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Acceptability: Moving from Tolerable to Desirable

Written by Exchanges Contributor Betsy Tolley, PhD, Acting Director of Behavioral, Epidemiological & Clinical Sciences at FHI 360.

I’ve heard contraceptive choice described as a choice of the most tolerable – or least objectionable – method. Why is that good enough?  Why aren’t there more choices that generate long-term contentment rather than dread? Options easy and convenient to use rather than demanding and interfering; perhaps it’s because contraceptive development efforts too often focus on technology and biomedical physiology while taking a very narrow view of acceptability.

Contraceptive clinical trials often reduce acceptability considerations to three questions:  Were women reportedly satisfied with the method? Would they recommend it to a friend? And did the trial have high continuation rates? These questions and current research approaches seem inadequate. For one, the experience of product use during research can differ from everyday use. Women may be more motivated by the monetary reimbursements or medical access gained by trial participation than by the product itself.  Trial-related medical tests and procedures may negatively affect their product experience. On the other hand, there may be more opportunities for side effect counseling and other types of support than would be available during everyday use.

Second, these questions don’t remotely touch on the complicated balancing act that women confront when trying to decide which method is best. Recently in Kenya, I chatted to a group of four women about their experiences using family planning methods. They had used a total of 16 methods over their reproductive years! They recounted stories of surprise pregnancies while on a method, of husbands displeased by a method’s heavier bleeding side effect, of problems with varicose veins and dizziness that they associated with the method; of concerns that copper IUDs might cause cancer and wondering where blood goes if not eliminated through menstruation.  These stories highlight the myriad of factors influencing a woman’s life situation and her acceptance of a family planning method …at a single point in her reproductive life.

The truth is that most currently available contraceptive options come with undesirable side effects or challenging use regimens.  Why? Maybe it’s because the contraceptive development field has prioritized efficacy and feasibility, while acceptability is only given secondary consideration.  The reality is efficacy and feasibility only matter if a product is acceptable and women use it!  The contraceptive field has been slow to adopt innovative ways to assess user perspectives into product development early in the development process. We could learn a thing or two from commercial product development – for example, the food industry or cosmetics.  These sectors play close attention to their consumers’ experiences – the touch, taste, and feel they experience when interacting with products.

When life circumstances change, women’s contraceptive needs often change too. In an ideal world, women would have a very broad range of desirable products to choose from and switch between, based on their changing needs. Innovative thinking on product acceptability, like that being offered up over the next few months by my esteemed colleagues in this blog series, can fuel discussions among product developers, challenging them to ask different questions and explore new angles when thinking about the ideal product attributes of family planning methods.  The blog series will unfold as follows:

  • Kate Guthrie, PhD, Warren Alpert Medical School of Brown University and the Miriam Hospital, will start things off by talking about how user perceptions of new contraceptive prototypes could and should inform early stage research efforts to design new, acceptable products.

  • Laneta Dorflinger, PhD, from FHI 360, will challenge the foundational assumption that monthly bleeding is necessary. While acknowledging that many women find family planning methods that cause amenorrhea (the absence of bleeding) unacceptable, she will offer up reasons why this bias limits women.

  • Rebecca Callahan, PhD, and Aurélie Brunie, PhD, of FHI 360, will share insights on the opportunities and challenges of conducting research with diverse populations focused on “hypothetical” contraceptive technologies (products in early stages of development).

  • Amelia Mackenzie, ScM, from FHI 360 will blog about the many influences in a clinical trial setting that can mask the accuracy of product acceptability findings.

  • Vanetta Thomas, MPH, and Laura Dellplain, MHS, from the Initiative for Multipurpose Prevention Technologies (IMPT) secretariat will share their insights on what they’ve learned about testing acceptability of multi-purpose prevention products currently under development.

  • Marta Pirzadeh, MPH, of FHI 360 and Fariyal Fikree, MD, MPH, DrPH of Pathfinderwill view method acceptability through the eyes of an adolescent — in this case, a 16-year-old Zambian girl.

  • Kevin Eisenfrats, CEO of Contraline, will delve into the acceptability of male contraceptive options (both existing and in design) and the role that urologist bias plays in influencing product choice/use by men.

This blog series aims to re-conceptualize acceptability and re-evaluate the weight we give it in contraceptive product development.  As researchers, we must listen harder and think smarter to come up with new and better methods that are truly acceptable.  After all, women and men around the world deserve better than “good enough.”



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