Family planning (FP) is one of the most significant public health advances of the twentieth century because it has given women greater agency to realize their reproductive intentions, that is, whether to have children, how many children to have, and when. This has advanced women’s reproductive health, education, and social and economic participation globally ^{1, 2} . However, many countries have struggled to increase FP use and benefit from those health, social, and economic dividends at a population level. Despite Senegal’s early (2012) commitment to the Family Planning 2020 (FP2020) global partnership and membership in the Ouagadougou Partnership, Senegal fell short of its goals of reaching a 45 percent modern contraceptive prevalence (MCP) and reducing unmet need for modern contraception to 10 percent by 2020 ³ . In 2020, the estimated MCP was 27.7 percent among married women and 19.8 percent among all women and unmet need was 22.4 percent among married women ³ . A version of this article was previously published as a dissertation on our university's website here.

Increasing MCP requires dual investments in improving the supply of quality contraceptive products and services and expanding demand for these products and services. Senegal has made significant supply-side improvements in the past decade, particularly through the implementation of an informed push model of contraceptive distribution and resource mobilization ^{4– 8} . However, demand-generation activities appear to have had less success in developing a well-informed population with a culture supportive of FP. Surveys between 2011 and 2015 of urban women and men from the Measurement, Learning & Evaluation (MLE) project in Senegal found that more than half of women and approximately half of men believed that contraceptives are dangerous to women’s health and that these perceptions did not change significantly over time” ^{9, 10} . In a 2020 publication, 45 percent of Senegalese women surveyed reported that their husbands were the major source of pressure to have more children and 62 percent reported that women should not use contraceptives without their husband’s permission ¹¹ . These data suggest that cognitive and social factors are probable deterrents to modern contraceptive uptake and continuation in Senegal, particularly in urban areas where supply chain barriers to FP are less pronounced.

Social and behavioral change (SBC) communication messages can increase FP knowledge, influence attitudes and social norms, and ultimately create informed, voluntary demand for FP ^{12– 15} . Several studies have presented evidence linking health communication programs to increased modern contraceptive use in Senegal ^{16– 21} . Effective SBC programming relies on audience segmentation, which traditionally identifies population subgroups based on geographic, demographic, or other characteristics that influence decision-making and predict priority outcomes ²² . Ideational segmentation is an important technique that can enhance FP SBC campaigns by providing insight into who to reach, how to reach them, and what messages to communicate. Ideation is defined as “the perceptions and ideas that individuals hold that reflect various social, environmental, and personal influences” ^{23, 24} . Several studies have identified associations between positive health ideation and healthy behavioral outcomes including modern contraceptive use ^{14, 25– 29} . Contraceptive ideation comprises three primary domains of psychosocial variables: cognitive (attitudes, values, knowledge, subjective norms, self-image), emotional (preferences and self-efficacy), and social (interpersonal communication, social support, and social influence) ^{26, 30, 31} . These psychosocial variables are foundational to women’s contraceptive decision-making. In the past decade, researchers have begun to use more specialized techniques to identify prototypical subgroups in heterogeneous populations that share key characteristics related to contraceptive ideation and use ^{14, 26, 27, 32, 33} . A latent class analysis among urban women of reproductive age in Nigeria identified prototypical classes of women who shared similar patterns of cognitive, emotional, and social indicators of contraceptive ideation ²⁹ . The study found a direct relationship between membership in certain classes and contraceptive use and suggested that a better understanding of contraceptive ideational profiles (CIPs) of women may improve how FP communication programs tailor messages to different audience segments. Additional research in Nigeria, Burkina Faso, and Kenya indicated that audience segmentation based on contraceptive ideation should be routinely applied to the development of health communication programming ^{13, 14, 29, 34, 35} . Ideational profiling as a method of audience segmentation takes a person-centered approach in that it seeks out prototypical patterns of key ideational indicators such as FP awareness, beliefs, efficacy, partner communication, partner support, and community support whereas standard regression approaches often examine the contributions of these indicators in isolation by controlling for covariates. Additionally, examining whether and how these patterns change over time can reveal nuances about how sub-populations are changing and evolving. These insights can inform responsive and impactful communications campaigns.

The objectives of this study were to 1) identify and describe contraceptive ideational profiles (CIPs) of urban, partnered women of reproductive age in Senegal, 2) examine how membership in those CIPs changed over time, and 3) determine whether exposures to various health communication interventions were predictive of transitions between CIPs over time. Analyzing the relative stability of ideational profiles over time and the impact of health communication on transitions between more empowered and less empowered ideational profiles can help communication programs better tailor FP message content and modalities. To our knowledge, this was the first application of latent transition analysis to advance the understanding of contraceptive ideation in a low-resource setting.

We analyzed data from the Measurement, Learning and Evaluation (MLE) project for the Urban Reproductive Health Initiative in Senegal that included survey data from a longitudinal (2011–2015) sample of urban Senegalese women of reproductive age (15–49) who lived in Dakar, Guédiawaye, Pikine, Mbao, Mbour, and Kaolack ^{10, 21} . In 2011, a two-stage sampling design was used to collect data from a random sample of 21 households in 268 study clusters, stratified by poor and non-poor, based on a probability proportional to their populations. Poor strata were oversampled to increase inclusion of poor households and women. All women ages 15–49 years in the selected households were eligible to participate in the 2011 baseline survey. At baseline, 9,614 women were interviewed and 6,927 of these women were re-interviewed at endline (2015) for a follow up of 73.5% ^{10, 21} . We restricted our dataset to 4,047 women who were in-union (married or living with a partner) at baseline and who responded to the endline survey. Several important survey questions were only asked of women who were in-union because premarital sex is taboo in Senegal. Additionally, initial exploratory latent profile analyses at baseline found no significant or meaningful differences when comparing profiles of women without endline data to profiles of women with endline data. A balanced dataset allowed us to clearly articulate and quantify movement between CIPs over time and endline probability weights accounted for attrition.

To estimate and characterize transitions between latent profiles over time, we conducted a latent transition analysis (LTA). LTA is a form of finite mixture modeling often used in health policy and health services research to identify unobservable, or latent, prototypical profiles within a large heterogeneous population based on observed response patterns and to assess how profiles and profile membership changes over time ^{36– 39} . LTA assumes that there is a mixture of discrete distributions that comprise the population heterogeneity and identifies the most likely model by defining a finite number of profiles ⁴⁰ . LTA assumes an underlying latent categorical variable that gives rise to the observed variables and returns the probability of membership in each profile based on patterns of item-response probabilities. LTA has become an important person-centered tool for examining changes and trends in groupings of health and behavioral characteristics ^{41, 42} .

We selected ideational indicators (constructs) of the latent contraceptive ideational profile (CIP) variable based on 1) Kincaid’s theoretic framework of contraceptive ideation, 2) evidence from the literature on important factors in FP decision-making, 3) previous research on contraceptive ideational profiles in low-resource settings, and 4) a review of the shape and variance of available variables in the dataset ^{29, 34, 35} . Wurpts and Geiser (2014) suggest that using at least five indicators with strong relationships to the latent profile variable contributes to greater certainty in defining the classes ⁴³ . After considering tradeoffs between including more indicator variables and increasing the risk of data sparseness and including a subset of indicator variables that risk not adequately specifying the model, we ultimately selected six indicators for which there is substantial evidence of their importance in contraceptive decision-making.

Once we selected theory- and evidence-based domains and indicators of our latent variable, we created constructs using the available variables in the MLE dataset ( Table 1). Three indicators were continuous constructs comprised of multiple survey questions. For FP awareness, women were asked to name any FP methods they knew. When they had listed all methods they knew, they were then prompted on whether they had heard of other methods that they had not spontaneously listed. For each method that a woman mentioned spontaneously, she received a score of 1 point. For each method that she had heard of when prompted, she received 0.5 points. Points were summed and the resulting construct had a range of 0 to 13. For misconceptions, women were asked whether they totally agreed, agreed, disagreed, or totally disagreed with seven statements about common negative beliefs and misconceptions about FP. Responses received -2, -2, 2, and 2 points, respectively, such that high scores indicated a strong rejection of misconceptions. Perceived self-efficacy was scored in the same way for eight questions about a woman’s beliefs about her ability to act on her contraceptive intentions. For constructs that were a composite of multiple variables, we examined Cronbach’s alpha to test whether the variables reliably measured the same phenomenon and found satisfactory internal consistency.

Figure 1 visualizes the latent transition conceptual model for contraceptive ideation. In this model, we hypothesize that there is a categorical latent variable that explains similarities in contraceptive ideation among subgroups of women. We also hypothesize that exposures to various types of FP health communication programming may differentially affect membership in the endline CIPs and transitions between baseline and endline CIPs.

LTA model selection considerations included model fit, parsimony, interpretation, and utility for answering our research questions of interest. We ultimately selected the LTA model with four CIPs at baseline and endline because it represented improved model fit over the two- and three-CIP models producing lower log likelihood, AIC, BIC, and ABIC statistics. We did not select the five-CIP or higher models because they had issues of extreme sparseness in their contingency tables, with some CIPs having no members. Sparseness is problematic for examining how key covariates influence transitions between CIPs over time. Although we did not identify measurement invariance over time, we still found it useful to constrain the item response probabilities so that the interpretation of the CIPs was the same at baseline and endline. Measurement variance may have been due to overall improvements in contraceptive ideation over time, as indicated by overall increases in the scores of indicators at endline. The constrained model fit statistics represented only slight decreases in model fit compared to the unconstrained models but improved entropy.

Once we selected the model, we analyzed the item response probabilities for each of the six indicators to interpret each of the four latent CIPs. Table 2 presents the mean item response probabilities for each indicator for the constrained four CIP LTA model. For all item response probabilities, CIP 1 had the lowest (least desirable or least empowered) scores across all indicators, though some were not statistically different from CIP 2. CIP 4 had the highest (most desirable, most empowered) scores across all indicators, with no overlap of confidence intervals with other CIPs. CIPs 2 and 3 were qualitatively different in that women in CIP 2 were more likely to reject negative beliefs and misconceptions than women in CIP 3 but otherwise had lower FP awareness, self-efficacy, partner support, partner communication, and social support. CIP 1 had the smallest proportional membership at baseline and endline. At endline, the proportional memberships of CIP 1 decreased and CIP 4 increased compared to baseline, indicating improvements in contraceptive ideation over time.

Figure 2 presents a standardized z-score distribution of the constrained latent CIP indicators by CIP using baseline population means and standard deviations. This figure visualizes the directionality and strength of the mean estimate of the indicator for each latent CIP related to the mean of the population (z-score of 0). This visualization aided in the qualitative labeling of the CIPs.

To our knowledge, this study is the first to demonstrate the utility of longitudinal latent variable modeling of contraceptive ideation and its particular relevance to FP communication programs. We identified four prototypical profiles of women who demonstrated unique defining characteristics of contraceptive ideation that indicated that they might be differentially receptive to various FP communication modalities and messages. The four profiles included a group of women who reported very low scores on all six ideational indicators (CIP 1: Lowest efficacy and FP awareness, highest misconceptions, unsupported); two qualitatively different profiles of women, one of which was driven by low self-efficacy but a rejection of misconceptions about FP and the other of which was characterized by strong misconceptions about FP but fairly high contraceptive awareness (CIP 2: Low efficacy and FP awareness, rejects misconceptions, unsupported, and CIP 3: Moderate efficacy, high FP awareness, high misconceptions, moderate support, respectively); and a fourth profile in which women were cognitively, emotionally, and socially empowered in their contraceptive ideation (CIP 4: Highest efficacy and FP awareness, fewest misconceptions, most supported). The insights about these groups of women can help decision-makers appropriately allocate resources to the design of responsive FP interventions and messages. For example, women in CIPs 1 and 2 might benefit from empowering messages that focus on bolstering their self-efficacy whereas women in CIP 3 might benefit from myth-busting positive messaging. Using longitudinal data, we found that over a four-year period (2011–2015) women generally transitioned to become members of more empowered CIPs.

In terms of predictors of endline CIP membership, we found that TV, radio, religious leaders, and community conversations with CHW were all effective modalities in that they each were associated with lower odds of membership in less empowered endline CIPs compared to more empowered CIP 4. Only TV and CHWs differentiated endline membership between endline CIP 1 and endline CIP 2. Another way to interpret this insight is that hearing about FP from TV and from discussion with CHW was a significant differentiator for endline CIP 1 compared to all other CIPs. Communications programs might consider using these channels if the primary goal is to just move people out of CIP 1. Unsurprisingly, exposure to additional communication modalities was also predictive of membership in more empowered endline CIPs. Programs should therefore strive to reinforce FP messages through different channels, as this may increase the credibility, strength, or internalization of the messages for women, their partners, and their communities, all of which can contribute to more positive ideation. In terms of content, we found that messages about the legitimacy of FP and birth spacing were the strongest predictors of membership in more empowered ideational CIPs among the different communication messages used in this program. It was interesting to note that messages about birth spacing were consistent differentiators of endline CIP 1 from all other CIPs, so perhaps this message resonated most with this least empowered group. Programs should consider weaving these themes into their other messages around spousal communication, the position of Islam on FP, the limitation of family size, or rumors and fears about FP.

When we examined transitions that were conditioned on baseline membership, one interesting finding was that the significance and magnitude of many of the indicators changed compared with the more simple endline analyses (Models1–3). This suggests that history matters; that the effects of these exposures are influenced by where a woman is coming from, ideationally.

FP programs can use LTA methodology with nationally representative population data or with smaller programmatic datasets to target women and communities with positive health messaging through appropriate communication channels. Knowing how women in different CIPs access and respond to communication content and modalities can help programs reach the audience segments with effective messages through trusted channels.

This study is novel and important for three reasons. First, we demonstrated that latent variable modeling can effectively segment women based on their patterns of social, emotional, and cognitive factors underlying contraceptive ideation. Second, our analysis shed light on women’s transitions between ideational statuses over time. Third, we explored how health communication message content and modality may have influenced those transitions. These insights can be used to create and shape engaging message content and disseminate it through appropriate channels based on ideational needs and channel preferences. These steps can be replicated in other settings using indicators that are locally available and relevant.

The results of this study have important implications for FP communication programs in Senegal and other settings in which socio-cultural norms limit women’s contraceptive decision-making. Communication programs should apply contraceptive ideational profiling as an enhanced SBC approach to achieve a more nuanced understanding of the ideational states and needs of the population and to respond effectively to those needs. Future work should focus on 1) developing a validated toolkit for selecting indicators for contraceptive ideational profiling based on commonly available data sources, 2) creating clear processes for FP communication programs to implement ideational profiling, and 3) empirically evaluating whether latent ideational profiling is better able to reach and engage constituents with relevant content compared with traditional segmentation approaches. Ultimately, this ideational segmentation can be a novel SBC program enhancement to support the Government of Senegal and other countries to reach their FP 2030 Goals.