrollment and data collection are being conducted digitally within the app and include a daily coital diary, prospective pregnancy intentions and sociodemographic information. We used data from the first six cycles to calculate life-table failure rates. RESULTS: We enrolled 718 women age 18-39 years. Of the 629 women 18-35 years old, 15 women became pregnant during the first six cycles for a typical use failure rate of 3.5% [95% CI 1.7-5.2]. All pregnancies occurred with incorrect use, so we did not calculate a perfect use failure rate. CONCLUSIONS: These findings are promising and suggest that the 13-cycle results will demonstrate high efficacy of Dot. IMPLICATIONS: While final 13-cycle efficacy results are forthcoming, 6-cycle results suggest that Dot's guidance provides women with useful information for preventing pregnancy.

Men on the move and the wives left behind: the impact of migration on family planning in Nepal.

Nepali migration is longstanding, and increased from 2.3% of the total population in 2001 to 7.2% in 2011. The estimated 1.92 million migrants are predominantly men. Consequently, 32% of married women have husbands working abroad. Social structures are complicated as many married women live with their in-laws who typically assume decision-making power, including access to health services. This study compares access to reproductive health services, fertility awareness, and decision-making power among a sample of married women aged 15-24 years (n = 1123) with migrant husbands (n = 485), and with resident husbands (n = 638). Predictably, women with migrant husbands had significantly lower contraceptive use than other married women (9.3% vs 30.3%, respectively), and expressed a higher intention to become pregnant in the next year. Despite their intentions, women with migrant husbands scored lower on a fertility awareness index, were less likely to discuss pregnancy planning with their spouse, and less likely to describe their relationships positively. Decision-making for both groups of married women was dominated by both husbands and in-laws in different ways. Yet, across multiple normative scales, fewer women with migrant husbands felt pressure to conform to existing social norms. Married women with migrant husbands reflect a subset of women, with unique fertility issues and desires. Interventions that increase knowledge of fertility among this subset of women, promote healthy preconception behaviours. Linking women for counselling opportunities throughout the pre and postnatal periods may help improve health outcomes for mothers and children.

Changes in sexual risk behavior among participants in a PrEP HIV prevention trial.

BACKGROUND: One of the concerns raised regarding the introduction of any new HIV-prevention measure, such as PrEP, is the potential for risk disinhibition or sexual risk compensation. The oral tenofovir HIV prevention trial has been the subject of international discussion in this regard. METHODS: This article maps the changes in sexual risk behavior among women participating in the oral tenofovir HIV prevention trial in Ghana. Content-driven, thematic analysis was carried out on qualitative data obtained from in-depth interviews with study participants. Growth curve analysis was the primary method used to document trends over time in self-reported sexual behavior collected monthly. RESULTS: Overall, the study found that sexual risk behavior did not increase during the trial. Number of sexual partners and rate of unprotected sex acts decreased across the 12-month period of study enrollment. Certain subgroups of women, however, exhibited different growth curves. Data indicate that the HIV prevention counseling associated with the trial was effective. CONCLUSIONS: Counseling during the trial was effective. Different types of counseling and messaging may be needed for different subgroups within a population. These findings also have implications for required sample sizes for future HIV prevention trials where seroconversion is the main outcome.

Lessons From the Dot Contraceptive Efficacy Study: Analysis of the Use of Agile Development to Improve Recruitment and Enrollment for mHealth Research.

BACKGROUND: Smartphone apps that provide women with information about their daily fertility status during their menstrual cycles can contribute to the contraceptive method mix. However, if these apps claim to help a user prevent pregnancy, they must undergo similar rigorous research required for other contraceptive methods. Georgetown University's Institute for Reproductive Health is conducting a prospective longitudinal efficacy trial on Dot (Dynamic Optimal Timing), an algorithm-based fertility app designed to help women prevent pregnancy. OBJECTIVE: The aim of this paper was to highlight decision points during the recruitment-enrollment process and the effect of modifications on enrollment numbers and demographics. Recruiting eligible research participants for a contraceptive efficacy study and enrolling an adequate number to statistically assess the effectiveness of Dot is critical. Recruiting and enrolling participants for the Dot study involved making decisions based on research and analytic data, constant process modification, and close monitoring and evaluation of the effect of these modifications. METHODS: Originally, the only option for women to enroll in the study was to do so over the phone with a study representative. On noticing low enrollment numbers, we examined the 7 steps from the time a woman received the recruitment message until she completed enrollment and made modifications accordingly. In modification 1, we added call-back and voicemail procedures to increase the number of completed calls. Modification 2 involved using a chat and instant message (IM) features to facilitate study enrollment. In modification 3, the process was fully automated to allow participants to enroll in the study without the aid of study representatives. RESULTS: After these modifications were implemented, 719 women were enrolled in the study over a 6-month period. The majority of participants (494/719, 68.7%) were enrolled during modification 3, in which they had the option to enroll via phone, chat, or the fully automated process. Overall, 29.2% (210/719) of the participants were enrolled via a phone call, 19.9% (143/719) via chat/IM, and 50.9% (366/719) directly through the fully automated process. With respect to the demographic profile of our study sample, we found a significant statistical difference in education level across all modifications (P<.05) but not in age or race or ethnicity (P>.05). CONCLUSIONS: Our findings show that agile and consistent modifications to the recruitment and enrollment process were necessary to yield an appropriate sample size. An automated process resulted in significantly higher enrollment rates than one that required phone interaction with study representatives. Although there were some differences in demographic characteristics of enrollees as the process was modified, in general, our study population is diverse and reflects the overall United States population in terms of race/ethnicity, age, and education. Additional research is proposed to identify how differences in mode of enrollment and demographic characteristics may affect participants' performance in the study. TRIAL REGISTRATION: ClinicalTrials.gov NCT02833922; http://clinicaltrials.gov/ct2/show/NCT02833922 (Archived by WebCite at http://www.webcitation.org/6yj5FHrBh).

Conflict of Interest Addendum: Assessing the Efficacy of an App-Based Method of Family Planning: The Dot Study Protocol.

[This corrects the article DOI: 10.2196/resprot.6886.].

Modeling the impact of novel male contraceptive methods on reductions in unintended pregnancies in Nigeria, South Africa, and the United States.

OBJECTIVE: We modeled the potential impact of novel male contraceptive methods on averting unintended pregnancies in the United States, South Africa, and Nigeria. STUDY DESIGN: We used an established methodology for calculating the number of couple-years of protection provided by a given contraceptive method mix. We compared a "current scenario" (reflecting current use of existing methods in each country) against "future scenarios," (reflecting whether a male oral pill or a reversible vas occlusion was introduced) in order to estimate the impact on unintended pregnancies averted. Where possible, we based our assumptions on acceptability data from studies on uptake of novel male contraceptive methods. RESULTS: Assuming that only 10% of interested men would take up a novel male method and that users would comprise both switchers (from existing methods) and brand-new users of contraception, the model estimated that introducing the male pill or reversible vas occlusion would decrease unintended pregnancies by 3.5% to 5.2% in the United States, by 3.2% to 5% in South Africa, and by 30.4% to 38% in Nigeria. Alternative model scenarios are presented assuming uptake as high as 15% and as low as 5% in each location. Model results were sensitive to assumptions regarding novel method uptake and proportion of switchers vs. new users. CONCLUSION: Even under conservative assumptions, the introduction of a male pill or temporary vas occlusion could meaningfully contribute to averting unintended pregnancies in a variety of contexts, especially in settings where current use of contraception is low. IMPLICATIONS: Novel male contraceptives could play a meaningful role in averting unintended pregnancies in a variety of contexts. The potential impact is especially great in settings where current use of contraception is low and if novel methods can attract new contraceptive users.

Gender-transformative Bandebereho couples' intervention to promote male engagement in reproductive and maternal health and violence prevention in Rwanda: Findings from a randomized controlled trial.

BACKGROUND: Rigorous evidence of the effectiveness of male engagement interventions, particularly on how these interventions impact relationship power dynamics and women's decision-making, remains limited. This study assessed the impact of the Bandebereho gender-transformative couples' intervention on impact on multiple behavioral and health-related outcomes influenced by gender norms and power relations. METHODS: We conducted a multi-site randomised controlled trial in four Rwandan districts with expectant/current fathers and their partners, who were randomised to the intervention (n = 575 couples) or control group (n = 624 couples). Primary outcomes include women's experience of physical and sexual IPV, women's attendance and men's accompaniment at ANC, modern contraceptive use, and partner support during pregnancy. At 21-months post-baseline, 1123 men and 1162 partners were included in intention to treat analysis. Generalized estimating equations with robust standard errors were used to fit the models. FINDINGS: The Bandebereho intervention led to substantial improvements in multiple reported outcomes. Compared to the control group, women in the intervention group reported: less past-year physical (OR 0.37, p<0.001) and sexual IPV (OR 0.34, p<0.001); and greater attendance (IRR 1.09, p<0.001) and male accompaniment at antenatal care (IRR 1.50, p<0.001); and women and men in the intervention group reported: less child physical punishment (women: OR 0.56, p = 0.001; men: OR 0.66, p = 0.005); greater modern contraceptive use (women: OR 1.53, p = 0.004; men: OR 1.65, p = 0.001); higher levels of men's participation in childcare and household tasks (women: beta 0.39, p<0.001; men: beta 0.33, p<0.001); and less dominance of men in decision-making. CONCLUSIONS: Our study strengthens the existing evidence on male engagement approaches; together with earlier studies our findings suggest that culturally adapted gender-transformative interventions with men and couples can be effective at changing deeply entrenched gender inequalities and a range of health-related behavioral outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02694627.

Assessing the Efficacy of an App-Based Method of Family Planning: The Dot Study Protocol.

BACKGROUND: Some 222 million women worldwide have unmet needs for contraception; they want to avoid pregnancy, but are not using a contraceptive method, primarily because of concerns about side effects associated with most available methods. Expanding contraceptive options-particularly fertility awareness options that provide women with information about which days during their menstrual cycles they are likely to become pregnant if they have unprotected intercourse-has the potential to reduce unmet need. Making these methods available to women through their mobile phones can facilitate access. Indeed, many fertility awareness applications have been developed for smartphones, some of which are digital platforms for existing methods, requiring women to enter information about fertility signs such as basal body temperature and cervical secretions. Others are algorithms based on (unexplained) calculations of the fertile period of the menstrual cycle. Considering particularly this latter (largely untested) group, it is critical that these apps be subject to the same rigorous research as other contraceptive methods. Dynamic Optimal Timing, available via the Dot app as a free download for iPhone and Android devices, is one such method and the only one that has published the algorithm that forms its basis. It combines historical cycle data with a woman's own personal cycle history, continuing to accrue this information over time to identify her fertile period. While Dot has a theoretical failure rate of only 3 in 100 for preventing pregnancy with perfect use, its effectiveness in typical use has yet to be determined. OBJECTIVE: The study objective is to assess both perfect and typical use to determine the efficacy of the Dot app for pregnancy prevention. METHODS: To determine actual use efficacy, the Institute for Reproductive Health is partnering with Cycle Technologies, which developed the Dot app, to conduct a prospective efficacy trial, following 1200 women over the course of 13 menstrual cycles to assess pregnancy status over time. This paper outlines the protocol for this efficacy trial, following the Standard Protocol Items: Recommendations for Intervention Trials checklist, to provide an overview of the rationale, methodology, and analysis plan. Participants will be asked to provide daily sexual history data and periodically answer surveys administered through a call center or directly on their phone. RESULTS: Funding for the study was provided in 2013 under the United States Agency for International Development Fertility Awareness for Community Transformation project. Recruitment for the study will begin in January of 2017. The study is expected to last approximately 18 months, depending on recruitment. Findings on the study's primary outcomes are expected to be finalized by September 2018. CONCLUSIONS: Reproducibility and transparency, important aspects of all research, are particularly critical in developing new approaches to research design. This protocol outlines the first study to prospectively test both the efficacy (correct use) and effectiveness (actual use) of a pregnancy prevention app. This protocol and the processes it describes reflect the dynamic integration of mobile technologies, a call center, and Health Insurance Portability and Accountability Act-compliant study procedures. Future fertility app studies can build on our approaches to develop methodologies that can contribute to the evidence base around app-based methods of contraception. CLINICALTRIAL: ClinicalTrials.gov NCT02833922; https://clinicaltrials.gov/ct2/show/NCT02833922 (Archived be WebCite at http://www.webcitation.org/6nDkr0e76).

Jordan's 2002 to 2012 Fertility Stall and Parallel USAID Investments in Family Planning: Lessons From an Assessment to Guide Future Programming.

Health practitioners, researchers, and donors are stumped about Jordan's stalled fertility rate, which has stagnated between 3.7 and 3.5 children per woman from 2002 to 2012, above the national replacement level of 2.1. This stall paralleled United States Agency for International Development (USAID) funding investments in family planning in Jordan, triggering an assessment of USAID family planning programming in Jordan. This article describes the methods, results, and implications of the programmatic assessment. Methods included an extensive desk review of USAID programs in Jordan and 69 interviews with reproductive health stakeholders. We explored reasons for fertility stagnation in Jordan's total fertility rate (TFR) and assessed the effects of USAID programming on family planning outcomes over the same time period. The assessment results suggest that the increased use of less effective methods, in particular withdrawal and condoms, are contributing to Jordan's TFR stall. Jordan's limited method mix, combined with strong sociocultural determinants around reproduction and fertility desires, have contributed to low contraceptive effectiveness in Jordan. Over the same time period, USAID contributions toward increasing family planning access and use, largely focused on service delivery programs, were extensive. Examples of effective initiatives, among others, include task shifting of IUD insertion services to midwives due to a shortage of female physicians. However, key challenges to improved use of family planning services include limited government investments in family planning programs, influential service provider behaviors and biases that limit informed counseling and choice, pervasive strong social norms of family size and fertility, and limited availability of different contraceptive methods. In contexts where sociocultural norms and a limited method mix are the dominant barriers toward improved family planning use, increased national government investments toward synchronized service delivery and social and behavior change activities may be needed to catalyze national-level improvements in family planning outcomes.