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Uwajeneza P, Babenko-Mould Y, Evans M, Mukamana D. Teaching family planning to nurse and midwife students: A constructivist grounded theory study. Nurse Educ Pract 2024; 76:103916. [PMID: 38359684 DOI: 10.1016/j.nepr.2024.103916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/17/2024]
Abstract
AIM This study aimed to describe nurse/midwife educators' understanding and enactment of teaching family planning methods with nursing/midwifery students in educational programs in Rwanda. More precisely, the aim of this study was to generate a substantive theory that explains how nurse/midwife educators introduce family planning methods into their teaching practice to facilitate learning among nurse/midwife students in Rwanda. BACKGROUND High maternal mortality remains a global health issue. In 2017, approximately 295,000 women worldwide died from complications related to pregnancy or childbirth and 94% of these maternal deaths occurred in low-income countries. Evidence shows that family planning improves maternal health outcomes and significantly contributes to reducing maternal mortality. Low family planning uptake is partly attributed to inadequate education of healthcare providers to provide family planning services. DESIGN This study followed the constructivist grounded theory methodology articulated by Kathy Charmaz (2006; 2014). METHODS The primary data source was individual semi-structured interviews with 25 nurse/midwife educators recruited from all the schools/faculties/departments of nursing and midwifery in Rwanda, augmented with written documents related to family planning education in nursing/midwifery preservice programs. RESULTS The substantive Theory that emerged from the data analysis indicated that the process of teaching family planning in preservice nursing/midwifery education among nurse/midwife educators has three phases: preparing, facilitating and evaluating. Factors that had an impact on the process and actions that nurse/midwife educators undertook to address the challenges related to those factors were identified. The main influential factors that had a significant impact on nurse/midwife educators' ability to teach family planning are contextual factors and personal factors related to the nurse/midwife educators. The contextual factors included the availability of resources, student-teacher ratio, number of students in clinical placements and the time allocated to the family planning unit. The personal factors related to the nurse/midwife educators included knowledge, skills, confidence, attitude, beliefs and moral values toward family planning methods. CONCLUSION These study findings generated valuable knowledge that can guide the improvement of teaching family planning in preservice nursing/midwifery programs in Rwanda and other limited-resource countries and contexts. With the insights provided by this study, future research should investigate strategies to overcome highlighted barriers, increase nurse/midwife educators' expertise in teaching family planning and enhance the preparedness of nurse/midwife students on some family planning methods identified in this study.
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Affiliation(s)
- Pauline Uwajeneza
- Arthur Labatt Family School of Nursing, Western University, London, Ontario N6A 5B9, Canada; Ruli Higher Institute of Health, District Road 51, Ruli Sector, PO Box 1285, Kigali, Rwanda.
| | - Yolanda Babenko-Mould
- Arthur Labatt Family School of Nursing, Western University, London, Ontario N6A 5B9, Canada
| | - Marilyn Evans
- Arthur Labatt Family School of Nursing, Western University, London, Ontario N6A 5B9, Canada
| | - Donatilla Mukamana
- School of Nursing and Midwifery, University of Rwanda, PO Box 3286, Kigali, Rwanda
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Abstract
BACKGROUND The unmet need for safe and effective contraception still remains high. In 2017, about 25% of women of childbearing age who wanted to avoid pregnancy in the developing world were not using a modern contraceptive method. The biggest proportion (21%) of these women live in Sub-Saharan Africa. Little attention has been paid to the health systems factors impacting the integration of family planning into HIV services. This systematic review intends to document health systems factors constraining or facilitating the integration of family planning into HIV services. METHODS A search of electronic databases such as PubMed and Google Scholar was conducted using keywords. We considered peer-reviewed articles which were published in English between 1st January 2010 and 31st December 2020. The peer-reviewed articles which were considered focussed on identifying barriers and facilitators at the levels of the health system which influence the success or failure of integrated family planning and HIV programs, availability of integrated family planning services in HIV care, the evidence on the feasibility, effectiveness and cost-effectiveness of integrating family planning and HIV services and investigating the outcomes of programs aimed at strengthening family planning integration in HIV counselling, testing and care. Twenty-seven articles that identify factors affecting integration of family planning into HIV services met the inclusion criteria and were thematically analysed. RESULTS Health systems factors constraining integration of family planning and HIV services were human resource turnover and shortages, lack of policy guidance on integrated care, poor oversight, unclear service delivery guidelines, inadequate infrastructure and insufficient monitoring systems. Facilitators to the successful integration of family planning into HIV services were identified as training in family planning for service providers, the creation of a supportive policy environment to accommodate service integration, supportive supervision and a positive attitude by service providers towards service integration. CONCLUSION Increase in the health workforce to support integrated service delivery, skills enhancement for service providers and improvement in family planning commodity stock levels play a key role in facilitating the integration of family planning into HIV services.
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Affiliation(s)
- Luka Nkhoma
- School of Public Health, University of Zambia, Lusaka, Zambia
| | | | - Joseph Mumba Zulu
- Institute of Distance Education, University of Zambia, Lusaka, Zambia
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Mazzei A, Ingabire R, Karita E, Mukamuyango J, Nyombayire J, Parker R, Tichacek A, Allen S, Wall KM. Cross-sectional assessment of government health center needs to implement long-acting reversible contraception services in rural Rwanda. BMC Womens Health 2021; 21:411. [PMID: 34911535 PMCID: PMC8672509 DOI: 10.1186/s12905-021-01555-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/12/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is unmet need for family planning in Rwanda. We previously developed an evidence-based couples' family planning counseling (C)FPC program in the capital city that combines: (1) fertility goal-based family planning counseling with a focus on long-acting reversible contraceptive (LARC) for couples wishing to delay pregnancy; (2) health center capacity building for provision of LARC methods, and (3) LARC promotion by community health workers (CHW) trained in community-based provision of oral and injectable contraception. From 2015 to 2016, this service was integrated into eight government health centers in Kigali, reaching 6072 clients and resulting in 5743 LARC insertions. METHODS From May to July 2016, we conducted cross-sectional health center needs assessments in 30 rural health centers using surveys, key informant interviews, logbook extraction, and structured observations. The assessment focused on the infrastructure, materials, and human resources needed for LARC demand creation and provision. RESULTS Few nurses had received training in LARC insertion [41% implant, 27% intrauterine device (IUD)]. All health centers reported working with CHW, but none trained in LARC promotion. Health centers had limited numbers of IUDs (median 10), implants (median 39), functional gynecological exam tables (median 2), and lamps for viewing the cervix (median 0). Many did not have backup power supplies (40%). Most health centers reported no funding partners for family planning assistance (60%). Per national guidelines, couples' voluntary HIV counseling and testing (CVCT) was provided at the first antenatal visit at all clinics, reaching over 80% of pregnant women and their partners. However, only 10% of health centers had integrated family planning and HIV services. CONCLUSIONS To successfully implement (C)FPC and LARC services in rural health centers across Rwanda, material and human resource capacity for LARC provision will need to be greatly strengthened through equipment (gynecological exam tables, sterilization capacity, lamps, and backup power supplies), provider trainings and follow-up supervision, and new funding partnerships. Simultaneously, awareness of LARC methods will need to be increased among couples through education and promotion to ensure that demand and supply scale up together. The potential for integrating (C)FPC with ongoing CVCT in antenatal clinics is unique in Africa and should be pursued.
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Affiliation(s)
- Amelia Mazzei
- Projet San Francisco, Rwanda Zambia Health Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Kigali, Rwanda
| | - Rosine Ingabire
- Projet San Francisco, Rwanda Zambia Health Research Group, Kigali, Rwanda
| | - Etienne Karita
- Projet San Francisco, Rwanda Zambia Health Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Kigali, Rwanda
| | | | - Julien Nyombayire
- Projet San Francisco, Rwanda Zambia Health Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Kigali, Rwanda
| | - Rachel Parker
- Rwanda Zambia Health Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Amanda Tichacek
- Rwanda Zambia Health Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Susan Allen
- Rwanda Zambia Health Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Kristin M Wall
- Rwanda Zambia Health Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA.
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA.
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Henry D, Wood S, Moshashane N, Ramontshonyana K, Amutah C, Maleki P, Howlett C, Brooks MJ, Mussa A, Joel D, Steenhoff AP, Akers AY, Morroni C. Facilitators and Barriers to Implementation of Long-Acting Reversible Contraceptive Services for Adolescent Girls and Young Women in Gaborone, Botswana. J Pediatr Adolesc Gynecol 2021; 34:504-513. [PMID: 33766793 PMCID: PMC8277689 DOI: 10.1016/j.jpag.2021.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/08/2021] [Accepted: 03/15/2021] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVE Botswana has a high pregnancy rate among adolescent girls and young women (AGYW). Long-acting reversible contraceptive (LARC) use among AGYW in Botswana is low, despite its high effectiveness for preventing pregnancy. Using an implementation science framework, we assessed barriers and facilitators to LARC implementation among AGYW in Botswana. DESIGN Cross-sectional mixed methods. SETTING Gaborone, Botswana. PARTICIPANTS Twenty sexually active AGYW ages 18-24 years; 20 health system stakeholders. INTERVENTIONS Surveys and semistructured interviews grounded in the Consolidated Framework for Implementation Research. MAIN OUTCOME MEASURES Themes reflecting barriers and facilitators of LARC implementation. RESULTS The median age for AGYW was 22 (interquartile range, 21-23) years. Twenty percent were using an implant and none had ever used an intrauterine device. Barriers and facilitators of LARC implementation spanned factors at each Consolidated Framework for Implementation Research domain: (1) LARC characteristics like side effects; (2) the clinics' inner settings, including availability of youth-friendly services; (3) characteristics of health system stakeholders, such as LARC skills, and AGYW experiences, attitudes, and beliefs about LARCs; (4) the outer setting external to clinics and Botswana's health system including reproductive health law and policy for minor adolescents; and (5) the implementation process level such as the availability of free or low-cost LARCs. CONCLUSION We identified multilevel, context-specific factors that affect LARC implementation. Our findings can inform the development of interventions to increase LARC implementation in Botswana by addressing intersecting factors across patient, clinic, health system, and sociopolitical levels, such as providing confidential services to minors and improving LARC training and supply chain pipelines.
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Affiliation(s)
- Drisana Henry
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Sarah Wood
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania; Global Health Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Neo Moshashane
- Botswana-Harvard AIDS Institute Partnership; Botswana-UPenn Partnership
| | | | - Christina Amutah
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Pegah Maleki
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Claire Howlett
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Merrian J Brooks
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Global Health Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Andrew P Steenhoff
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania; Global Health Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Botswana-UPenn Partnership; University of Botswana, Gabarone, Botswana
| | - Aletha Y Akers
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chelsea Morroni
- Botswana-Harvard AIDS Institute Partnership; Botswana-UPenn Partnership; MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
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Espey J, Ingabire R, Nyombayire J, Hoagland A, Da Costa V, Mazzei A, Haddad LB, Parker R, Mukamuyango J, Umutoni V, Allen S, Karita E, Tichacek A, Wall KM. Postpartum long-acting contraception uptake and service delivery outcomes after a multilevel intervention in Kigali, Rwanda. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:173-178. [PMID: 32938708 PMCID: PMC8861892 DOI: 10.1136/bmjsrh-2020-200741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Postpartum family planning (PPFP) is critical to reduce maternal-child mortality, abortion and unintended pregnancy. As in most countries, the majority of PP women in Rwanda have an unmet need for PPFP. In particular, increasing use of the highly effective PP long-acting reversible contraceptive (LARC) methods (the intrauterine device (IUD) and implant) is a national priority. We developed a multilevel intervention to increase supply and demand for PPFP services in Kigali, Rwanda. METHODS We implemented our intervention (which included PPFP promotional counselling for clients, training for providers, and Ministry of Health stakeholder involvement) in six government health facilities from August 2017 to October 2018. While increasing knowledge and uptake of the IUD was a primary objective, all contraceptive method options were discussed and made available. Here, we report a secondary analysis of PP implant uptake and present already published data on PPIUD uptake for reference. RESULTS Over a 15-month implementation period, 12 068 women received PPFP educational counselling and delivered at a study facility. Of these women, 1252 chose a PP implant (10.4% uptake) and 3372 chose a PPIUD (27.9% uptake). On average providers at our intervention facilities inserted 83.5 PP implants/month and 224.8 PPIUDs/month. Prior to our intervention, 30 PP implants/month and 8 PPIUDs/month were inserted at our selected facilities. Providers reported high ease of LARC insertion, and clients reported minimal insertion anxiety and pain. CONCLUSIONS PP implant and PPIUD uptake significantly increased after implementation of our multilevel intervention. PPFP methods were well received by clients and providers.
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Affiliation(s)
- Julie Espey
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Rosine Ingabire
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Projet San Francisco, Kigali, Rwanda
| | - Julien Nyombayire
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Projet San Francisco, Kigali, Rwanda
| | - Alexandra Hoagland
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Projet San Francisco, Kigali, Rwanda
| | - Vanessa Da Costa
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Amelia Mazzei
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Projet San Francisco, Kigali, Rwanda
| | - Lisa B Haddad
- Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jeannine Mukamuyango
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Projet San Francisco, Kigali, Rwanda
| | - Victoria Umutoni
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Etienne Karita
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Projet San Francisco, Kigali, Rwanda
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kristin M Wall
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, Georgia, USA
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Mukamuyango J, Ingabire R, Parker R, Nyombayire J, Abaasa A, Asiki G, Easter SR, Wall KM, Nyirazinyoye L, Tichacek A, Kaslow N, Price MA, Allen S, Karita E. Uptake of long acting reversible contraception following integrated couples HIV and fertility goal-based family planning counselling in Catholic and non-Catholic, urban and rural government health centers in Kigali, Rwanda. Reprod Health 2020; 17:126. [PMID: 32807177 PMCID: PMC7433361 DOI: 10.1186/s12978-020-00981-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When integrated with couples' voluntary HIV counselling and testing (CVCT), family planning including long acting reversible contraceptives (LARC) addresses prongs one and two of prevention of mother-to-child transmission (PMTCT). METHODS In this observational study, we enrolled equal numbers of HIV concordant and discordant couples in four rural and four urban clinics, with two Catholic and two non-Catholic clinics in each area. Eligible couples were fertile, not already using a LARC method, and wished to limit or delay fertility for at least 2 years. We provided CVCT and fertility goal-based family planning counselling with the offer of LARC and conducted multivariate analysis of clinic, couple, and individual predictors of LARC uptake. RESULTS Of 1290 couples enrolled, 960 (74%) selected LARC: Jadelle 5-year implant (37%), Implanon 3-year implant (26%), or copper intrauterine device (IUD) (11%). Uptake was higher in non-Catholic clinics (85% vs. 63% in Catholic clinics, p < 0.0001), in urban clinics (82% vs. 67% in rural clinics, p < 0.0001), and in HIV concordant couples (79% vs. 70% of discordant couples, p = .0005). Religion of the couple was unrelated to clinic religious affiliation, and uptake was highest among Catholics (80%) and lowest among Protestants (70%) who were predominantly Pentecostal. In multivariable analysis, urban location and non-Catholic clinic affiliation, Catholic religion of woman or couple, younger age of men, lower educational level of both partners, non-use of condoms or injectable contraception at enrollment, prior discussion of LARC by the couple, and women not having concerns about negative side effects of implant were associated with LARC uptake. CONCLUSIONS Fertility goal-based LARC recommendations combined with couples' HIV counselling and testing resulted in a high uptake of LARC methods, even among discordant couples using condoms for HIV prevention, in Catholic clinics, and in rural populations. This model successfully integrates prevention of HIV and unplanned pregnancy.
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Affiliation(s)
| | - Rosine Ingabire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Julien Nyombayire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Andrew Abaasa
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, London, WC1E 7HT, UK
- Medical Research Council, Uganda Vaccine Research Institute & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Gershim Asiki
- Medical Research Council, Uganda Vaccine Research Institute & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Sarah Rae Easter
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin M Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Nadine Kaslow
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA, USA
| | - Matt A Price
- International AIDS Vaccine Initiative, New York, NY, USA
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA, USA
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA.
| | - Etienne Karita
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
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Mukamuyango J, Ingabire R, Parker R, Nyombayire J, Easter SR, Wall KM, Tichacek A, Nyirazinyoye L, Kaslow N, Allen S, Karita E. Motivational interviewing to promote long-acting reversible contraception among Rwandan couples wishing to prevent or delay pregnancy. Am J Obstet Gynecol 2020; 222:S919.e1-S919.e12. [PMID: 31838122 DOI: 10.1016/j.ajog.2019.11.1280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/19/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Few family-planning programs in Africa base demand creation and service delivery on theoretical models. Motivational interviewing is a counseling modality that facilitates reflection on the benefits and disadvantages of a health outcome to encourage behavior change. OBJECTIVES We evaluate a couples-focused joint family-planning and HIV counseling intervention using motivational interviewing to enhance uptake of long-acting reversible contraception (Paragard copper intrauterine device or Jadelle hormonal implant) among Rwandan couples. STUDY DESIGN In this experimental study, couples receiving care at 8 government health clinics in Kigali, the capital city, were referred from a parent study of couples who did not want more children or wanted to wait at least 2 years for their next pregnancy. Long-acting reversible contraception methods were offered on site following joint HIV testing and family-planning counseling. At the first follow-up visit 1 month after enrollment in the parent study, couples who had not yet chosen a long-acting reversible contraception method were interviewed separately using motivational interviewing and then brought together and again offered long-acting reversible contraception. RESULTS Following motivational interviewing, 78 of 229 couples (34%) requested a long-acting reversible contraception method (68 implant and 10 intrauterine device). Long-acting reversible contraception uptake after motivational interviewing was associated with the woman being Catholic (vs Protestant/Muslim/other, adjusted odds ratio, 2.87, 95% confidence interval, 1.19-6.96, P = .019) or having an income (vs no income, adjusted odds ratio, 2.54, 95% confidence interval, 1.12-5.73, P = .025); the couple having previously discussed long-acting reversible contraception (adjusted odds ratio, 8.38, 95% confidence interval, 2.54-27.59, P = .0005); either partner believing that unplanned pregnancy was likely with their current method (adjusted odds ratio, 6.67, 95% confidence interval, 2.77-16.11, P < .0001); or that they might forget to take or make an appointment for their current method (adjusted odds ratio, 4.04, 95% confidence interval, 1.32-12.34, P = .014). Neither partner mentioning that condoms also prevent HIV/sexually transmitted infection was associated with long-acting reversible contraception uptake (adjusted odds ratio, 2.86, 95% confidence interval, 1.17-7.03, P = .022), as was the woman citing long-term duration of action of the implant as an advantage (adjusted odds ratio, 5.41, 95% confidence interval, 1.86-15.76, P = .002). The woman not listing any side effects or disadvantages of implants was associated with long-acting reversible contraception uptake (adjusted odds ratio, 5.42, 95% confidence interval, 2.33-12.59, P < .0001). Clinic location (rural vs urban), couple HIV status, and concerns about negative economic effects of an unplanned pregnancy were significant in bivariate but not multivariate analysis. CONCLUSION Encouraging couples to reflect on the benefits and disadvantages of long-acting reversible contraception methods, the likelihood of unplanned pregnancy with their current contraception, and the impact of an unplanned pregnancy is an effective motivational interviewing technique in family-planning counseling. One third of couples who did not want a pregnancy for at least 2 years but had not chosen a long-acting reversible contraception method when provided with standard family-planning counseling did so after motivational interviewing. Involving the male partner in family-planning discussions facilitates joint decision making about fertility goals and contraceptive choice. Combining family planning and joint HIV testing for couples allows targeted focus on dual-method use with discordant couples, who are advised to use condoms for HIV/sexually transmitted infection prevention along with a more effective contraceptive for added protection against unplanned pregnancy.
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Wall KM, Bayingana R, Ingabire R, Ahlschlager L, Tichacek A, Allen S, Karita E. Rwandan stakeholder perspectives of integrated family planning and HIV services. Int J Health Plann Manage 2018; 33:e1037-e1049. [PMID: 30047594 PMCID: PMC6289844 DOI: 10.1002/hpm.2586] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 06/29/2018] [Indexed: 11/20/2022] Open
Abstract
The purpose of this qualitative study was to understand the knowledge, attitudes, and practices among key Rwandan policymakers and stakeholders related to family planning (FP) and integrated HIV/FP services. Motivational in-depth interview format and content was developed after an extensive policy review. A convenience sample of 10 high-level HIV and FP Rwandan policymakers and stakeholders completed the interview. Stakeholders demonstrated strong foundational knowledge of HIV and FP. Given the choice, stakeholders would allocate more monies to FP and less to HIV than currently distributed. Respondents felt that improved FP method knowledge, especially long-acting reversible contraception, among clients/couples and providers, was needed to address myths, misconceptions, and biases. The most often cited way to integrate HIV/FP services was development of integrated tools (eg, training materials, data collection tools, and advocacy and policy guidance). We recommend strategies for policy advancement supportive of HIV/FP service integration inclusive of couples and long-acting reversible contraception methods.
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Affiliation(s)
- Kristin M. Wall
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public HealthEmory UniversityAtlantaGAUSA
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Roger Bayingana
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public HealthEmory UniversityKigaliRwanda
| | - Rosine Ingabire
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public HealthEmory UniversityKigaliRwanda
| | - Lauren Ahlschlager
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public HealthEmory UniversityAtlantaGAUSA
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public HealthEmory UniversityAtlantaGAUSA
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public HealthEmory UniversityAtlantaGAUSA
| | - Etienne Karita
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public HealthEmory UniversityKigaliRwanda
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