Positive deviance for promoting dual-method contraceptive use among women in Uganda

概要

［課程－２］
審査の結果の要旨
氏名

小杉

穂高

This study aimed to examine the effectiveness of the positive deviance approach in promoting dualmethod contraception among married or in-union women using highly effective contraceptives in
Mbarara District, Uganda. This study consisted of two phases. In Phase I, I explored the barriers that
make dual-method contraceptive use rare and the behaviors of women who practice dual-method
contraception (positive deviants [PDs]). Then, in Phase II, I examined the effects of the behavioral
intervention, which was developed using the findings of Phase I, on dual-method contraceptive use
among married or in-union women in the same study area.
In Phase I, I identified 9 PDs and 141 non-PDs through screening of 150 women who used highly
effective contraceptives at five health facilities. The results of the in-depth interviews demonstrated
that women faced several barriers to dual-method contraceptive use, such as their partners’ objections,
distrust, shyness about introducing condoms into marital relationships, and limited access to condoms.
However, the PDs successfully used dual-method contraception by practicing several PD behaviors,
such as initiating discussions for the dual-method use, educating their partners on sexual risks and
condom use, and accessing condoms themselves.
In Phase II, I conducted an exploratory sequential mixed methods study with a clustered randomized
controlled trial in 20 health facilities. More women in the intervention group used dual-method
contraception at the last sexual intercourse at two months (AOR = 4.29; 95% CI 2.12–8.69) and at
eight months (AOR = 2.19; 95% CI 1.07–4.48) than in the control group. Moreover, consistent dualmethod contraceptive use was more prevalent in the intervention group than in the control group at
two months (AOR = 13.71; 95% CI 3.59–52.43), and the intervention effect remained at four, six, and
eight months. More women discussed HIV/STI risk with their partners in the intervention than in the
control group at two months (AOR = 2.70; 95% CI: 1.72–4.23). The intervention’s effect on
communication about HIV/STI risk lasted throughout the follow-up period. However, the incidence
of pregnancy did not differ significantly between the groups.
The positive deviance intervention increased dual-method contraceptive use among women and could
be effective at reducing the dual risk of unintended pregnancies and HIV infections. This approach
helped women uptake and adhere to dual-method contraceptive use by disseminating PD behaviors
that exist in their community. Because women who use highly effective contraceptives may be more

reachable compared to men, interventions targeting such women should reduce this dual risk more
effectively. This study demonstrated that the intervention targeting only women can change behaviors
of couples to practice dual-method contraceptive use.
This study has provided useful reference for developing programs based on the positive deviance
approach to promote dual-method contraceptive use and other behavioral changes that usual
approaches, which often look for outside solutions, have failed to address and often against social
norms.
よって本論文は博士(保健学)の学位請求論文として合格と認められる。