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Table 2 Factors influencing use and non-use of contraception

From: Factors influencing contraceptive use or non-use among Aboriginal and Torres Strait Islander people: a systematic review and narrative synthesis

Social Ecological Model Level Theme Factors influencing non-use Factors influencing use
Intrapersonal Knowledge • Misperceptions/misinformation about implant [5]
• Lack of knowledge about available methods [5, 19,20,21,22, 29,30,31]
• Lack of knowledge about sexual and reproductive health generally [18]
• Information about contraception from non-medical sources [21, 22]
• Do not know where to access condoms in community, how much they cost, or know where but not how [32, 33]
• Overwhelming information on internet, difficult to identify reliable information [31]
• Able to identify sources of credible information regarding sex and contraception in the community [25, 31]
• Knowledge of advice regarding safe sex and contraception [34]
• Know condoms are preventative against HIV [32]
• Know where to access condoms [27, 32, 33]
• Knowledge about some available contraceptive methods [30]
Shame, embarrassment • Women felt ashamed and shy about accessing condoms [30]
• Embarrassment and shame prevents buying or accessing condoms [24]
• Shame and stigma prevents attending and asking for contraception in a clinical context [28, 31]
• Shame and embarrassment in talking about family planning and contraception with health care providers, parents, sexual partners, in school settings, etc. [18, 26, 33]
• Fear of lack of confidentiality and privacy when accessing community health centres [19, 20].
• STI’s not considered shameful in a South-East Northern Territory community, as genital infections are common among men who have undergone the ritual subincision of the penis [35]
• Women reported being able to access and carry condoms without stigmatisation [24]
Female specific • Women typically not responsible for condoms [32]
• Desire to not use contraception [31]
• Desire to use contraception [31]
• Clear fertility intentions and plans for (future) pregnancy [31]
Male specific • Men assume condom use is women’s responsibility [23]
• Men refuse to wear a condom because they want a baby [5, 33]
• Men refuse to wear a condom [24]
• Men dislike condoms and prefer sex without [18, 24]
• None reported
Contraceptive specific • Men dislike condoms and prefer sex without [18, 24]
• Condoms considered protection for men only [32]
• Women typically not responsible for condoms [32]
• Men assume condom use is women’s responsibility [23]
• Condoms impact men’s sexual pleasure (and sometimes women’s) [32]
• Condoms primarily considered for STI, not pregnancy, prevention [32]
• Negative experiences or unwanted side effects with hormonal contraception, leading to discontinuation or ‘taking a break’ [5, 21, 22, 30]
• Dissatisfaction with available methods [31]
• Positive experiences with contraceptive implant [5]
• Positive side effects, including lighter periods [5]
Interpersonal Sexual relationship • Women suggested that men preferred sex without condoms [24, 30]
• Women unable to negotiate condom use [17, 18, 23, 24, 33]
• Shame about talking about condom use with partner [33]
• Condoms not used in established relationships [24, 27, 32]
• Condoms not used because partner’s sexual history is known [34]
• Condoms not used because partner does not like them (non-gender specific) [25, 34]
• Condoms not used because partner trusted [25, 34]
• Couples do not discuss condom use, or sex and reproductive health matters [32, 33, 35]
• Men refuse to wear a condom [24]
• Partner refused to wear a condom because he wanted a baby, or pressured woman to stop using hormonal contraception for same reason [5, 33]
• Do not use contraception because pregnancy is desired [18]
• Couples discuss condom use [33]
• Some emphasised importance of condom use and would abstain from sex if one was not available [24]
• Using contraception improves sex life by facilitating sex without procreation [21, 22]
• Condoms good for casual relationships [24, 27, 32]
• Proactively picking up free condoms when sex was anticipated [24]
Healthcare providers/ educators • Shame and embarrassment talking about family planning and contraception with healthcare professionals or during sex education in school [18, 26, 33] • Given advice regarding safe sex and contraception [34]
• Positive interactions with health care providers, facilitating contraceptive information provision [31]
• Aboriginal nurse aid accompanying women to appointments [28]
Family/friend relationships • Shame and embarrassment talking about family planning and contraception with health care providers, parents, sexual partners, in school settings, etc. [18, 26, 33]
• Misperceptions, misinformation, and negative experiences of family and friends [31]
• Ability to talk to family and friends about contraception and reproductive health [31]
• Mothers supportive of daughters contraceptive use (and even taking them to the clinic for contraception) [5]
• Support of extended family (e.g. Aunties) in accessing or using contraception [18]
• Mothers report the importance of women not having babies when they are too young [5]
Community members • Condom use not sanctioned by community Elders [35]
• Negative attitudes towards contraception among some female community members [21, 22, 29, 30]
• Positive attitudes towards contraception among some community members [19,20,21,22, 29]
Context of sex • Non-consensual sex and sexual assault [17, 24, 33]
• Drug and alcohol use among men and women impede ability to practice safe sex [24, 27, 33]
• Not using contraception in the heat of the moment as noted by both male and female high school students [18]
• Never carry condoms with them [27]
• Inability to anticipate sex and therefore do not have condom available [18, 24, 25]
• Using contraception improves sex life by facilitating sex without procreation [21, 22]
• Couples discuss condom use [33]
• Carrying condoms to be prepared for unplanned sex [24]
Local Access • Do not know where to access condoms in community, how much they cost, or know where but not how [32, 33]
• Overwhelming information on internet, difficult to identify reliable information [31]
• Limited access to contraception in two regional areas of Queensland [18, 31]
• Cannot afford cost of IUD [28]
• Free condoms sometimes run out [24]
• Homelessness exacerbates issue of condom access [24]
• Lack of a suitable general practitioner, or other trusted person to provide family planning advice [29]
• Lack of culturally appropriate information about contraceptive options, or information provided which assumes a higher level of health literacy than is present, and health care provider does not provide information without judgement [31]
• Timing of postpartum contraceptive advice [31]
• Fear of lack of confidentiality and privacy when accessing community health centres [19, 20]
• Women reported being able to access condoms without stigmatisation [24]
• Able to identify sources of credible information regarding sex and contraception in the community [25, 31]
• Given advice regarding safe sex and contraception [34]
• Know where to access condoms [27, 32, 33]
• Condoms accessible in community, including free condoms [24]
Cultural appropriateness of services and information • Lack of culturally appropriate information for men [19, 20]
• Lack of culturally appropriate clinical care [19, 20]
• Lack of culturally appropriate promotion of contraception and sexual and reproductive health information [29, 30, 35]
• Unease in clinical environment [28]
• Explanations of contraception and STIs within a western medicine paradigm are not consistent with traditional understandings of the body [30]
• Readily available access to condoms at women’s centre not seen as culturally appropriate by women of one remote community [33]
• Aboriginal nurse aid accompanying women to appointments [28]
Stigma • Women faced stigmatisation for carrying condoms [18]
• Embarrassment and shame prevent buying or accessing condoms [24]
• Shame of stigma around sexual assault, as well as condom negotiation, experienced by women of a remote central Australian community [33]
• Shame and stigma prevents attending and asking for contraception in a clinical context [28, 31]
• Fear of lack of confidentiality and privacy when accessing community health centres [19, 20]
• Women reported being able to access and carry condoms without stigmatisation [24]
Societal Economic factors • Homelessness exacerbates issue of condom access [24]
• Cannot afford cost of contraception [28]
• Condoms accessible in community, including free condoms [24]
Cultural norms • Contraception is taboo [18, 26, 29]
• Cultural norms among women from four allied communities in the Northern Territory regarding the female body; women do not expose their pelvic region to strangers, especially men [19, 20]
• Cultural norms regarding first pregnancy; women do not use contraception to delay first pregnancy [29, 30]
• Within a community in the South-East Northern Territory, cultural norms (e.g. the subincision of penises as a transition to manhood and women not being involved in male health, including penises) limit who is permitted to access condoms, where condoms are able to be distributed, how condoms are perceived, and therefore whether or not they are actually used [35]
• STIs are not considered shameful in a South-East Northern Territory community, as genital infections are common among men who have undergone the ritual subincision of the penis [35]
• Cultural understandings of the female reproductive body; explanations of contraception and STIs within a western medicine paradigm and not consistent with traditional understandings of the body [30]
• Reproduction is highly valued and pregnancy and childrearing acceptable, natural and desirable [30, 31, 35]
• ‘Transformative potential of motherhood’ [17]
• Cultural and gender constraints prevent women from engaging in condom negotiation [33]
• None reported