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Nabhan A, Kabra R, Ashraf A, Elghamry F, Kiarie J. Implementation strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning, a mixed-methods systematic review. BMC Womens Health 2023; 23:574. [PMID: 37932747 PMCID: PMC10629088 DOI: 10.1186/s12905-023-02735-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 10/26/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Demand generation aims to increase clients' desire to use family planning. The aim of this work was to systematically summarize strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning. METHODS We searched electronic bibliographic databases from inception to October 2022. We included quantitative, qualitative, and mixed methods reports on demand generation strategies in family planning, regardless of country, language, publication status, or methodological limitations. We assessed abstracts, titles and full-text papers according to the inclusion criteria, extracted data, and assessed methodological quality of included reports. We used the convergent integrated approach and a deductive thematic synthesis to summarize demand generation themes and subthemes. We used the health system building blocks to synthesize the factors affecting implementation (barriers and facilitators). We used GRADE-CERQual to assess our confidence in the findings. RESULTS Forty-six studies (published 1990-2022) were included: forty-one quantitative, one qualitative, and four mixed methods). Three were from one high-income country, and forty three from LMIC settings. Half of reports were judged to be of unclear risk of bias. There were unique yet interrelated strategies of scaling-up demand generation for family planning. Interpersonal communication strategies increase adoption and coverage of modern contraceptive methods, but the effect on sustainability is uncertain. Mass media exposure increases knowledge and positive attitudes and may increase the intention to use modern contraceptive methods. Demand-side financing approaches probably increase awareness of contraceptives and the use of modern contraceptive methods among poor clients. Multifaceted Demand generation approaches probably improve adoption, coverage and sustainability of modern methods use. Factors that influence the success of implementing these strategies include users knowledge about family planning methods, the availability of modern methods, and the accessibility to services. CONCLUSIONS Demand generation strategies may function independently or supplement each other. The myriad of techniques of the different demand generation strategies, the complexities of family planning services, and human interactions defy simplistic conclusions on how a specific strategy or a bundle of strategies may succeed in increasing and sustaining family planning utilization. TRIAL REGISTRATION Systematic review registration: Center for Open Science, osf.io/286j5.
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Affiliation(s)
- Ashraf Nabhan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, Egypt.
| | - Rita Kabra
- Department of Sexual and Reproductive Health including UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Alyaa Ashraf
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - James Kiarie
- Department of Sexual and Reproductive Health including UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
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Nabhan A, Kabra R, Allam N, Ibrahim E, Abd-Elmonem N, Wagih N, Mostafa N, Kiarie J. Implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning, a mixed-methods systematic review. BMC Womens Health 2023; 23:379. [PMID: 37468942 PMCID: PMC10357879 DOI: 10.1186/s12905-023-02518-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/29/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Post pregnancy family planning includes both postpartum and post-abortion periods. Post pregnancy women remain one of the most vulnerable groups with high unmet need for family planning. This review aimed to describe and assess the quality of the evidence on implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning. METHODS Electronic bibliographic databases (MEDLINE, PubMed, Scopus, the Cochrane Library, and Global Index Medicus) were searched from inception to October 2022 for primary quantitative, qualitative, and mixed method reports on scaling up post pregnancy family planning. Abstracts, titles, and full-text papers were assessed according to the inclusion criteria to select studies regardless of country, language, publication status, or methodological limitations. Data were extracted and methodological quality assessed using the Mixed Methods Appraisal Tool. The convergent integrated approach and a deductive thematic synthesis were used to identify themes and sub-themes of strategies to scale up post pregnancy family planning. The health system building blocks were used to summarize barriers and facilitators. GRADE-CERQual was used to assess our confidence in the findings. RESULTS Twenty-nine reports (published 2005-2022) were included: 19 quantitative, 7 qualitative, and 3 mixed methods. Seven were from high-income countries, and twenty-two from LMIC settings. Sixty percent of studies had an unclear risk of bias. The included reports used either separate or bundled strategies for scaling-up post pregnancy family planning. These included strategies for healthcare infrastructure, policy and regulation, financing, human resource, and people at the point of care. Strategies that target the point of care (women and / or their partners) contributed to 89.66% (26/29) of the reports either independently or as part of a bundle. Point of care strategies increase adoption and coverage of post pregnancy contraceptive methods. CONCLUSION Post pregnancy family planning scaling up strategies, representing a range of styles and settings, were associated with improved post pregnancy contraceptive use. Factors that influence the success of implementing these strategies include issues related to counselling, integration in postnatal or post-abortion care, and religious and social norms. TRIAL REGISTRATION Center for Open Science, OSF.IO/EDAKM.
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Affiliation(s)
- Ashraf Nabhan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, Egypt.
| | - Rita Kabra
- Department of Sexual and Reproductive Health Including UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Nahed Allam
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Cairo, Egypt
| | - Eman Ibrahim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Cairo, Egypt
| | | | - Nouran Wagih
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - James Kiarie
- Department of Sexual and Reproductive Health Including UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
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Tiwari A, Thapa A, Choudhury N, Khatri R, Sapkota S, Wu WJ, Halliday S, Citrin D, Schwarz R, Maru D, Rayamazi HJ, Paudel R, Bhatt LD, Bhandari V, Marasini N, Khadka S, Bogati B, Saud S, Kshetri YKB, Bhatta A, Magar KR, Shrestha R, Kafle R, Poudel R, Gautam S, Basnett I, Shrestha GN, Nirola I, Adhikari S, Thapa P, Kunwar L, Maru S. A Type II hybrid effectiveness-implementation study of an integrated CHW intervention to address maternal healthcare in rural Nepal. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001512. [PMID: 36963046 PMCID: PMC10021605 DOI: 10.1371/journal.pgph.0001512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 12/26/2022] [Indexed: 01/25/2023]
Abstract
Skilled care during pregnancy, childbirth, and postpartum is essential to prevent adverse maternal health outcomes, yet utilization of care remains low in many resource-limited countries, including Nepal. Community health workers (CHWs) can mitigate health system challenges and geographical barriers to achieving universal health coverage. Gaps remain, however, in understanding whether evidence-based interventions delivered by CHWs, closely aligned with WHO recommendations, are effective in Nepal's context. We conducted a type II hybrid effectiveness-implementation, mixed-methods study in two rural districts in Nepal to evaluate the effectiveness and the implementation of an evidence-based integrated maternal and child health intervention delivered by CHWs, using a mobile application. The intervention was implemented stepwise over four years (2014-2018), with 65 CHWs enrolling 30,785 families. We performed a mixed-effects Poisson regression to assess institutional birth rate (IBR) pre-and post-intervention. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the implementation during and after the study completion. There was an average 30% increase in IBR post-intervention, adjusting for confounding variables (p<0.0001). Study enrollment showed 35% of families identified as dalit, janjati, or other castes. About 78-89% of postpartum women received at least one CHW-counseled home visit within 60 days of childbirth. Ten (53% of planned) municipalities adopted the intervention during the study period. Implementation fidelity, measured by median counseled home visits, improved with intervention time. The intervention was institutionalized beyond the study period and expanded to four additional hubs, albeit with adjustments in management and supervision. Mechanisms of intervention impact include increased knowledge, timely referrals, and longitudinal CHW interaction. Full-time, supervised, and trained CHWs delivering evidence-based integrated care appears to be effective in improving maternal healthcare in rural Nepal. This study contributes to the growing body of evidence on the role of community health workers in achieving universal health coverage.
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Affiliation(s)
| | | | - Nandini Choudhury
- Possible, New York, NY, United States of America
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, United States of America
| | | | - Sabitri Sapkota
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, United States of America
- Possible, Kathmandu, Nepal
| | - Wan-Ju Wu
- Possible, New York, NY, United States of America
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA, United States of America
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, United States of America
| | - Scott Halliday
- Possible, New York, NY, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - David Citrin
- Possible, New York, NY, United States of America
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Anthropology, University of Washington, Seattle, WA, United States of America
| | - Ryan Schwarz
- Possible, New York, NY, United States of America
- Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America
- Department of Medicine, Harvard Medical School, Boston, MA, United States of America
- Department of Medicine, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Duncan Maru
- Possible, New York, NY, United States of America
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, United States of America
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, United States of America
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | | | | | | | | | | | - Sonu Khadka
- Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
| | | | - Sita Saud
- Civil Service Hospital, Kathmandu, Nepal
| | | | | | - Kshitiz Rana Magar
- Department of Public Health and Community Program, Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Ramesh Shrestha
- Department of Public Health and Community Program, Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | | | | | | | | | - Goma Niroula Shrestha
- Department of Health Services, Nursing and Social Security Division (NSSD), Ministry of Health and Population, Nepal
| | - Isha Nirola
- Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Samrachana Adhikari
- Department of Population Health, NYU School of Medicine, New York, NY, United States of America
| | - Poshan Thapa
- University of New South Wales, School of Population Health, Sydney, Australia
| | | | - Sheela Maru
- Possible, New York, NY, United States of America
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, United States of America
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, United States of America
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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Choudhury N, Tiwari A, Wu WJ, Bhandari V, Bhatta L, Bogati B, Citrin D, Halliday S, Khadka S, Marasini N, Pandey S, Ballard M, Rayamazi HJ, Sapkota S, Schwarz R, Sullivan L, Maru D, Thapa A, Maru S. Comparing two data collection methods to track vital events in maternal and child health via community health workers in rural Nepal. Popul Health Metr 2022; 20:16. [PMID: 35897038 PMCID: PMC9327361 DOI: 10.1186/s12963-022-00293-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/03/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Timely tracking of health outcomes is difficult in low- and middle-income countries without comprehensive vital registration systems. Community health workers (CHWs) are increasingly collecting vital events data while delivering routine care in low-resource settings. It is necessary, however, to assess whether routine programmatic data collected by CHWs are sufficiently reliable for timely monitoring and evaluation of health interventions. To study this, we assessed the consistency of vital events data recorded by CHWs using two methodologies-routine data collected while delivering an integrated maternal and child health intervention, and data from a birth history census approach at the same site in rural Nepal. METHODS We linked individual records from routine programmatic data from June 2017 to May 2018 with those from census data, both collected by CHWs at the same site using a mobile platform. We categorized each vital event over a one-year period as 'recorded by both methods,' 'census alone,' or 'programmatic alone.' We further assessed whether vital events data recorded by both methods were classified consistently. RESULTS From June 2017 to May 2018, we identified a total of 713 unique births collectively from the census (birth history) and programmatic maternal 'post-delivery' data. Three-fourths of these births (n = 526) were identified by both. There was high consistency in birth location classification among the 526 births identified by both methods. Upon including additional programmatic 'child registry' data, we identified 746 total births, of which 572 births were identified by both census and programmatic methods. Programmatic data (maternal 'post-delivery' and 'child registry' combined) captured more births than census data (723 vs. 595). Both methods consistently classified most infants as 'living,' while infant deaths and stillbirths were largely classified inconsistently or recorded by only one method. Programmatic data identified five infant deaths and five stillbirths not recorded in census data. CONCLUSIONS Our findings suggest that data collected by CHWs from routinely tracking pregnancies, births, and deaths are promising for timely program monitoring and evaluation. Despite some limitations, programmatic data may be more sensitive in detecting vital events than cross-sectional census surveys asking women to recall these events.
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Affiliation(s)
- Nandini Choudhury
- grid.429937.2Possible, New York, USA ,grid.59734.3c0000 0001 0670 2351Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY USA
| | | | - Wan-Ju Wu
- grid.429937.2Possible, New York, USA ,grid.239424.a0000 0001 2183 6745Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA USA ,grid.189504.10000 0004 1936 7558Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA USA
| | | | | | | | - David Citrin
- grid.429937.2Possible, New York, USA ,grid.59734.3c0000 0001 0670 2351Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Anthropology, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Henry M. Jackson School of International Studies, University of Washington, Seattle, WA USA
| | - Scott Halliday
- grid.429937.2Possible, New York, USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA
| | | | | | | | - Madeleine Ballard
- grid.59734.3c0000 0001 0670 2351Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY USA ,Community Health Impact Coalition, New York, NY USA
| | | | | | - Ryan Schwarz
- grid.429937.2Possible, New York, USA ,grid.62560.370000 0004 0378 8294Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Medicine, Harvard Medical School, Boston, MA USA ,grid.32224.350000 0004 0386 9924Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA USA
| | - Lisa Sullivan
- grid.189504.10000 0004 1936 7558Boston University School of Public Health, Boston, MA USA
| | - Duncan Maru
- grid.429937.2Possible, New York, USA ,grid.59734.3c0000 0001 0670 2351Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY USA ,grid.59734.3c0000 0001 0670 2351Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, USA ,grid.59734.3c0000 0001 0670 2351Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY USA ,grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | - Sheela Maru
- grid.429937.2Possible, New York, USA ,grid.59734.3c0000 0001 0670 2351Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY USA ,grid.59734.3c0000 0001 0670 2351Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, USA ,grid.59734.3c0000 0001 0670 2351Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY USA
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Tiwari A, Wu WJ, Citrin D, Bhatta A, Bogati B, Halliday S, Goldberg A, Khadka S, Khatri R, Kshetri Y, Rayamazi HJ, Sapkota S, Saud S, Thapa A, Vreeman R, Maru S. “Our mothers do not tell us”: a qualitative study of adolescent girls’ perspectives on sexual and reproductive health in rural Nepal. Sex Reprod Health Matters 2022; 29:2068211. [PMID: 35695251 PMCID: PMC9225746 DOI: 10.1080/26410397.2022.2068211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Adolescent girls in low- and middle-income countries continue to face poor sexual and reproductive health (SRH). In Nepal, early marriage and motherhood, gender-based violence, and unmet need for contraception remain pervasive. Adolescent girls in rural areas bear a disproportionate burden of poor reproductive health outcomes, but there are limited context-specific data. This is a qualitative study to identify factors that impact adolescent girls’ utilisation of and access to SRH services in a rural district of Nepal. We conducted 21 individual interviews with adolescent girls aged 15–19 years, and three focus group discussions with community health workers. We used an inductive analytic approach to identify emergent and recurrent themes and present the themes using the social ecological model. Individual-level factors that contribute to low uptake of services among adolescent girls include lack of knowledge, self-perceived lack of need, low decision-making autonomy, and shyness. Interpersonal factors that impact access include unsupportive family norms, absence of open communication, and need for permission from family members to access care. At the community level, disparate gender norms, son preference, and judgment by community members affect adolescent SRH. Inadequate sex education, far travel distance to facilities, lack of female healthcare providers and teachers, and inability to access abortion services were identified as organisational and systems barriers. Stigma was a factor cross-cutting several levels. Our findings suggest the need for multi-level strategies to address these factors to improve adolescent girls’ SRH.
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Affiliation(s)
| | - Wan-Ju Wu
- Assistant Professor, Boston Medical Center, Department of Obstetrics and Gynecology, Boston, MA, USA; Boston University School of Medicine, Department of Obstetrics and Gynecology, Boston, MA, USA; Possible, New York, USA
| | - David Citrin
- Adviser, Possible, New York, USA; University of Washington, Department of Global Health, Seattle, WA, USA; University of Washington, Department of Anthropology, Seattle, WA, USA; Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA
| | - Aasha Bhatta
- Community Health Program Associate, Nyaya Health Nepal, Kathmandu, Nepal
| | - Bhawana Bogati
- Community Health Program Associate, Nyaya Health Nepal, Kathmandu, Nepal
| | - Scott Halliday
- Adviser, Possible, New York, USA; University of Washington, Department of Global Health, Seattle, WA, USA
| | - Alisa Goldberg
- Associate Professor, Brigham and Women's Hospital, Department of Obstetrics, Gynecology, and Reproductive Biology, Boston, MA, Harvard Medical School, Boston MA, USA
| | - Sonu Khadka
- Community Health Program Associate, Nyaya Health Nepal, Kathmandu, Nepal
| | - Rekha Khatri
- Qualitative Research Manager, Possible, Kathmandu, Nepal
| | - Yashoda Kshetri
- Community Health Program Associate, Nyaya Health Nepal, Kathmandu, Nepal
| | | | - Sabitri Sapkota
- Director of Research, Possible, Kathmandu, Nepal; Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA
| | - Sita Saud
- Community Health Program Associate, Nyaya Health Nepal, Kathmandu, Nepal
| | | | - Rachel Vreeman
- Chair, Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai New York, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai; Arnhold Institute for Global Health, New York, NY, USA
| | - Sheela Maru
- Assistant Professor, Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA; Icahn School of Medicine at Mount Sinai, Department of Health Systems Design and Global Health, New York, USA; Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology and Reproductive Science, New York, NY, USA; Possible, New York, USA
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