Project Summary/Abstract: In response to the Notice of Special Interest for ancillary reproductive health projects to existing large and/or longitudinal studies, we propose to perform the Desire to Avoid Pregnancy Postpartum (DAPP) study. Our primary goal is to adapt the previously US-validated Desire to Avoid Pregnancy (DAP) scale to the context of women living in western Kenya and evaluate its psychometric performance, including predictive validity for contraceptive use. This research is necessary for the development of shared decision-making tools for reproductive health that are urgently needed to improve effective contraceptive use, prevent unplanned pregnancy, and improve pregnancy outcomes. Much is still unknown about reasons for contraceptive non-use, but contraceptive need has been narrowly defined by dichotomous questions about pregnancy intention that is not clinically or culturally applicable and little is known about the role that pregnancy ambivalence or indifference, plays in contraceptive decision-making. Our central hypothesis is that women with lower DAP scores, indicating greater pregnancy ambivalence, are less likely to use contraception in the postpartum period, and that HIV status interacts with pregnancy preferences to determine contraceptive use. We posit that the cultural adaptation and refinement of the DAP scale will result in an important tool to be used during reproductive health shared decision-making in the clinical context. We will leverage our strengths, including strong working relationships with the AMPATH HIV treatment program, a large cohort recruited for the MANGO-Kenya pharmacovigilance study as part of East Africa International Epidemiology Databases to Evaluate AIDS that can be followed longitudinally, and extensive experience in qualitative research and psychometric methodologies to achieve the following aims. Specific Aim (SA)-1: We will utilize the outpatient HIV and reproductive health care clinics at Moi Teaching and Referral Hospital to recruit participants for qualitative analysis through focus group discussions and field testing to adapt the DAP scale for the cultural context of women living in western Kenya. We will explore current DAP items and potential responses and iteratively refine the scale items, responses, and Swahili translations based on feedback from participants and from psychometric analysis through field-testing. SA-2: We will leverage the cohort of women with and without HIV recruited through MANGO-Kenya to follow them through 6 months postpartum to identify their pregnancy preferences and contraceptive use or non-use to evaluate the psychometric performance of the adapted DAP scale, including whether the DAP score has predictive validity for the clinically relevant outcome of postpartum contraceptive use. We will also explore other reasons for contraceptive use and non-use, including barriers to access that may impact use, and use logistic regression to understand how pregnancy pr...