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Understanding ‘missed appointments’ for pills and injectables: a mixed methods study in Senegal
  1. Francesca L Cavallaro1,
  2. Diane Duclos1,
  3. Jenny A Cresswell1,
  4. Sylvain Faye2,
  5. David Macleod1,
  6. Adama Faye3,
  7. Caroline A Lynch1
  1. 1 Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
  2. 2 Départment de sociologie, Université Cheikh Anta Diop, Dakar, Senegal
  3. 3 Institut Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
  1. Correspondence to Dr Francesca L Cavallaro; francesca.cavallaro{at}


Introduction High discontinuation rates of contraceptive methods have been documented in sub-Saharan Africa. However, little is known about gaps within individual episodes of method use, despite their implications for unintended pregnancies. The objective of this mixed methods study was to examine the prevalence of, and explore the factors contributing to, delays in repeat appointments for pills and injectables in Senegal.

Methods First, we constructed a longitudinal data set of women’s contraceptive consultations using routine records from 67 facilities in Senegal. Consultations for pills and injectables were classified as on time, delayed or with unknown delay status based on time since previous appointment. We described the prevalence of delayed appointments and used backward stepwise regression to build a mixed-effects model to investigate risk factors for delay. Second, we conducted workshops with family planning (FP) providers, and indepth interviews and focus group discussions with women of reproductive age, to explore factors contributing to delays.

Results Almost one-third (30%) of appointments for pills and injectables were delayed, resulting in risk of pregnancy. Previous delay, pill use, lower educational level, higher parity, third and subsequent visits, and Islamic faith were independently predictive of delays (p<0.04 for all). Although women’s ‘forgetfulness’ was initially mentioned as the main reason for delays by women and providers, examining the routines around appointment attendance revealed broader contextual barriers to timely refills—particularly widespread covert use, illiteracy, financial cost of FP services and limited availability of FP services.

Conclusion Delays in obtaining repeat pills and injections are common among contraceptive users in Senegal, exposing women to unintended pregnancies. Strategies to reduce such delays should move beyond a narrow focus on individual women to consider contraceptive behaviour within the broader socioeconomic and health systems context. In particular, effective interventions addressing low acceptability of contraception and appointment reminder strategies in high illiteracy contexts are needed.

  • family planning
  • contraception
  • adherence
  • discontinuation
  • delay
  • Senegal

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  • Handling editor Seye Abimbola

  • Contributors FLC designed and conducted the quantitative analysis, with support from JAC. DD designed the qualitative analysis and conducted the analysis with SF. CAL was the principal investigator of the Informed Push Model evaluation, and contributed to all aspects of the study design and conduct, with input from AF, FLC, DD and SF. AF and FLC managed the quantitative data collection, and DD and SF managed the qualitative data collection. FLC wrote the first draft of the manuscript. All authors provided input on the manuscript and approved the final version.

  • Funding Funding for the evaluation of the Informed Push Model was provided by MSD for Mothers.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Ethical approval for the evaluation of the Informed Push Model was granted by the ethics committee of the Senegalese Ministry of Health and Social Action, and of the London School of Hygiene & Tropical Medicine, UK, which also granted ethical approval for this secondary analysis.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The full data set is available from the corresponding author at