ZIKV-Related Ideations and Modern Contraceptive Use: Cross-Sectional Evidence from the Dominican Republic, El Salvador, Honduras, and Guatemala

"Health promotion and communication targeting family planning are essential in the region as this is still an area of high unmet family planning need and endemic ZIKV."

The initial surge of congenital Zika virus (ZIKV) syndrome prompted several Latin America and the Caribbean (LAC) ministries of health to recommend that women postpone or avoid pregnancy by using family planning until the ZIKV epidemic subsided. Women in areas with high rates of impoverishment and violence, and with poor healthcare infrastructure and lack of resources, were especially vulnerable to ZIKV due to elevated exposure to mosquitos and increased risk of unplanned pregnancy. Demand-side factors, such as pro-natalist religious ideologies, unequal gender roles, prohibitive social norms, and expectations regarding gender and sexuality, also limit the uptake of modern contraception in these countries. To explain these demand-side factors, the ideational model of communication and behaviour change focuses on multilevel determinants of behaviours. This study examines whether ZIKV-related ideational factors are related to modern contraceptive use among women and men with sexual partners in the Dominican Republic (DR), El Salvador, Guatemala, and Honduras.

On the ideational model, in the context of ZIKV:

• Cognitive ideational factors include those related to family planning (knowledge of modern contraceptives), as well as those related to ZIKV (knowledge, risk perceptions, subjective norms related to ZIKV, and ZIKV preventive behaviours).
• Emotional ideational factors related to family planning include self-efficacy related to partner communication and contraceptive use.
• Social ideation includes communication about family planning with partner.

So, on this model, if women believe that they are highly susceptible to contracting the disease, that contraception (e.g., condom use) is effective in protecting against the disease, and that the disease is severe and would lead to harmful outcomes (such as microcephaly), they are more likely to use modern contraception to reduce this risk. They are also more likely to use modern contraception if the use is easy and they have confidence in their ability to practice the behaviour, if they perceive that others are also using modern contraception, and if they can effectively communicate with their partners about contraception.

The analysis uses data from a representative sample of 2,600 men and women aged 18-49 years living in select United States Agency for International Development (USAID)-funded project areas within the DR (N = 651), El Salvador (N = 672), Guatemala (N = 668), and Honduras (N = 609). Data were collected as part of a formative research study to inform the USAID ZIKV response, which examined knowledge, attitudes, and practices, as well as exposure to ZIKV information through different channels. The association between self-reported use of modern contraception and measures of ZIKV knowledge, risk perceptions and social norms, and contraceptive self-efficacy was examined via sex-disaggregated multivariate logistic regression models.

Some family planning ideations were significantly associated with modern contraceptive use. Social ideations played a role in use of contraceptives for both men and women. Specifically, both men (odds ratio (OR) 3.70, 95% confidence interval (CI) 1.36-10.06, P < 0.05) and women (OR 3.71, 95% CI 2.30-5.99, P < 0.0001), who reported discussing family planning with their partner in the last year were more likely to use modern contraception compared with those who did not. In addition, respondents who reported having heard of at least three modern contraceptive methods in the past year were more likely to use modern contraceptives than those who had had heard of two or less.

There was no significant relation for both men and women between ZIKV-related cognitive ideations including concern about contracting ZIKV, perceived risk of contracting ZIKV, community social norms regarding ZIKV, and modern contraceptive use. These null results indicate that risk perceptions and subjective norms regarding the disease and transmission may not be the most effective points for intervention to increase use of modern contraceptives as a preventive behaviour. Instead, family planning ideations may be more useful to target for behavioural change.

The only significant association for ZIKV-related ideations was an inverse relation between knowledge that ZIKV can affect a fetus by causing birth defects and contraceptive use for women only. That is, knowledge that ZIKV can affect a fetus was negatively associated with modern contraceptive use for women (OR 0.49, 95% CI 0.29-0.85, P < 0.05), which was contrary to the researchers' expectation. Given the cross-sectional nature of the survey, women not using contraception, possibly due to fertility intentions or structural and normative gender-based barriers, may be more likely to remember that ZIKV can affect a fetus. The researchers suggest that further investigation is needed to understand the relationship between knowledge of birth defects and vertical transmission of ZIKV as they relate to contraceptive use for women, including access to contraceptives.

In concluding, the researchers stress that, although no longer an epidemic, "ZIKV is still endemic throughout the LAC. It is imperative that in the future public health emergencies that affect birth outcomes, such as ZIKV, and health promotion focus on the known determinants of contraception use, such as knowledge and partner communication, instead of relying on the fear of the outbreak to change fertility decision-making behavior."