{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T23:28:08Z","timestamp":1787614088197,"version":"build-2736575974"},"reference-count":35,"publisher":"BMJ","issue":"8","license":[{"start":{"date-parts":[[2021,8,17]],"date-time":"2021-08-17T00:00:00Z","timestamp":1629158400000},"content-version":"unspecified","delay-in-days":16,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100003168","name":"Foundation for Advanced Studies on International Development","doi-asserted-by":"publisher","award":["Scholarship grant"],"award-info":[{"award-number":["Scholarship grant"]}],"id":[{"id":"10.13039\/501100003168","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2021,7,28]]},"published-print":{"date-parts":[[2021,8]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To examine the effects of a positive deviance intervention on dual-method contraceptive use among married or in-union women.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Open-label cluster randomised controlled trial.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>20 health facilities in Mbarara District, Uganda.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>960 married or in-union women aged 18\u201349\u2009years using a non-barrier modern contraceptive method.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interventions<\/jats:title>\n                    <jats:p>A combination of clinic-based and telephone-based counselling and a 1-day participatory workshop, which were developed based on a preliminary qualitative study of women practising dual-method contraception.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary outcome measure<\/jats:title>\n                    <jats:p>Dual-method contraceptive use at the last sexual intercourse and its consistent use in the 2\u2009months prior to each follow-up. These outcomes were measured based on participants\u2019 self-reports, and the effect of intervention was assessed using a mixed-effects logistic regression model.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>More women in the intervention group used dual-method contraception at the last sexual intercourse at 2\u2009months (adjusted OR (AOR)=4.12; 95% CI 2.02 to 8.39) and 8\u2009months (AOR=2.16; 95% CI 1.06 to 4.41) than in the control group. At 4 and 6\u2009months, however, the proportion of dual-method contraceptive users was not significantly different between the two groups. Its consistent use was more prevalent in the intervention group than in the control group at 2\u2009months (AOR=14.53; 95% CI 3.63 to 58.13), and this intervention effect lasted throughout the follow-up period.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The positive deviance intervention increased dual-method contraceptive use among women, and could be effective at reducing the dual risk of unintended pregnancies and HIV infections. This study demonstrated that the intervention targeting only women can change behaviours of couples to practise dual-method contraception. Because women using non-barrier modern contraceptives may be more reachable than men, interventions targeting such women should be recommended.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>UMIN000037065.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2020-046536","type":"journal-article","created":{"date-parts":[[2021,8,18]],"date-time":"2021-08-18T13:21:52Z","timestamp":1629292912000},"page":"e046536","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":5,"title":["Positive deviance for promoting dual-method contraceptive use among women in Uganda: a cluster randomised controlled trial"],"prefix":"10.1136","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6388-9498","authenticated-orcid":false,"given":"Hodaka","family":"Kosugi","sequence":"first","affiliation":[{"name":"Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2058-1722","authenticated-orcid":false,"given":"Akira","family":"Shibanuma","sequence":"additional","affiliation":[{"name":"Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Junko","family":"Kiriya","sequence":"additional","affiliation":[{"name":"Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7196-7671","authenticated-orcid":false,"given":"Ken Ing Cherng","family":"Ong","sequence":"additional","affiliation":[{"name":"Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen","family":"Mucunguzi","sequence":"additional","affiliation":[{"name":"Programme Section, UNICEF Uganda Country Office, Kampala, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7866-5198","authenticated-orcid":false,"given":"Conrad","family":"Muzoora","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5659-3237","authenticated-orcid":false,"given":"Masamine","family":"Jimba","sequence":"additional","affiliation":[{"name":"Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2021,8,18]]},"reference":[{"key":"2025121222285657000_11.8.e046536.1","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0220970","article-title":"Prevalence and determinants of unintended pregnancy in sub-Saharan Africa: a multi-country analysis of demographic and health surveys","volume":"14","author":"Ameyaw","year":"2019","journal-title":"PLoS One"},{"key":"2025121222285657000_11.8.e046536.2","unstructured":"UNAIDS . UNAIDS data 2019, 2019. Available: https:\/\/www.unaids.org\/sites\/default\/files\/media_asset\/2019-UNAIDS-data_en.pdf [Accessed 21 Mar 2020]."},{"key":"2025121222285657000_11.8.e046536.3","doi-asserted-by":"publisher","DOI":"10.2174\/1874613601610010034"},{"key":"2025121222285657000_11.8.e046536.4","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-016-3783-5"},{"key":"2025121222285657000_11.8.e046536.5","first-page":"Cd010915","article-title":"Behavioral interventions for improving dual-method contraceptive use","volume":"3","author":"Lopez","year":"2014","journal-title":"Cochrane Database Syst Rev"},{"key":"2025121222285657000_11.8.e046536.6","first-page":"51","article-title":"Barriers to use of dual protection among married women in a suburban setting","volume":"4","author":"Mutowo","year":"2015","journal-title":"Nurs Health Sci"},{"key":"2025121222285657000_11.8.e046536.7","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1007\/s12546-017-9195-2","article-title":"Condom use among married and cohabiting women and its implications for HIV infection in Mahikeng, South Africa","volume":"35","author":"Osuafor","year":"2018","journal-title":"J Popul Res"},{"key":"2025121222285657000_11.8.e046536.8","doi-asserted-by":"publisher","DOI":"10.1136\/jfprhc-2015-101175"},{"key":"2025121222285657000_11.8.e046536.9","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0216208","article-title":"Consistent condom use among highly effective contraceptive users in an HIV-endemic area in rural Kenya","volume":"14","author":"Kosugi","year":"2019","journal-title":"PLoS One"},{"key":"2025121222285657000_11.8.e046536.10","doi-asserted-by":"publisher","DOI":"10.1016\/S0277-9536(99)00060-X"},{"key":"2025121222285657000_11.8.e046536.11","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2013.06.024"},{"key":"2025121222285657000_11.8.e046536.12","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1016\/j.contraception.2011.01.023","article-title":"Adherence to dual-method contraceptive use","volume":"84","author":"Peipert","year":"2011","journal-title":"Contraception"},{"key":"2025121222285657000_11.8.e046536.13","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1001\/jamapediatrics.2013.1089","article-title":"Prime time: sexual health outcomes at 24 months for a clinic-linked intervention to prevent pregnancy risk behaviors","volume":"167","author":"Sieving","year":"2013","journal-title":"JAMA Pediatr"},{"key":"2025121222285657000_11.8.e046536.14","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1080\/09688080.2018.1510701","article-title":"The empower Nudge lottery to increase dual protection use: a proof-of-concept randomised pilot trial in South Africa","volume":"26","author":"Gal\u00e1rraga","year":"2018","journal-title":"Reprod Health Matters"},{"key":"2025121222285657000_11.8.e046536.15","unstructured":"Ministry of Health, Uganda . Uganda population-based HIV impact assessment (UPHIA) 2016-2017: final report. Kampala: Ministry of Health, 2019."},{"key":"2025121222285657000_11.8.e046536.16","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2015-009991"},{"key":"2025121222285657000_11.8.e046536.17","unstructured":"Uganda Bureau of Statistics . Uganda demographic and health survey 2016, 2018. Available: https:\/\/dhsprogram.com\/pubs\/pdf\/FR333\/FR333.pdf [Accessed 10 Aug 2020]."},{"key":"2025121222285657000_11.8.e046536.18","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.329.7475.1177"},{"key":"2025121222285657000_11.8.e046536.19","doi-asserted-by":"crossref","first-page":"664","DOI":"10.1080\/01639625.2017.1286194","article-title":"Positive deviance in theory and practice: a conceptual review","volume":"39","author":"Herington","year":"2018","journal-title":"Deviant Behav"},{"key":"2025121222285657000_11.8.e046536.20","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph17145009","article-title":"Positive deviance for dual-method promotion among women in Uganda: a qualitative study","volume":"17","author":"Kosugi","year":"2020","journal-title":"Int J Environ Res Public Health"},{"key":"2025121222285657000_11.8.e046536.21","doi-asserted-by":"crossref","DOI":"10.1186\/s13063-020-4192-8","article-title":"Positive deviance for dual-method promotion among women in Uganda: study protocol for a cluster randomized controlled trial","volume":"21","author":"Kosugi","year":"2020","journal-title":"Trials"},{"key":"2025121222285657000_11.8.e046536.22","unstructured":"Uganda Bureau of Statistics . The National population and housing census 2014\u2013Main report, 2016. Available: https:\/\/unstats.un.org\/unsd\/demographic\/sources\/census\/wphc\/Uganda\/UGA-2016-05-23.pdf [Accessed 31 Aug 2020]."},{"key":"2025121222285657000_11.8.e046536.23","unstructured":"Ministry of Health, Uganda . National health facility master list 2018. Kampala: Ministry of Health, 2089."},{"key":"2025121222285657000_11.8.e046536.24","doi-asserted-by":"publisher","DOI":"10.1007\/s10461-013-0631-9"},{"key":"2025121222285657000_11.8.e046536.25","unstructured":"WHO, Johns Hopkins Bloomberg School of Public Health . Center for communication programs. information and knowledge for optimal health (INFO). Decision-making tool for family planning clients and providers, 2005. Available: https:\/\/www.who.int\/reproductivehealth\/publications\/family_planning\/9241593229\/en\/ [Accessed 10 Aug 2019]."},{"key":"2025121222285657000_11.8.e046536.26","doi-asserted-by":"publisher","DOI":"10.1007\/s10461-012-0146-9"},{"key":"2025121222285657000_11.8.e046536.27","doi-asserted-by":"publisher","DOI":"10.1521\/aeap.14.2.172.23902"},{"key":"2025121222285657000_11.8.e046536.28","doi-asserted-by":"crossref","DOI":"10.1186\/1472-698X-13-22","article-title":"Validation of the condom use self-efficacy scale in Ethiopia","volume":"13","author":"Shaweno","year":"2013","journal-title":"BMC Int Health Hum Rights"},{"key":"2025121222285657000_11.8.e046536.29","doi-asserted-by":"publisher","DOI":"10.1023\/A:1007051506972"},{"key":"2025121222285657000_11.8.e046536.30","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2006.10.012"},{"key":"2025121222285657000_11.8.e046536.31","doi-asserted-by":"publisher","DOI":"10.2989\/16085906.2002.9626540"},{"key":"2025121222285657000_11.8.e046536.32","doi-asserted-by":"publisher","DOI":"10.1016\/S0968-8080(06)28268-5"},{"key":"2025121222285657000_11.8.e046536.33","doi-asserted-by":"publisher","DOI":"10.1016\/j.contraception.2012.06.007"},{"key":"2025121222285657000_11.8.e046536.34","doi-asserted-by":"crossref","DOI":"10.1186\/1472-6874-14-39","article-title":"Dual method use for protection of pregnancy and disease prevention among HIV-infected women in South East Nigeria","volume":"14","author":"Lawani","year":"2014","journal-title":"BMC Womens Health"},{"key":"2025121222285657000_11.8.e046536.35","unstructured":"Pascale R , Monique S , Sternin J . The power of positive deviance: How unlikely innovators solve the world\u2019s toughest problems. 1st edn. Brighton, Massachusetts: Harvard Business Press, 2010."}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2020-046536","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,13]],"date-time":"2025-12-13T06:29:05Z","timestamp":1765607345000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2020-046536"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,8]]},"references-count":35,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2021,8,18]]},"published-print":{"date-parts":[[2021,8]]}},"alternative-id":["10.1136\/bmjopen-2020-046536"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2020-046536","relation":{"has-preprint":[{"id-type":"doi","id":"10.1101\/2020.10.03.20206169","asserted-by":"object"}]},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,8]]}}}