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Table 2 Context-Intervention-Actor-Mechanism-Outcome (CIAMO) and Context-Actor-Mechanism-Outcome (CAMO) configurations and acceptability constructs

From: What mechanisms drive uptake of family planning when integrated with childhood immunisation in Ethiopia? A realist evaluation

Context Project interventions Actor, mechanism, and outcome Constructs of acceptability, diffusion of innovations, and/or accessibility
CIAMO 1: Healthcare delivery is conducted by HEWs at health posts and home (C) EPI and FP services offered at the 45 day post-natal check (I) HEWs (A) perceive a reduced work burden due to EPI/FP service integration (M) and therefore provide integrated services (O) Burden, affective attitude, observability, relative advantage
R: I strongly feel that having everything integrated is beneficial and actually makes my job easier. For example, when we go to vaccinate a child at 45 days we have to meet with the mother anyway and so that opportunity is used to also offer contraception. In my opinion this is a reduction of work rather than an increase.” HEW_3
CIAMO 2: Healthcare delivery is conducted by HEWs at health posts and home (C) Ongoing training on EPI and FP integrated service delivery (I) HEWs (A) feel that providing both services together has more impact’ (M) and therefore provide integrated services (O) Perceived effectiveness, relative advantage, compatibility, observability
“R: Because this project has allowed me and other health workers to address vaccinations and family planning together as one package. Therefore, I feel our efforts have more of an impact than they did prior to the project. We are now seeing better outcomes because of its introduction.” HEW_2
CIAMO 3: FP delivery is conducted by HEWs (C) HEWs given on-the job mentoring on implant insertion (I) HEWs (A) feel confident in their ability to provide implants for women (M) and therefore provide integrated services including implants (O) Self-efficacy, affective attitude, trialability
“R: Previously, the long-acting family planning was given at health centre level. Currently, it is given by the health extension workers after they take training …. They took the training but since they haven’t done this before, they may lack confidence. We overcame this by onsite mentorship with the presence of trained officer from the Woreda office, IRC and us. We made appointments with mothers to come and mentored the extension workers to practice giving the service while the team is there. Then we got in to the actual work after they practiced and started doing by themselves. Now it is good ….” Regional level coordinator_1
CAMO 1: HEWs are unable to remove implants (C) No defined intervention (I) HEWs (A) worry about not being able to remove implants (M) and therefore are limited in the FP services they can provide (O) Self-efficacy
R: I have only taken training with regarding to administering the contraceptives. I have not had training in removals. Removals are a bit of challenge here because none of us are currently carrying them out.” Nurse_1
CIAMO 4:
Strong belief in religious values among religious leaders and within the community (C)
Analysis of religious text together with religious leaders (I) Religious leaders (A) recognise that FP aligns with their religious values (M) and support the use of FP (O) Ethicality, opportunity costs, compatibility,
“The religious leaders were first saying that family planning was Haram but since the project they had increase awareness and now are fully on board to point that they are teaching about family planning in the Mosque.” MCH Woreda officer_1
CIAMO 5: Religious leaders accept that FP aligns with religious values (C) Religious leaders openly promote alignment of FP with religious principles (I) Male partners (A) respect and trust the views of religious leaders (M) and support the use of FP (O) Ethicality, opportunity costs, compatibility
“I did have a situation where the women wanted the contraception on the same day as the immunisation day but her husband, who was with her at the time did not want her to take any contraception … What I then did was go to their house together with another religious leader to educate the husband about the benefits of family planning. To my surprise he actually agreed for his wife to have the 3 year implant.” HEW_1
CAMO 2: Supportive community environment for FP (C) No defined intervention (I) Women (A) feel supported by their partners and the wider community when making decisions about FP (M) and choose to take up an MCM (O) Self-efficacy
I: What is your husband’s opinion regarding this program? R: He says nothing. We have agreed. There is no problem. I: What did he say when you first start it? R: After we have agreed, he asked me how long it was for and I told him that the 3 years is better. I explained to him that after our children grow with good health and clothes, I will then remove it and have another child. I: Did he agree on that? R: Yes, we have agreed.” Woman user_2
CIAMO 6: Women want long-term methods of contraception Provision of long acting contraceptives (I) Women (A) feel confident in their ability to access implants (M) and choose to take up long-acting contraceptives (O) Self-efficacy
“The awareness that we have gained about family planning has also been great … now thanks to the implant I can’t get pregnant while I still have it in. We now try to have a 3–5 year gap between each child.” Group leader_1
CAMO 3: HEWs are unable to remove implants (C) No defined intervention (I) Women (A) worry about their inability to access implant removal (M) and may not choose to take up an implant (O) Self-efficacy, accessibility, availability, burden, accommodation
R: There are many good things to this project …. An improvement I would suggest would be to train us in removals. Women are currently being referred 27 km away. Transport is 30 birr return. This is a burden to them and is hindering the project from reaching higher coverage levels.” Nurse_1