Abstract
INTRODUCTION: Despite progress in reducing Uganda's unmet need for family planning (FP), particularly in urban areas, it remains high with notable intraurban disparities. FP services in urban settings are delivered in a complex health system, which impacts service delivery and utilisation. Acknowledging the complexity of FP utilisation in these contexts, this study adopted a systems thinking approach, using causal loop diagrams (CLDs), to examine the interrelationships between the factors influencing FP uptake in urban east central Uganda. METHODS: This qualitative study, conducted in Jinja city and Iganga municipality, used community-based system dynamic modelling to create CLDs to visualise the interrelationships between the different factors. The CLDs were developed through two group model building workshops, involving 14 community members and other key stakeholders. Initial model building was based on themes derived from analysis of data from eight focus group discussions, eight key informant interviews and four indepth interviews. The resulting CLDs were subsequently validated in a separate meeting with the participants. RESULTS: The study identified 30 key factors influencing FP utilisation mediated through five mechanisms: reproductive autonomy, service access, client satisfaction, perceptions of FP as important and perceived susceptibility to sexually transmitted infections among women. It highlighted the role of self-regulating feedback loops related to side effects, commodity and supply availability and provider workload, which moderate FP use. Additionally, the study emphasised the positive reinforcing effects of enhanced access to FP information on service access and uptake. CONCLUSION: Effective FP intervention designs should account for the complex interplay of factors affecting utilisation. Key leverage points include addressing the underlying negative religious and sociocultural beliefs that shape system behaviour, improving information flow and data use for better commodity management and human resource sustainability, enhancing contraceptive pharmacovigilance systems, improving the management of side effects and increasing access to FP information.