Community Health Workers' Provision of Family Planning Services in Low- and Middle-Income Countries: A Systematic Review of Effectiveness

Increasing coverage and uptake of voluntary family planning in Uganda's emerging municipalities and secondary cities: An implementation research study protocol

INTRODUCTION

While urban areas are often perceived to have better access to healthcare services, including modern family planning (FP) services, urban dwellers including those with better socioeconomic status are faced with multidimensional challenges that shape their access to appropriate FP services. In Uganda's urban spaces, there is currently a lack of understanding among service providers, civil society organizations, and individuals/communities regarding the implementation of interventions that promote informed choice and voluntary use of family planning services. This knowledge gap has profound implications for reproductive rights. This study seeks to enhance existing efforts towards increasing coverage and uptake of Voluntary Family Planning (VFP) in Jinja City and Iganga Municipality, central eastern Uganda. Our primary question is, "What interventions can effectively be packaged and delivered to increase the uptake of VFP among different segments of urban residents?"

METHODS

We propose to use the Human-Centered Design (HCD) approach to understand the needs and challenges of users and community capabilities in ensuring access to VFP services. Co-creating with stakeholders' engagement and a data-driven-centric approach will steer design and adaptation that respond to the different population segments within the urban space. As such, the study will be implemented in three phases: formative assessment, design and implementation, and implementation monitoring and evaluation. The implementation process will incorporate robust monitoring, learning, and adaptation mechanisms. The primary focus of these mechanisms will be to utilize gathered information effectively to inform the design of the implementation and facilitate continuous learning throughout the process. The study will apply a process monitoring and evaluation approach to address questions related to what package of FP interventions work, for whom, under what circumstances and why.

DISCUSSION

Guided by strong learning and implementation flexibility, we hypothesize that our implementation will provide segmentation-specific high-impact interventions in an urban context.

REGISTRATION

This implementation research protocol has been registered on the Open Science Framework (OSF) repository Registries (https://osf.io/vqxu9; DOI: 10.17605/OSF.IO/VQXU9).

Access to quality contraceptive counselling among adolescent girls and young women in sub-Saharan Africa

BACKGROUND

Improving women's access to and use of modern contraceptives is a key global strategy for improving the sexual and reproductive health of women. However, the use of modern contraceptives among adolescent girls and young women in sub-Saharan Africa (SSA) remains relatively low, despite the numerous interventions to increase patronage. This study examined adolescent girls and young women's receipt of quality contraceptive counselling and its associated factors in SSA.

METHODS

Data for the study were extracted from the recent Demographic and Health Surveys of 20 countries in SSA, spanning from 2015 to 2021. A sample of 19,398 adolescent girls and young women aged 15 to 24 years was included in the study. We presented the proportion of adolescent girls and young women who received quality contraceptive counselling using a spatial map. Multilevel binary logistic regression analysis was carried out to examine the factors associated with the receipt of quality contraceptive counselling.

RESULTS

Overall, 33.2% of adolescent girls and young women had access to quality contraceptive counselling, ranging from 13.0% in Cameroon to 67.0% in Sierra Leone. The odds of receiving quality contraceptive counselling was higher among adolescent girls and young women aged 20-24 (AOR = 1.48, CI: 1.32-1.67), those with primary (AOR = 1.32, CI: 1.11-1.57) and secondary or higher education (AOR = 1.31, CI: 1.09-1.58), and those married (AOR = 1.32, CI: 1.15-1.52), cohabiting (AOR = 1.47, CI: 1.23-1.76), and previously married (AOR = 1.48, CI: 1.20-1.83) compared to their counterparts in the reference groups. Adolescent girls and young women who were currently working (AOR = 1.22, CI: 1.09-1.37), those who heard of family planning from radio in the last few months (AOR = 1.34, CI:1.21-1.50), those who visited the health facility in the last 12 months (AOR = 1.69, CI: 1.52-1.88), and those residing in the Southern (AOR = 5.01, CI: 3.86-6.51), Eastern (AOR = 2.54, CI: 1.96-3.30), and Western (AOR = 4.09, CI: 3.19-5.25) SSA were more likely to receive quality contraceptive counselling compared to their counterparts in the reference groups. Conversely, adolescent girls and young women who used the internet, those who had problem getting permission to seek medical help, those facing problem in seeking medical help for not wanting to go alone, those from the middle and richest wealth indices, and those from the rural areas were less likely to receive quality contraceptive counselling compared to their counterparts in the reference groups.

CONCLUSION

Receipt of quality contraceptive counselling among adolescent girls and young women was low. Considering the importance of quality contraceptive counselling on the uptake and continuation of contraception, policymakers need to institute measures that improve adolescent girls and young women's access to quality contraceptive counselling in SSA, especially in countries like Cameroon, Angola, Madagascar, Mauritania, and Guinea, taking into consideration the factors identified in the study. Increasing adolescent girls and young women's access to quality contraceptive counselling could greatly minimize the risk of unintended pregnancies and its associated maternal and child health burden in SSA and subsequently contribute to the attainment of the Sustainable Development Goal 3, target 3.7.

Strengthening Integrated Approaches for Family Planning and Menstrual Health

FP and menstrual health integration has the potential to improve individuals' health and well-being. The authors describe potential ways to integrate FP and menstrual health, outlining steps that stakeholders can take in designing integrated approaches.

The implementation and effectiveness of multi-tasked, paid community health workers on maternal and child health: A cluster-randomized pragmatic trial and qualitative process evaluation in Tanzania

Community health worker programs have proliferated worldwide based on evidence that they help prevent mortality, particularly among children. However, there is limited evidence from randomized studies on the processes and effectiveness of implementing community health worker programs through public health systems. This paper describes the results of a cluster-randomized pragmatic implementation trial (registration number ISRCTN96819844) and qualitative process evaluation of a community health worker program in Tanzania that was implemented from 2011-2015. Program effects on maternal, newborn and child health service utilization, childhood morbidity and sick childcare seeking were evaluated using difference-in-difference regression analysis with outcomes measured through pre- and post-intervention household surveys in intervention and comparison trial arms. A qualitative process evaluation was conducted between 2012 and 2014 and comprised of in-depth interviews and focus group discussions with community health workers, community members, facility-based health workers and staff of district health management teams. The community health worker program reduced incidence of illness and improved access to timely and appropriate curative care for children under five; however, there was no effect on facility-based maternal and newborn health service utilization. The positive outcomes occurred because of high levels of acceptability of community health workers within communities, as well as the durability of community health workers' motivation and confidence. Implementation factors that generated these effects were the engagement of communities in program startup; the training, remuneration and supervision of the community health workers from the local health system and community. The lack of program effects on maternal and newborn health service utilization at facilities were attributed to lapses in the availability of needed care at facilities. Strategies that strengthen and align communities' and health systems core capacities, and their ability to learn, adapt and integrate evidence-based interventions, are needed to maximize the health impact of community health workers.

Evaluation of the effect of the Momentum project on family planning outcomes among first-time mothers aged 15-24 years in Kinshasa, DRC

OBJECTIVES

This article presents the effect of Momentum, a nursing student-led community-based service delivery project, on postpartum family planning (FP) outcomes among first-time mothers in Kinshasa, Democratic Republic of the Congo.

STUDY DESIGN

We employed a quasi-experimental design, with three intervention and three comparison health zones (HZ). Data were collected through interviewer-administered questionnaires in 2018 and 2020. The sample consisted of 1927 nulliparous women aged 15-24 years who were 6 months pregnant at baseline. Random effects and treatment effects models were used to assess the effect of Momentum on 14 postpartum FP outcomes.

RESULTS

The intervention group was associated with a unit increase of 0.6 (95% confidence interval [CI]: 0.4, 0.8)) in contraceptive knowledge and personal agency (95% CI: 0.3, 0.9), a unit decrease of 0.9 (95% CI: -1.2, -0.5) in the number of FP myths/misconceptions endorsed, and percentage point increases of 23.4 (95% CI: 0.2, 0.3) in FP discussion with a health worker, 13.0 (95% CI: 0.1, 0.2) in obtaining a contraceptive method within 6 weeks of delivery, and 13.3 (95% CI: 0.1, 0.2) in modern contraceptive use within 12 months of delivery. Intervention effects included percentage point increases of 5.4 (95% CI: 0.0, 0.1) in partner discussion and 15.4 (95% CI: 0.1, 0.2) in perceived community support for postpartum FP use. The level of exposure to Momentum was significantly associated with all behavioral outcomes.

CONCLUSIONS

The study demonstrated the effect of Momentum on increased postpartum FP-related knowledge, perceived norms, personal agency, partner discussion, and modern contraceptive use.

IMPLICATIONS

Community-based service delivery by nursing students can potentially lead to improved postpartum FP outcomes among urban adolescent and young first-time mothers in other provinces of the Democratic Republic of the Congo and other African countries.

"We are their eyes and ears here on the ground, yet they do not appreciate us"-Factors influencing the performance of Kenyan community health volunteers working in urban informal settlements

This study explored factors that influence CHV performance in urban informal settlements (UIS) within Nairobi Kenya and ways in which CHVs can be supported to enhance their wellbeing and strengthen community strategies. The study was undertaken in two UIS within Nairobi County. Thirteen focus group discussions and three key informant interviews were conducted with a range of respondents. Various topics covering the design of the Community Health Strategy (CHS) and broader contextual factors that affect CHVs' performance, were discussed and data analysed using a framework analysis approach. The key programme design factors identified as influencing the performance of CHVs working in UIS included: CHV recruitment; training; availability of supplies and resources; and remuneration of CHVs. Health system factors that influenced CHVs performance included: nature of relationship between healthcare workers at local referral facilities and community members; availability of services and perceived corruption at referral facilities; and CHV referral outside of the local health facility. Whereas the broader contextual factors that affected CHV performance included: demand for material or financial support; perceived corruption in community programmes; and neighbourhood insecurity. These findings suggest that CHVs working in UIS in Kenya face a myriad of challenges that impact their wellbeing and performance. Therefore, to enhance CHVs' well-being and improve their performance, the following should be considered: adequate and timely remuneration for CHVs, appropriate holistic training, adequate supportive supervision, and ensuring a satisfactory supply of resources and supplies. Additionally, at the facility level, healthcare workers should be trained on appropriate and respectful relations with both the community and the CHVs, clarity of roles and scope of work, ensure availability of services, and safeguard against corrupt practices in public health facilities. Lastly, there's a need for improved and adequate security measures at the community level, to ensure safety of CHVs as they undertake their roles.

The role of community health workers in primary healthcare in the WHO-EU region: a scoping review

BACKGROUND

Existing evidence on the role of community health workers (CHWs) in primary healthcare originates primarily from the United States, Canada and Australia, and from low- and middle-income countries. Little is known about the role of CHWs in primary healthcare in European countries. This scoping review aimed to contribute to filling this gap by providing an overview of literature reporting on the involvement of CHWs in primary healthcare in WHO-EU countries since 2001 with a focus on the role, training, recruitment and remuneration.

METHODS

This systematic scoping review followed the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses, extension for Scoping Reviews. All published peer-reviewed literature indexed in PubMed, Web of Science, and Embase databases from Jan 2001 to Feb 2023 were reviewed for inclusion. Included studies were screened on title, abstract and full text according to predetermined eligibility criteria. Studies were included if they were conducted in the WHO-EU region and provided information regarding the role, training, recruitment or remuneration of CHWs.

RESULTS

Forty studies were included in this review, originating from eight countries. The involvement of CHWs in the WHO-EU regions was usually project-based, except in the United Kingdom. A substantial amount of literature with variability in the terminology used to describe CHWs, the areas of involvement, recruitment, training, and remuneration strategies was found. The included studies reported a trend towards recruitment from within the communities with some form of training and payment of CHWs. A salient finding was the social embeddedness of CHWs in the communities they served. Their roles can be classified into one or a combination of the following: educational; navigational and supportive.

CONCLUSION

Future research projects involving CHWs should detail their involvement and elaborate on CHWs' role, training and recruitment procedures. In addition, further research on CHW programmes in the WHO-EU region is necessary to prepare for their integration into the broader national health systems.

Interventions to support contraceptive choice and use: a global systematic map of systematic reviews

BACKGROUND

To review the highest level of available evidence, a systematic map identified systematic reviews that evaluated the effectiveness of interventions to improve contraception choice and increase contraception use.

METHODS

Systematic reviews published since 2000 were identified from searches of nine databases. Data were extracted using a coding tool developed for this systematic map. Methodological quality of included reviews was assessed using AMSTAR 2 criteria.

FINDINGS AND CONCLUSION

Fifty systematic reviews reported evaluations of interventions for contraception choice and use addressing three domains (individual, couples, community); Meta-analyses in 11 of the reviews mostly addressed interventions for individuals. We identified 26 reviews covering High Income Countries, 12 reviews covering Low Middle-Income Countries and the rest a mix of both. Most reviews (15) focussed on psychosocial interventions, followed by incentives (6) and m-health interventions (6). The strongest evidence from meta-analyses is for the effectiveness of motivational interviewing, contraceptive counselling, psychosocial interventions, school-based education, and interventions promoting contraceptive access, demand-generation interventions (community and facility based, financial mechanisms and mass media), and mobile phone message interventions. Even in resource constrained settings, community-based interventions can increase contraceptive use. There are gaps in the evidence on interventions for contraception choice and use, and limitations in study designs and lack of representativeness. Most approaches focus on individual women rather than couples or wider socio-cultural influences on contraception and fertility. This review identifies interventions which work to increase contraception choice and use, and these could be implemented in school, healthcare or community settings.

Do health service contacts with community health workers influence the intention to use modern contraceptives among non-users in rural communities? Findings from a cross-sectional study in Nigeria

BACKGROUND

Studies in many developing countries have shown that community health workers (CHWs) are valuable for boosting contraceptive knowledge and usage. However, in spite of the evidence, studies in Nigeria have rarely examined whether in the absence of skilled health personnel such as doctors and nurses in rural and remote communities, the health service contacts of non-users with CHWs drive the intention to use modern contraceptives. This study, therefore, examines the extent to which health service contacts with CHWs are associated with the intention to use modern contraceptives among non-users in rural communities of Nigeria.

METHODS

This study adopted a descriptive cross-sectional design. Data were extracted from the most recent Nigeria Demographic and Health Survey (NDHS). The study analyzed a weighted sample of 12,140 rural women. The outcome variable was the intention to use modern contraceptives. The main explanatory variable was health service contacts with CHWs. Statistical analyses were performed at three levels with the aid of Stata version 14. Three multivariable regression models were estimated using an adjusted Odds Ratio (aOR) with a 95% confidence interval. Statistical significance was set at p < 0.05.

RESULTS

Findings showed that more than a quarter (29.0%) of women intends to use modern contraceptives. Less than one-fifth (15.9%) of the women had health service contacts with CHWs. In Model 1, women who had health service contacts with CHWs were more likely to intend to use modern contraceptives (aOR =1.430, 95% CI: 1.212-1.687). Likewise, in Model 2, women who had health service contacts with CHWs had a higher likelihood of intending to use modern contraceptives (aOR = 1.358, 95% CI: 1.153-1.599). In Model 3, the odds of intention to use modern contraceptives were higher among women who had health service contacts with CHWs (aOR =1.454, 95% CI: 1.240-1.706).

CONCLUSION

In rural areas of Nigeria, health service contacts with CHWs are significantly associated with the intention to use modern contraceptives. Family planning programmers should leverage the patronage of CHWs for the purpose of family planning demand generation in rural areas.

An investigation of the impact of the Global Gag Rule on women's sexual and reproductive health outcomes in Uganda: a difference-in-differences analysis

In 2017, the Trump administration reinstated the Global Gag Rule (GGR), making non-U.S. non-governmental organisations ineligible for US government global health assistance if they provide access to or information about abortion. Little is known about the impact of the Trump administration’s GGR on women’s outcomes. Data for this analysis come from a panel of women surveyed in 2018 and 2019 in Uganda (n = 2755). We also used data from meetings with key stakeholders to create a detailed measure of exposure to the GGR within Uganda, classifying districts as more or less exposed to the GGR. Multivariable regression models were used to assess changes in contraceptive use, all births, unplanned births, and abortion from before to during implementation of the GGR. Difference-in-differences (DID) estimates were determined by calculating predicted probabilities from interaction terms for exposure/survey round. Descriptive analyses showed long-acting reversible contraceptive use increased more rapidly among women in less exposed districts after GGR implementation. DID estimates for contraceptive use were small. We observed a DID estimate of 3.5 (95% CI −0.9, 7.9) for all births and 2.9 (95% CI −0.2, 6.0) for unplanned births for women in more exposed districts during the period the policy was in effect. Our results suggest that the GGR may have attenuated Uganda’s recent progress in improving SRHR outcomes, with women in less exposed districts continuing to benefit from this progress, while previously increasing trends for women in more exposed districts levelled off. Although the GGR was rescinded in January 2021, the impact of these disruptions may be felt for years to come.

Mi Plan: Using a Pediatric-Based Community Health Worker Model to Facilitate Obtainment of Contraceptives Among Latino Immigrant Parents with Contraceptive Needs

BACKGROUND

Bilingual community health workers (CHWs) play an important role in helping Latino immigrants with limited English proficiency (LEP) access health care services and information. Contraceptive health care services and Spanish-language contraceptive information are particularly challenging to access for uninsured LEP immigrants. Contraceptive and reproductive care are longitudinal health needs, and pediatric settings pose a unique opportunity to address these needs among parents whose children access pediatric care. The purpose of this study was to pilot the feasibility of a CHW to support parental contraceptives needs within a pediatric setting serving a high number of Latino immigrant families. This article describes Mi Plan/My Plan, a CHW contraceptive counseling and resource navigation pilot program.

METHODS

The research team conducted a retrospective analysis of demographic and contraceptive use data from a 15-month CHW pilot within an urban, primary care pediatrics clinic. The CHW provided contraceptive counseling, referral, and appointment coordination. The outcome was desired contraceptive method obtainment within three months of counseling.

RESULTS

All 311 individuals counseled were Latina mothers with median child age of 3 months. At baseline, 64.3% were using contraception and 76.5% desired to start or change their current method. Among those who desired a change, 47.9% (114/238) obtained their desired method within three months of initial counselor contact.

CONCLUSION

Bilingual CHW contraceptive counseling and care coordination is feasible and acceptable in a pediatric setting serving a high number of Latino immigrant families. CHWs in pediatric settings support health care access equity and are relevant to optimal maternal and child health.

Individual and community-level determinants of knowledge of ovulatory cycle among women of reproductive age in 29 African countries: a multilevel analysis

Background

Knowledge of the ovulatory cycle (KOC) can help reduce the chances of unwanted pregnancies and may improve a woman’s reproductive health. However, little is known about the factors associated with knowledge of the ovulatory cycle across Africa. Therefore, we aimed to investigate the individual/household and community level determinants of KOC among women of childbearing age in 29 African countries.

Methods

We used data from the Demographic and Health Surveys of 29 African countries conducted between 2010 and 2020. Bivariate and multivariate multilevel logistic regressions were used to examine the association between women’s correct knowledge of the ovulatory cycle and individual/household and community-level factors. The results were reported using adjusted odds ratios (AOR) with a 95% confidence interval (CI).

Results

The pooled results showed that correct KOC among women was 15.5% (95% CI 14.2–17.0%), varying from 11.5% in Liberia to 57.1% in the Democratic Republic of Congo. Regarding regional distribution, the highest prevalence of KOC was observed in West Africa (38.8%) followed by East Africa (21.3%) and was lowest in Southern Africa (15.6%) and Central Africa (15.5%). After adjusting for potential confounders, at the individual level, we found the odds of KOC to be higher among older women (40–44 years-aOR 3.57, 95% CI 1.90–6.67, 45–49 years-aOR 2.49, 95% CI 1.29–4.82), and women with higher educational level (aOR 2.58, 95% CI 1.40–4.75); at the community level, higher KOC was among women exposed to media (aOR 2.24, 95% CI 1.32–3.81).

Conclusions

Knowledge of ovulatory cycle among women of reproductive age was found to be low in the region and varied by country. Women’s age and educational level were the individual-level factors associated with increased knowledge of ovulatory cycle while community-level media exposure was found to be associated with increased knowledge of ovulatory cycle in this study. This finding highlights the need for appropriate strategies (possibly use of mass media) to increase knowledge of ovulatory cycle among women of reproductive age, especially among adolescents in Africa.

From raw data to a score: comparing quantitative methods that construct multi-level composite implementation strength scores of family planning programs in Malawi

BACKGROUND

Data that capture implementation strength can be combined in multiple ways across content and health system levels to create a summary measure that can help us to explore and compare program implementation across facility catchment areas. Summary indices can make it easier for national policymakers to understand and address variation in strength of program implementation across jurisdictions. In this paper, we describe the development of an index that we used to describe the district-level strength of implementation of Malawi's national family planning program.

METHODS

To develop the index, we used data collected during a 2017 national, health facility and community health worker Implementation Strength Assessment survey in Malawi to test different methods to combine indicators within and then across domains (4 methods-simple additive, weighted additive, principal components analysis, exploratory factor analysis) and combine scores across health facility and community health worker levels (2 methods-simple average and mixed effects model) to create a catchment area-level summary score for each health facility in Malawi. We explored how well each model captures variation and predicts couple-years protection and how feasible it is to conduct each type of analysis and the resulting interpretability.

RESULTS

We found little difference in how the four methods combined indicator data at the individual and combined levels of the health system. However, there were major differences when combining scores across health system levels to obtain a score at the health facility catchment area level. The scores resulting from the mixed effects model were able to better discriminate differences between catchment area scores compared to the simple average method. The scores using the mixed effects combination method also demonstrated more of a dose-response relationship with couple-years protection.

CONCLUSIONS

The summary measure that was calculated from the mixed effects combination method captured the variation of strength of implementation of Malawi's national family planning program at the health facility catchment area level. However, the best method for creating an index should be based on the pros and cons listed, not least, analyst capacity and ease of interpretability of findings. Ultimately, the resulting summary measure can aid decision-makers in understanding the combined effect of multiple aspects of programs being implemented in their health system and comparing the strengths of programs across geographies.

Human-centred design of a new microneedle-based hormonal contraceptive delivery system

Background: It is estimated that 225 million women worldwide have an unmet need for family planning, and more than half live in low- and middle-income countries. Increasing the choice of contraceptive methods available can reduce this unmet need. Microneedle drug delivery systems represent a new technology for minimally invasive self-administration of contraceptives. We explored stakeholders’ views on different aspects of a proposed microneedle-based hormonal contraceptive delivery system. The feedback was used to iteratively develop this delivery system.

Methods: Focus group discussions and semi-structured interviews were conducted with potential stakeholders (women and trans males of childbearing age, their partners, and health professionals and organisations that provide family planning advice and contraception services) in Uganda, The Gambia, Malawi, and the UK, exploring concept acceptability and gathering feedback on different aspects of design and usability of the proposed delivery system.

Results: Participants viewed the concept of a new, microneedle-based contraceptive favourably. In Uganda, participants were presented with 7 different prototype applicators and identified desirable features of a preferred delivery device; their input reducing the number of prototypes that were subsequently evaluated by stakeholders in The Gambia and the UK. Participants in these countries helped to identify and/or confirm the most desirable characteristics of the applicator, resulting in design consolidation into a refined concept applicator. The final, optimised applicator prototype was validated during user research in Malawi. This human-centred design approach was also used to iteratively develop an information leaflet for the device. During these user studies, other preferred aspects of a contraceptive delivery system were also evaluated, such as anatomical site of application, duration of action, and return to fertility.

Conclusions: A new microneedle-based contraceptive delivery system was iteratively developed using a human-centred design approach and was favourably received by potential stakeholders. The product is now being refined for testing in pre-clinical studies.

Knowledge and Information Exposure About Family Planning Among Women of Reproductive Age in Informal Settlements of Kira Municipality, Wakiso District, Uganda

Introduction: A high unmet need for family planning (FP) prevails in sub-Saharan Africa. Knowledge, awareness creation, and ensuring accessibility are frequently used to increase FP uptake. However, evidence on knowledge or information dissemination about FP among marginalized populations in urban settings in Africa is limited. This study explored the knowledge of FP methods, media exposure, and contact with FP providers among women from an informal settlement in Uganda.

Methods: Using a cross-sectional study design, we interviewed 626 women aged 15–49 years living in informal settlements of Kira municipality, selected through multistage sampling. Using a standard questionnaire, data was collected on socioeconomic characteristics, knowledge of FP methods, and access to media FP messages among others. Binomial log-linear regression was used to assess disparities in exposure to media FP messages or provider information. Data were analyzed using STATA version 14, at a 5% level of statistical significance.

Results: Nearly all women in the survey were aware of FP methods (99.7%). On average, each woman was aware of 10 FP methods. The most commonly known methods were male condoms (98.2%), injectables (97.4%), and the oral contraceptive pill (95.2%). Use of any contraceptive was found among 42.7% of respondents. Exposure to media was found in 70.6% of the respondents, mostly through television (58.5%) and radio (58.3%). Discussing FP with a provider was significantly associated with media exposure (aPR 1.4, 95% CI: 1.24–1.56). Less than 50% of women who were not using FP had contact with an FP provider. Women in union (aPR 1.6, 95% CI: 1.01–2.68) and those with access to media messages (aPR 2.5, 95% CI: 1.37–4.54) were more likely to have contact with a provider to discuss FP.

Conclusion: There is high general awareness about FP methods and media exposure, but method use was low. Further exploration of women's understanding of FP methods and the fit between existing education programs and FP knowledge needs in this urban setting should be conducted. The potential for mobile health solutions in this urban population should be explored. Future studies should focus on the knowledge and understanding of FP among unmarried and nulliparous women and those with no access to media information.

Evaluating the impact of female community health volunteer involvement in a postpartum family planning intervention in Nepal: A mixed-methods study at one-year post-intervention

Introduction

This is a one-year post-intervention study following an initiative to provide orientation to female community health volunteers (FCHVs) on postpartum family planning in Nepal. In light of positive results in the earlier post-intervention study, this study was designed to provide a more long-term perspective on sustainability by assessing the effect at one-year post-intervention.

Methods

This mixed-methods study was conducted in January 2020 in Morang district, Nepal. We collected quantitative data from a knowledge assessment of FCHVs who had participated in the intervention on postpartum family planning, data on their community-based counseling coverage and through interviews with postpartum mothers in two selected hospitals. Qualitative data were collected through six key informant interviews with health providers and four focus group discussions with FCHVs involved in the intervention. We performed descriptive and multivariate analyses for quantitative data and thematic analysis for qualitative data.

Results

In total, 206 FCHVs participated in the one-year post-intervention study with significant improvement in knowledge of postpartum family planning as compared to pre-intervention period. The adjusted odds ratios (AOR) for knowledge of the 5 key messages on postpartum family planning as compared to the pre-intervention period included 1) knowledge on postpartum family planning can be used immediately after birth (AOR = 18.1, P<0.001), 2) postpartum intra-uterine device (PPIUD) can provide protection up to 12 years (AOR = 2.9, P = 0.011), 3) mothers who undergo cesarean section can use PPIUD (AOR = 2.3, P<0.001), 4) PPIUD can be inserted immediately after birth (AOR = 6.2, P <0.001), and 5) women should go for follow-up immediately if the IUD strings are seen outside vulva (AOR = 2.0, P = 0.08). The FCHVs answering 4 or more questions correctly was 10 times higher (AOR = 10.1, P<0.001) at one-year post-intervention, whereas it was 25 times higher at immediate-post-test (AOR = 25.1, p<0.001) as compared to pre-intervention phase.

The FCHVs had counseled 71% of the pregnant women (n = 538) within their communities at one-year post-intervention. The postpartum mothers in hospitals had a 2 times higher odds of being counseled by FCHVs during their pregnancy at one-year post-intervention (AOR = 1.8, P = 0.039) than in pre-intervention phase. The qualitative findings suggested a positive impression regarding the FCHV’s involvement in postpartum family planning counseling in the communities, however, supervision and monitoring over a longer term was identified as a key challenge and that may influence sustainability of community-based and hospital-based postpartum family planning services.

Conclusion

The FCHVs’ knowledge and community-based activities on postpartum family planning remained higher than in the pre-intervention. However, it declined when compared to the immediate post-intervention period. We propose regular supervision and monitoring of the work of the FCHVs to sustain progress.

The role of structural and process quality of family planning Care in Modern Contraceptive use in Indonesia: a multilevel analysis

Introduction

Despite contraceptive behaviors are influenced by multiple and multilevel variables, studies on modern contraceptive use in Indonesia has concentrated on single-level and mostly individual and household variables, and less interest has been devoted to multilevel analysis that accounts for community and SDP characteristics that may affect woman’s decision to use modern FP method. This study aimed to assess the role of structural and process quality of family planning care in modern contraceptive use among women in reproductive ages in Indonesia.

Methods

This study analyzed data from the 2016 PMA2020 survey of 10,210 women in 372 enumeration areas in Indonesia. The data were analyzed using categorical principal component analysis and multilevel mixed-effects logistic regression.

Results

The key variables for structural quality were number of contraceptive provided, SDP supports CHWs, available water and electricity, and skilled FP personnel, while the main factors for process quality were privacy of clients and provision of post-abortion service. There were significant differences across communities in how study variables associated with modern FP adoption. The finding shows the evidence of significant roles of structural and process quality FP care in modern contraceptive use. Moreover, women with high autonomy in FP decision, those who had free national/district health insurance, and those living in a community with higher proportion of women visited by CHW, had higher odds of modern contraceptive usage. Yet, women who live in a community with higher mean ideal number of children or greater proportion of women citing personal/husband/religion opposition to FP, had lower odds of modern contraceptive use than their counterparts.

Conclusion

Study findings suggest improvement in structural and process quality of FP care will yield substantial growths in modern contraceptive use. Moreover, FP workers should also address adverse cultural/traditional customs in community and should target communities where the demand for modern FP was degraded by opposing social beliefs and norms. There was significant variation across communities in how individual, household, community, and SDP factors affect modern FP practice, hence, context should be taken into consideration in the development of FP intervention and promotion programs.

Patient-public engagement strategies for health system improvement in sub-Saharan Africa: a systematic scoping review

Background

Actively involving patients and communities in health decisions can improve both peoples’ health and the health system. One key strategy is Patient-Public Engagement (PPE). This scoping review aims to identify and describe PPE research in Sub-Saharan Africa; systematically map research to theories of PPE; and identify knowledge gaps to inform future research and PPE development.

Methods

The review followed guidelines for conducting and reporting scoping reviews. A systematic search of peer-reviewed English language literature published between January 1999 and December 2019 was conducted on Scopus, Medline (Ovid), CINAHL and Embase databases. Independent full text screening by three reviewers followed title and abstract screening. Using a thematic framework synthesis, eligible studies were mapped onto an engagement continuum and health system level matrix to assess the current focus of PPE in Sub-Saharan Africa.

Results

Initially 1948 articles were identified, but 18 from 10 Sub-Saharan African countries were eligible for the final synthesis. Five PPE strategies implemented were: 1) traditional leadership support, 2) community advisory boards, 3) community education and sensitisation, 4) community health volunteers/workers, and 5) embedding PPE within existing community structures. PPE initiatives were located at either the ‘involvement’ or ‘consultation’ stages of the engagement continuum, rather than higher-level engagement. Most PPE studies were at the ‘service design’ level of the health system or were focused on engagement in health research. No identified studies reported investigating PPE at the ‘individual treatment’ or ‘macro policy/strategic’ level.

Conclusion

This review has successfully identified and evaluated key PPE strategies and their focus on improving health systems in Sub-Saharan Africa. PPE in Sub-Saharan Africa was characterised by tokenism rather than participation. PPE implementation activities are currently concentrated at the ‘service design’ or health research levels. Investigation of PPE at all the health system levels is required, including prioritising patient/community preferences for health system improvement.

Human-centred design of a new microneedle-based hormonal contraceptive delivery system

Background: It is estimated that 225 million women worldwide have an unmet need for family planning, and more than half live in low- and middle-income countries. Increasing the choice of contraceptive methods available can reduce this unmet need. Microneedle drug delivery systems represent a new technology for minimally invasive self-administration of contraceptives. We explored stakeholders’ views on different aspects of a proposed microneedle-based hormonal contraceptive delivery system. The feedback was used to iteratively develop this delivery system. Methods: Focus group discussions and semi-structured interviews were conducted with potential stakeholders (women and trans males of childbearing age, their partners, and health professionals and organisations that provide family planning advice and contraception services) in Uganda, The Gambia, Malawi, and the UK, exploring concept acceptability and gathering feedback on different aspects of design and usability of the proposed delivery system. Results: Participants viewed the concept of a new, microneedle-based contraceptive favourably. In Uganda, participants were presented with 7 different prototype applicators and identified desirable features of a preferred delivery device; their input reducing the number of prototypes that were subsequently evaluated by stakeholders in The Gambia and the UK. Participants in these countries helped to identify and/or confirm the most desirable characteristics of the applicator, resulting in design consolidation into a refined concept applicator. The final, optimised applicator prototype was validated during user research in Malawi. This human-centred design approach was also used to iteratively develop an information leaflet for the device. During these user studies, other preferred aspects of a contraceptive delivery system were also evaluated, such as anatomical site of application, duration of action, and return to fertility. Conclusions: A new microneedle-based contraceptive delivery system was iteratively developed using a human-centred design approach and was favourably received by potential stakeholders. The product is now being refined for testing in pre-clinical studies.

Human-centred design of a new microneedle-based hormonal contraceptive delivery system

Background: It is estimated that 225 million women worldwide have an unmet need for family planning, and more than half live in low- and middle-income countries. Increasing the choice of contraceptive methods available can reduce this unmet need. Microneedle drug delivery systems represent a new technology for minimally invasive self-administration of contraceptives. We explored stakeholders’ views on different aspects of a proposed microneedle-based hormonal contraceptive delivery system. The feedback was used to iteratively develop this delivery system. Methods: Focus group discussions and semi-structured interviews were conducted with potential stakeholders (women and trans males of childbearing age, their partners, and health professionals and organisations that provide family planning advice and contraception services) in Uganda, The Gambia, Malawi, and the UK, exploring concept acceptability and gathering feedback on different aspects of design and usability of the proposed delivery system. Results: Participants viewed the concept of a new, microneedle-based contraceptive favourably. In Uganda, participants were presented with 7 different prototype applicators and identified desirable features of a preferred delivery device; their input reducing the number of prototypes that were subsequently evaluated by stakeholders in The Gambia and the UK. Participants in these countries helped to identify and/or confirm the most desirable characteristics of the applicator, resulting in design consolidation into a refined concept applicator. The final, optimised applicator prototype was validated during user research in Malawi. This human-centred design approach was also used to iteratively develop an information leaflet for the device. During these user studies, other preferred aspects of a contraceptive delivery system were also evaluated, such as anatomical site of application, duration of action, and return to fertility. Conclusions: A new microneedle-based contraceptive delivery system was iteratively developed using a human-centred design approach and was favourably received by potential stakeholders. The product is now being refined for testing in pre-clinical studies.

Reducing unmet need for contraceptive services among youth in Homabay and Narok counties, Kenya: the role of community health volunteers - a qualitative study

Background

Access to contraceptive services is a cornerstone of human well-being. While Community Health Volunteers (CHVs) promote family planning in Kenya, the unmet need for contraceptives among youth remains high. CHVs seem to pay little specific attention to the contraceptive needs of the youth.

Methods

We conducted a qualitative study exploring the role of CHVs in increasing access and uptake of contraceptive services among youth aged 18–24 years in Narok and Homabay Counties, Kenya. We undertook 37 interviews and 15 focus group discussions involving CHVs, youth, community members, community leaders, youth leaders and health programme managers. Data were recorded, transcribed, translated, coded and thematically analysed, according to a framework that included community, CHV and health system-related factors.

Results

CHVs often operated in traditional contexts that challenge contraceptive use among unmarried female and male youth and young married couples. Yet many CHVs seemed to have overcome this potential ‘barrier’ as well as reigning misconceptions about contraceptives. While private and facility-based public contraceptive services were somehow available, CHVs were the preferred service provider for many youth due to ease of access and saving time and transport costs. This was influenced by varied perceptions among youth of CHVs’ knowledge, skills and attitudes regarding contraceptives and provider-client interaction, and specifically their commitment to maintain confidentiality.

Conclusions

CHVs have the potential to increase access to contraceptives for young people, reducing unmet need for contraceptives. Their knowledge, skills and attitudes need strengthening through training and supervision, while incentives to motivate them and broadening the range of contraceptives they are allowed to offer should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06363-x.

Youths' perceptions of community health workers' delivery of family planning services: a cross-sectional, mixed-methods study in Nakaseke District, Uganda

BACKGROUND

High rates of unintended adolescent pregnancy are a significant health problem in Uganda. To improve access to family planning (FP) services, community-based Village Health Teams (VHTs) are widely employed in Uganda to deliver education and services. However, evaluations of FP programs suggest that mainly older, married women use VHT FP services.

METHODS

To better understand youth reluctance to use VHTs, we collected quantitative FP and contraceptive-seeking behavior data from a survey of 250 youths aged 15-25 in randomly selected households in Nakaseke District, which we triangulated with data from 3 focus group discussions (FGDs) (n = 15).

RESULTS

Most respondents received FP services from the formal health sector, not VHTs. Only half had talked to a VHT, but 65% knew that VHTs provide free FP services, and most (82%) felt comfortable talking to VHTs about FP. The main reasons for discomfort were fear that VHTs would violate privacy (mentioned by 60% of those not comfortable), that VHTs would talk to parents (33%), shyness (mentioned by 42% of those ≤18), and fear of being judged (14%). Concern about side effects was the most common reason for not using FP methods. Survey respondents said having VHTs of the same sex was important, particularly those in the youngest age group (OR = 4.45; 95%CI: 1.24, 16.00) and those who were unmarried (OR = 5.02; 95%CI: 2.42, 10.39). However, FGD participants (who were older than survey respondents on average) often preferred older VHTs of the opposite sex, whom they viewed as more professional and trustworthy. Respondents said the primary deciding factors for using VHTs were whether privacy would be respected, the proximity of care, and the respectfulness of care.

CONCLUSIONS

VHTs are a known source of FP services but not widely used by youth due to privacy and quality of care concerns. VHT messaging and training should increase focus on ensuring privacy, protecting confidentiality, providing respectful care, and addressing concerns about contraceptive side effects. Preferences for VHTs of similar age and sex may be more important for younger adolescents than older youths for whom quality concerns predominate.

Health for the People: Past, Current, and Future Contributions of National Community Health Worker Programs to Achieving Global Health Goals

National community health worker programs are at the dawn of a new era, given the growing recognition of their importance for achieving global health goals and for controlling the COVID-19 pandemic. Now is the time to provide them with the respect and funding that they need and deserve.

Women's empowerment, intrahousehold influences, and health system design on modern contraceptive use in rural Mali: a multilevel analysis of cross-sectional survey data

BACKGROUND

Persistent challenges in meeting reproductive health and family planning goals underscore the value in determining what factors can be leveraged to facilitate modern contraceptive use, especially in poor access settings. In Mali, where only 15% of reproductive-aged women use modern contraception, understanding how women's realities and health system design influence contraceptive use helps to inform strategies to achieve the nation's target of 30% by 2023.

METHODS

Using household survey data from the baseline round of a cluster-randomized trial, including precise geolocation data from all households and public sector primary health facilities, we used a multilevel model to assess influences at the individual, household, community, and health system levels on women's modern contraceptive use. In a three-level, mixed-effects logistic regression, we included measures of women's decision-making and mobility, as well as socio-economic sources of empowerment (education, paid labor), intrahousehold influences in the form of a co-residing user, and structural factors related to the health system, including distance to facility.

RESULTS

Less than 5% of the 14,032 women of reproductive age in our study used a modern method of contraception at the time of the survey. Women who played any role in decision-making, who had any formal education and participated in any paid labor, were more likely to use modern contraception. Women had three times the odds of using modern contraception if they lived in a household with another woman, typically a co-wife, who also used a modern method. Compared to women closest to a primary health center, those who lived between 2 and 5 km were half as likely to use modern contraception, and those between 5 and 10 were a third as likely.

CONCLUSIONS

Despite chronically poor service availability across our entire study area, some women-even pairings of women in single households-transcended barriers to use modern contraception. When planning and implementing strategies to expand access to contraception, policymakers and practitioners should consider women's empowerment, social networks, and health system design. Accessible and effective health systems should reconsider the conventional approach to community-based service delivery, including distance as a barrier only beyond 5 km.

Understanding perceived access barriers to contraception through an African feminist lens: a qualitative study in Uganda

BACKGROUND

There are many barriers that impact a woman's access to contraception in rural sub-Saharan Africa, such as financial constraints, supply shortages, stigma, and misconceptions. Through and African Feminist lens, this study examines how these perceived barriers intersect with each other, and how they negatively impact women's access to family planning and their perceived value of contraceptives in Luweero, Uganda.

METHODS

This qualitative study analyzed data collected from healthcare workers at one private clinic and one public clinic that offer family planning services in four focus group discussions in Luweero, Central Region, Uganda. Two focus group discussions were held in each clinic. Eligible participants spoke English, were at least 18 years of age, and had at least 3 years of experience as a healthcare worker in Luweero. Among the participants were nurses, midwives, family planning counsellors, and village health workers, both male and female. Coded transcripts were analyzed using a reflexive methodology through an African Feminist lens.

RESULTS

Most of the responses indicated that financial constraints experienced either by the clinic or the women significantly impact access to family planning. Certain social barriers were discussed, and the participants explained that barriers such as stigma, misconceptions, lack of knowledge, religiosity and cultural values impact women's motivation or ability to access contraceptive methods. Side effects also have a significant role to play in women's ability or motivation to navigate through these perceived social barriers.

CONCLUSIONS

Participants determined that increased funding for transportation for village health teams, consistent funding for free contraception, and expanded sensitization efforts that particularly target men would be some of the most impactful methods they can adapt to address some of these barriers.

Participation in community-based health care interventions (CBHIs) and its association with hypertension awareness, control and treatment in Indonesia

BACKGROUND

Little attention has been paid to whether CBHIs improve awareness, treatment and control of hypertension in the contexts of low- and middle- income countries (LMICs). This study therefore aims to examine participation in CBHIs for non-communicable diseases (NCDs) and its association with awareness, treatment, and control of hypertension among Indonesians.

METHODS

This study used data from the 2014 Indonesia Family Life Survey (IFLS), drawn from 30,351 respondents aged 18 years and older. Participation in CBHIs was measured by respondents' participation in CBHIs for NCDs (Posbindu PTM and Posbindu Lansia) during the 12 months prior to the survey. Logistic regressions were used to identify the relationships between participation in CBHIs for NCDs and awareness, treatment, and control of blood pressure among respondents with hypertension.

RESULTS

The age-adjusted prevalence of hypertension was 31.2% and 29.2% in urban and rural areas, respectively. The overall age-adjusted prevalence was 30.2%. Approximately 41.8% of respondents with hypertension were aware of their condition, and only 6.6% of respondents were receiving treatment. Participation in CBHIs for NCDs was associated with 50% higher odds of being aware and 118% higher odds of receiving treatment among adults with hypertension. There was no significant association between participation in CBHIs for NCDs and controlled hypertension.

CONCLUSION

Our data emphasise the importance of CBHIs for NCDs to improve the awareness and treatment of hypertension in the Indonesian population.

Impact of home-based family planning counselling and referral on modern contraceptive use in Karachi, Pakistan: a retrospective, cross-sectional matched control study

OBJECTIVES

To assess: (1) the impact of a reproductive health program on modern contraceptive use from baseline to program close; (2) the sustained impact from baseline to follow-up 36 months later; and (3) the exposure-adjusted impact at program close and follow-up.

DESIGN

Retrospective, cross-sectional matched control study.

SETTING

Karachi, Pakistan.

PARTICIPANTS

2561 married women aged 16-49 years.

INTERVENTIONS

The Willows Program, a community-based family planning counselling and referral program implemented from 2013 to 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was community-level modern contraceptive prevalence rate (mCPR), measured for January 2013 (baseline), June 2015 (program close) and at follow-up 36 months later. A secondary outcome was exposure-adjusted mCPR (among women reporting a family planning home visit) at program close and at follow-up.

RESULTS

There was no significant effect on community-level mCPR at program close (2.4 percentage point increase in intervention over comparison; 95% CI -2.2 to 7.0) or at follow-up (1.9 percentage point decrease; 95% CI -6.7 to 2.8). Only 18% of women in the intervention area reported receiving a family planning visit in the preceding 5 years. Among those reporting a visit, we observed a significant 10.3 percentage point increase (95% CI 4.6 to 15.9) from baseline to close, and a non-significant 2.0 percentage point increase (95% CI -3.8 to 7.8) from baseline to follow-up, relative to matched women in the comparison area. The cost per new modern method user was US$1089, while the cost per user-year during the intervention period was US$455.

CONCLUSIONS

The program had a positive short-term effect on women who received a family planning visit; however, this effect was not sustained. Program coverage was low and did not significantly increase community-level family planning use. Findings highlight the need to increase community coverage of high-quality counselling and contextually relevant interventions for family planning demand generation.

Identifying barriers, facilitators, and implementation strategies for a faith-based physical activity program

Background

Community engagement is critical to the acceleration of evidence-based interventions into community settings. Harnessing the knowledge and opinions of community leaders increases the likelihood of successful implementation, scale-up, and sustainment of evidence-based interventions. Faith in Action (Fe en Acción) is an evidence-based promotora-led physical activity program designed to increase moderate-to-vigorous physical activity among churchgoing Latina women.

Methods

We conducted in-depth interviews using a semi-structured interview guide based on the Consolidated Framework for Implementation Research (CFIR) at various Catholic and Protestant churches with large Latino membership in San Diego County, California to explore barriers and facilitators to implementation of Faith in Action and identify promising implementation strategies for program scale-up and dissemination. We interviewed 22 pastors and church staff and analyzed transcripts using an iterative-deductive team approach.

Results

Pastors and church staff described barriers and facilitators to implementation within three domains of CFIR: characteristics of individuals (lack of self-efficacy for and knowledge of physical activity; influence on churchgoers' behaviors), inner setting (church culture and norms, alignment with mission and values, competing priorities, lack of resources), and outer setting (need for buy-in from senior leadership). From the interviews, we identified four promising implementation strategies for the scale-up of faith-based health promotion programs: (1) health behavior change training for pastors and staff, (2) tailored messaging, (3) developing community collaborations, and (4) gaining denominational support.

Conclusions

While churches can serve as valuable partners in health promotion, specific barriers and facilitators to implementation must be recognized and understood. Addressing these barriers through targeted implementation strategies at the adopter and organizational level can facilitate improved program implementation and lead the way for scale-up and dissemination.

Contraceptive use in Appalachian women who use drugs and were recruited from rural jails

This study describes a secondary data analysis of contraceptive use across the lifetime and within the six months prior to incarceration in a sample of 400 currently incarcerated women recruited from rural, Appalachian jails, who were using drugs prior to incarceration. Phase 1 (baseline) data from an NIH funded study were used to examine rates of contraceptive use, reasons for nonuse of condoms, and correlates of condom use. Results indicate that the majority (96.5%) of respondents reported lifetime use of contraceptives, and most (70.5%) had a history of using multiple methods, with male condoms, oral contraceptive pills, and contraceptive injections being the most commonly used methods. Almost 69% of respondents reported nonuse of contraceptives within the last six months, despite high rates of involvement in risky, intimate male partnerships prior to incarceration. Contraceptive use was found to be historically acceptable in this sample, in stark contrast to rates of use within the last six months prior to incarceration, suggesting that reproductive justice-informed, social work interventions to help improve current contraceptive use are warranted as a harm-reduction approach.

Community-based postpartum contraceptive counselling in rural Nepal: a mixed-methods evaluation

Unmet need for postpartum contraception in rural Nepal remains high and expanding access to sexual and reproductive healthcare is essential to achieving universal healthcare. We evaluated the impact of an integrated intervention that employed community health workers aided by mobile technology to deliver patient-centred, home-based antenatal and postnatal counselling on postpartum modern contraceptive use. This was a pre–post-intervention study in seven village wards in a single municipality in rural Nepal. The primary outcome was modern contraceptive use among recently postpartum women. We performed a multivariable logistic regression to examine contraceptive use among postpartum women pre- and one-year post-intervention. We conducted qualitative interviews to explore the implementation process. There were 445 postpartum women in the pre-intervention group and 508 in the post-intervention group. Modern contraceptive use increased from 29% pre-intervention to 46% post-intervention (p < 0.0001). Adjusting for age, caste, and household expenditure, time since delivery and sex of child in the index pregnancy, postpartum women one-year post-intervention had twice the odds (OR 2.3; CI 1.7, 3.1; p < 0.0001) of using a modern contraceptive method as compared to pre-intervention. Factors at the individual, family, and systems level influenced women’s contraceptive decisions. The intervention contributed to increasing contraceptive use through knowledge transfer, demand generation, referrals to healthcare facilities, and follow-up. A community-based, patient-centred contraceptive counselling intervention supported by mobile technology and integrated into longitudinal care delivered by community health workers appears to be an effective strategy for improving uptake of modern contraception among postpartum women in rural Nepal.

Perceptions and experiences of men and women towards acceptability and use of contraceptives in underserved areas of Karachi, Pakistan: a midline qualitative assessment of Sukh initiative, Karachi Pakistan

Background

Family planning (FP) is an essential component of Sustainable Development Goals (SDG) and contributes directly to SDG targets 3.7 and 5.6. In Pakistan, contraceptive use has remained stagnant over the past 5 years. This change has been very slow when compared to the FP2020 pledge. The Sukh initiative project was conceived and implemented to alleviate these challenges by providing access to quality contraceptive methods in some underserved areas of Karachi, Pakistan. A qualitative study was conducted to understand the perceptions and experiences of men and women towards acceptability and contraceptive use.

Methods

A qualitative study was conducted at ten Sukh stations located in four towns of Karachi. Focus group discussions (FGDs) were conducted with married women of reproductive age (MWRA) and married men who received FP services through the Sukh initiative. Study participants were purposively sampled for focus group discussions (FGDs). Interview data was manually transcribed and analyzed using thematic analysis.

Results

A total of 20 FDGs (Men = 10 FGDs; MWRA = 10 FGDs) were conducted. Three overarching themes were identified: (I) Appropriateness and means to promote contraceptive use; (II) Equity and Accessibility to contraceptives; and (III) Perspective on available FP services. Generally, both men and women were informed about FP methods but women were more cognizant of FP information. The door to door services by community health workers in Sukh initiative areas was largely appreciated both by women and men as it has made the accessibility and availability of the information and services easy. Women suggested that the Sukh initiative should bring some strategies that can help men broaden their perspective towards FP. The study informed that the men feel left out from the FP programs. Therefore, male participants expressed keen interest in initiatives for men in their communities that would cater to their FP needs.

Conclusions

This qualitative study provided a unique opportunity to understand the perceptions of men and women towards the phenomena of contraceptive use. The study identified the need for trained and qualified female and male healthcare providers and well-established health facilities alongside door-to-door services.

Adapting a health video library for use in Afghanistan: provider-level acceptability and lessons for strengthening operational feasibility

BACKGROUND

Community health workers (CHWs) in Afghanistan are a critical care extender for primary health services, including reproductive, maternal, neonatal, and child health (RMNCH) care. However, volunteer CHWs face challenges including an ever-expanding number of tasks and insufficient time to conduct them. We piloted a health video library (HVL) intervention, a tablet-based tool to improve health promotion and counseling by CHWs. We qualitatively assessed provider-level acceptability and operational feasibility.

METHODS

CHWs implemented the HVL pilot in three rural districts of Balkh, Herat, and Kandahar provinces. We employed qualitative methods, conducting 47 in-depth interviews (IDIs) with male and female CHWs and six IDIs with community health supervisors. We used semi-structured interview guides to explore provider perceptions of program implementation processes and solicit feedback on how to improve the HVL intervention to inform scale-up. We conducted a thematic analysis.

RESULTS

CHWs reported that the HVL increased time efficiencies, reduced work burden, and enhanced professional credibility within their communities. CHWs felt video content and format were accessible for low literacy clients, but also identified challenges to operational feasibility. Although tablets were considered easy-to-use, certain technical issues required continued support from supervisors and family. Charging tablets was difficult due to inconsistent electricity access. Although some CHWs reported reaching most households in their catchment area for visits with the HVL, others were unable to visit all households due to sizeable populations and gender-related barriers, including women's limited mobility.

CONCLUSIONS

The HVL was acceptable and feasible for integration into existing CHW duties, indicating it may improve RMNCH counseling, contributing to increased care-seeking behaviors in Afghanistan. Short-term challenges with technology and hardware can be addressed through continued training and provision of solar chargers. Longer-term challenges, including tablet costs, community coverage, and gender issues, require further consideration with an emphasis on equitable distribution.

'I have a lot of faith in her': Value of community health workers in addressing family planning in rural Ghana

In rural settings with shortages in trained health care workers, community health workers (CHWs) play an important role in the delivery of health care services. The Ghana Health Service initiated a national CHW programme in 2016 to expand health services to rural populations. This study explored the perceived role and value of CHWs in addressing family planning issues in the Amansie West district of Ghana. The study included in-depth interviews (IDIs) with 28 women in the community, ages 18-49, and 30 CHWs. Using inductive thematic analysis, IDIs were coded to explore opinions on the CHWs' role and perceived value in the delivery of family planning. Participants explained that CHWs provided family planning as part of a healthcare package through household visits and referrals to government services. The value of CHWs in delivering family planning was seen in confidentiality, accessibility, and comfort. Participants recommended an enlarged CHW workforce with a range of commodities and programmatic support. The findings suggest CHWs play an important role in promoting family planning, by serving as a bridge between the community and clinics. In rural communities where resources are scarce, CHWs are an invaluable part of the broader healthcare system.

Investigating the early impact of the Trump Administration's Global Gag Rule on sexual and reproductive health service delivery in Uganda

Background

The Global Gag Rule (GGR), reinstated by President Trump in January 2017, makes non-U.S. non-governmental organizations ineligible for U.S. foreign assistance if they provide access to or information about abortion. While evidence suggests previous iterations of the GGR negatively impacted sexual and reproductive health outcomes, no studies have quantitatively assessed the impacts of the Trump administration’s GGR.

Methods

We constructed a panel dataset of facilities (76% public) using 2017/2018 Performance Monitoring and Accountability 2020 service delivery point (SDP) surveys in Uganda. Based on information from stakeholder meetings, we classified districts as more or less exposed to the GGR; 45% (N = 34) of study districts were classified as “more exposed”, which corresponded to 145 “more exposed” and 142 “less exposed” health facilities in our sample. We assessed changes in provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, engagement with community health workers (CHWs), service integration, and quality of care from 2017 (pre-GGR) to 2018 (post-GGR). Multivariable regression models were estimated, and difference-in-differences impact estimators were determined by calculating predicted probabilities from interaction terms for exposure and survey round.

Findings

We observed no immediate impact of the GGR on the provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, service integration, or quality of care. We did observe a significant impact of the policy on the average number of CHWs, with “more exposed” facilities engaging 3.8 fewer CHWs post-GGR (95% CI:-7.31,-0.32).

Conclusions

The reduction in CHWs could reduce contraceptive use and increase unintended pregnancies in Uganda. The lack of other significant findings may not be surprising given the short post-GGR observation window. Rapid organizational responses and stopgap funding from foreign governments may have mitigated any immediate impacts on service delivery in the short term. The true impact may not be felt for many years, as stopgap funding potentially ebbs and service providers adapt to new funding environments.

Enabling and hindering factors of health surveillance assistants' roles in the provision of contraceptive services in Mangochi, Malawi

Background

Contraceptive services are essential for promoting people’s health, and economic and social well-being. Despite increased contraceptive use over the past decades, unmet need is still high in Malawi. As a result of task shifting, health surveillance assistants (HSAs), Malawi’s paid community health worker cadre, provide an expanded range of contraceptive services, aimed at increasing access at community level. We conducted a qualitative study to explore enabling and hindering factors of HSAs’ roles in the provision of modern contraceptive services in Mangochi district, Malawi.

Methods

The study involved HSAs and their supervisors, a variety of community members, health workers and policy makers using 34 interviews and 12 focus group discussions. Data were recorded, transcribed, translated, coded and thematically analysed according to a framework that included community-, HSA- and health system-related factors.

Results

HSAs were found to be trusted providers of contraceptive services. At community level, gender norms, decision-making and beliefs about contraceptives were intertwined. They resulted in women using contraceptive services, including those offered by HSAs, in secret. There were misconceptions about contraceptives among both men and women, which were insufficiently addressed by HSAs. Residence and age of HSAs influenced their role in the provision of contraceptive services to (young) community members, whereas sex was not regarded as an enabling or hindering factor. While most community members reported to be satisfied with the quality of HSAs’ services, quality was compromised by a lack of contraceptive supplies and other resources, and limited supportive supervision and training.

Conclusions

HSAs in Mangochi are important contraceptive service providers. Their ability to ensure male involvement, increase access to services for youth and address misconceptions about contraceptives needs improvement. This requires a thorough understanding of socio-cultural norms and improved behavioural change communication competencies, which need to be incorporated in future training under Malawi’s Community Health Strategy. 

Improving post-partum family planning services provided by female community health volunteers in Nepal: a mixed methods study

Background

Family planning services in the post-partum period, termed post-partum family planning (PPFP) is critical to cover the unmet need for contraception, especially when institutional delivery rates have increased. However, the intention to choose PPFP methods such as post-partum intrauterine devices (PPIUD) remains low in countries such as Nepal. Community health workers such as Female Community Health Volunteers (FCHVs) could play an important role in improving the service coverage of PPFP in Nepal. However, their knowledge of PPFP and community-based services related to PPFP remain unclear. This study aims to assess the effect on community-based PPFP services by improving FCHV’s knowledge through orientation on PPFP.

Methods

We conducted this mixed-methods study in Morang District in Nepal. The intervention involved orientation of FCHVs on PPFP methods. We collected quantitative data from three sources; via a survey of FCHVs that assessed their knowledge before and after the intervention, from their monthly reporting forms on counseling coverage of women at different stages of pregnancy from the communities, and by interviewing mothers in their immediate post-partum period in two selected hospitals. We also conducted six focus group discussions with the FCHVs to understand their perception of PPFP and the intervention. We performed descriptive and multivariable analyses for quantitative results and thematic analysis for qualitative data.

Results

In total, 230 FCHVs participated in the intervention and their knowledge of PPFP improved significantly after it. The intervention was the only factor significantly associated with their improved knowledge (adjusted odds ratio = 24, P < 0.001) in the multivariable analysis. FCHVs were able to counsel 83.3% of 1872 mothers at different stages of pregnancy in the communities. In the two hospitals, the proportion of mothers in their immediate post-partum period whom reported they were counseled by FCHVs during their pregnancy increased. It improved from 7% before the intervention to 18.1% (P < 0.001) after the intervention. The qualitative findings suggested that the intervention improved their knowledge in providing PPFP counseling.

Conclusion

The orientation improved the FCHV’s knowledge of PPFP and their community-based counseling. Follow-up studies are needed to assess the longer term effect of the FCHV’s role in improving community-based PPFP services.

The impact of adding community-based distribution of oral contraceptives and condoms to a cluster randomized primary health care intervention in rural Tanzania

Background

Efforts to expand access to family planning in rural Africa often focus on the deployment of community health agents (CHAs).

Methods

This paper reports on results of the impact of a randomized cluster trial of CHA deployment on contraceptive uptake among 3078 baseline and 2551 endline women of reproductive age residing in 50 intervention and 51 comparison villages in Tanzania. Qualitative data were collected to broaden understanding of method preference, reasons for choice, and factors that explain non-use.

Results

Regression difference-in-differences results show that doorstep provision of oral contraceptive pills and condoms was associated with a null effect on modern contraceptive uptake [p = 0.822; CI 0.857; 1.229]. Discussions suggest that expanding geographic access without efforts to improve spousal and social support, respect preference for injectable contraceptives, and address perceived risk of side-effects offset the benefits of adopting contraceptives provided by community-based services.

Conclusions

The results of this study demonstrate that increasing access to services does not necessarily catalyze contraceptive use as method choice and spousal dynamics are key components of demand for contraception. Findings attest to the importance of strategies that respond to the climate of demand.

Trial registration

Controlled-Trial.comISRCTN96819844. Retrospectively registered on 29.03.2012.

Evaluating an MFI Community Health Worker Program: How microfinance group networks influence intervention outreach and impact

Background

Community Health Workers (CHWs) are considered to be a cost-effective and inclusive solution to address the persistent health workforce shortage in many low and middle-income countries. In recent years, microfinance institutions (MFIs) got increasingly engaged in providing health services delivered by CHWs. Despite their growing importance, little is known about the impacts and implementation barriers of these mostly small-scale initiatives. This paper evaluates an MFI-led CHW program in the Philippines and studies the role of microfinance group networks in influencing program outreach and impact. The intervention aims at disseminating information in poor communities, improving health monitoring through increased check-ups and raising social support.

Methods

Clustered randomized controlled trial in 70 communities in the greater area of Metro Manila, the Philippines. The main data was collected in a baseline and follow-up survey and is complemented with extensive sociometric network and geographical data. The main outcome variable is a composite health index based on 10 indicators. The role of the health worker’s embeddedness and connectedness in the community for program success is tested using tools of social network analysis.

Results

The intervention led to a 3.8% (95% confidence interval (CI) = 1.3, 6.4) improvement in the composite health outcome. Effects across indicators are mixed and mainly driven by changes in immediate health monitoring behavior: The probability for routine examinations increased in the treatment group by 10.6% (95% CI = 3.2, 18.1), for regular blood pressure checks by 9.6% (95% CI = 3.3, 15.9), and for having access to a health care provider by 7.2% (95% CI = 0.93, 13.5). No statistical effects on general knowledge and social support are observable. Social networks are a key driver of program outreach and impact. Close friends and acquaintances of health workers used and benefited substantially more from the program than more distant ties.

Conclusions

Despite the promising immediate behavioral impacts, it remains questionable to what extent such small-scale MFI initiatives can bring transformative and sustainable changes without external support. Microfinance group networks played an important role for the success of the health intervention and further research is needed to better understand how these affect the health care utilization decisions of the clients.

Lessons learned from a public sector community-based distribution program for scaling up DMPA-SC contraceptive services in Nigeria

Background: From August 2016 to December 2017, the United Nations Population Fund (UNFPA) in Nigeria, through three implementing partners, scaled up the public sector delivery of subcutaneous depot medroxyprogesterone acetate (DMPA-SC, brand name Sayana Press) across 10 states. The public sector program featured a proactive community-based distribution (CBD) model, led by community health extension workers (CHEWs) and supported by community health volunteers (CHVs). Methods: We conducted monitoring and evaluation (M&E) alongside program implementation to understand the program’s reach, particularly in terms of clients served, and their proportions of new users of modern contraception and younger women. Key performance indicators (KPIs) were calculated from end-user data digitized from client registers. To evaluate performance trends over time and understand geographic variation, we analyzed quarterly data in Excel and Stata 15, and complemented these analyses with data from interviews conducted periodically with program staff and performance documentation submitted by implementing partners. Results: The program reached 144,505 clients, of whom 88% (n=127,315) were women. Among women reached, 92% (n=116,614) chose DMPA-SC. The program reached a high percentage of new users of modern contraception: 80% (n=93,075) of DMPA-SC clients were new users, as were 80% (n=111,350) of overall clients. However, only 26% (n=36,313) of clients were under 25. From performance reports and interviews with program staff, many involved credited the CBD model with reaching a client base largely comprised of new users of modern contraception. Conclusions: Our analysis of the Nigeria public sector DMPA-SC program suggests that the combination of DMPA-SC and proactive CBD may accelerate contraceptive uptake and reduce unmet need in Nigeria. While some strategies for increasing the cost-efficiency of the CBD emerged, future research on this delivery model should focus on key concerns about the modality’s sustainability.

Can community health workers increase modern contraceptive use among young married women? A cross-sectional study in rural Niger

BACKGROUND

The Republic of Niger has the highest rate of early marriage and adolescent fertility in the world. Recent global health initiatives, such as Family Planning 2020, have reinvigorated investments in family planning in low- and middle-income countries (LMICs). As part of this initiative, Niger has implemented ambitious plans to increase contraceptive prevalence through policies designed to increase coverage and access to family planning services. One strategy involves the deployment of volunteer community health workers (relais communautaires) in rural settings to improve access to family planning services, especially among adolescents and youth. The objective of this article is to determine if visits by relais are associated with increased use of modern contraception among young married women in rural Niger.

METHODS

Cross-sectional data from a household survey were collected from young married women between the ages of 13 and 19 in three rural districts in the region of Dosso, Niger from May to August 2016. Multivariate logistic regression was conducted to assess the odds of married female youth reporting current use of modern contraceptive methods based on being visited by a relais in the past three months.

RESULTS

A total of 956 young married women were included in the final analysis. Among study participants, 9.3% reported a relais visit to discuss health issues in the past three months and 11.4% reported currently using a modern method of contraception. Controlling for socio-demographic variables, the odds of current use of modern contraceptive methods were higher among young married women who were visited by a relais in the last three months compared to those not visited by a relais during this period (AOR = 1.94[95% CI 1.07-3.51]). In this study setting, relais were less likely to visit nulliparous women and women that worked in the past 12 months.

CONCLUSION

Young married women visited by relais were more likely to use modern contraceptive methods compared to those not visited by a relais. These results are consistent with similar family planning studies from sub-Saharan Africa and suggest that relais in Niger may be able to provide access to essential family planning services in rural and hard-to-reach areas. Additional efforts to understand the contraceptive barriers faced by nulliparous women and working women should be a key research priority in Niger.

TRIAL REGISTRATION

Clinical trial registration number 2016-1430 ; registered on October 7, 2016 (retrospectively registered).

Community health volunteers could help improve access to and use of essential health services by communities in LMICs: an umbrella review

A number of primary studies and systematic reviews focused on the contribution of community health workers (CHWs) in the delivery of essential health services. In many countries, a cadre of informal health workers also provide services on a volunteer basis [community health volunteers (CHV)], but there has been no synthesis of studies investigating their role and potential contribution across a range of health conditions; most existing studies are narrowly focused on a single condition. As this cadre grows in importance, there is a need to examine the evidence on whether and how CHVs can improve access to and use of essential health services in low- and middle-income countries (LMICs). We report an umbrella review of systematic reviews, searching PubMed, the Cochrane library, the database of abstracts of reviews of effects (DARE), EMBASE, ProQuest dissertation and theses, the Campbell library and DOPHER. We considered a review as 'systematic' if it had an explicit search strategy with qualitative or quantitative summaries of data. We used the Joanna Briggs Institute (JBI) critical appraisal assessment checklist to assess methodological quality. A data extraction format prepared a priori was used to extract data. Findings were synthesized narratively. Of 422 records initially found by the search strategy, we identified 39 systematic reviews eligible for inclusion. Most concluded that services provided by CHVs were not inferior to those provided by other health workers, and sometimes better. However, CHVs performed less well in more complex tasks such as diagnosis and counselling. Their performance could be strengthened by regular supportive supervision, in-service training and adequate logistical support, as well as a high level of community ownership. The use of CHVs in the delivery of selected health services for population groups with limited access, particularly in LMICs, appears promising. However, success requires careful implementation, strong policy backing and continual support by their managers.

Team- and individual-level motivation in complex primary care system change: A realist evaluation of the Salud Mesoamerica Initiative in El Salvador

Background:We study the role of individual and team-level motivation in explaining large-scale primary care performance improvements in El Salvador, one of the top-performing countries in the Salud Mesoamerica Initiative.Methods:Case study with outlier sampling of high-performing, community health teams in El Salvador. Design includes scoping review of literature, document review, non-participant observation, and qualitative analysis of in-depth interviews following a realist case study protocol.Results:The interplay between program interventions and organizational, community and policy contexts trigger multi-level motivational mechanisms that operate in complex, dynamic fashion. Interventions like performance measurement and team-based, in-kind incentives foster motivation among individual members of high-performing teams, which may be moderated by working conditions, supervision practices, and by the stress exerted by the interventions themselves. Individuals report a strong sense of public service motivation and an overarching sense of commitment to the community they serve. At the interpersonal level, the linkage between performance measurement and in-kind incentives triggers a sense of collective efficacy and increases team motivation and improvement behaviors. The convening of learning forums and performance dialogue increases the stakes for high-performing teams, helps them make sense of performance data, and leads to performance information utilization for healthcare improvements. Closeness to communities creates strong emotional linkages among team members that further increases collective efficacy and social identity. Such changes in individuals, team, and organizational behaviors can contribute to improved delivery of primary care services and explain the gains in performance demonstrated by the program.Conclusions:This case suggests that primary care systems that rely on multi-disciplinary teams for the provision of care can benefit from performance measurement and management interventions that leverage individual and team-level motivation. Realist evaluation can help prioritize policy-relevant research and enhance the design and evaluation of large-scale performance reforms in primary care systems in low- and middle-income settings.

Realities and experiences of community health volunteers as agents for behaviour change: evidence from an informal urban settlement in Kisumu, Kenya

BACKGROUND

Community health workers play an important role in health service delivery and are increasingly involved in behaviour change interventions, including for hygiene-related behaviour change. However, their role and capacity to deliver behaviour change interventions, particularly in high-density urban settlements, remain under-researched. This study examines the behaviour change-related activities of community health volunteers (CHVs)-community health workers affiliated with the Kenyan Ministry of Health-in a peri-urban settlement in Kenya, in order to assess their capabilities, opportunities to work effectively, and sources of motivation.

METHODS

This mixed-methods study included a census of 16 CHVs who work in the study area. All CHVs participated in structured observations of their daily duties, structured questionnaires, in-depth interviews, and two focus group discussions. Structured data were analysed descriptively. Thematic content analysis was followed for qualitative data. Results were synthesized and interpreted using the capability, opportunity, motivation for behaviour change framework, COM-B.

RESULTS

In addition to their responsibilities with the Ministry of Health, CHVs partnered with a range of non-governmental organizations engaged in health and development programming, often receiving small stipends from these organizations. CHVs reported employing a limited number of behaviour change techniques when interacting with community members at the household level. Capability: While supervision and support from the MOH was robust, CHV training was inconsistent and inadequate with regard to behaviour change and CHVs often lacked material resources necessary for their work. Opportunity: CHVs spent very little time with the households in their allocated catchment area. The number of households contacted per day was insufficient to reach all assigned households within a given month as required and the brief time spent with households limited the quality of engagement.

MOTIVATION

Lack of compensation was noted as a demotivating factor for CHVs. This was compounded by the challenging social environment and CHVs' low motivation to encourage behaviour change in local communities.

CONCLUSIONS

In a complex urban environment, CHVs faced challenges that limited their capacity to be involved in behaviour change interventions. More resources, better coordination, and additional training in modern behaviour change approaches are needed to ensure their optimal performance in implementing health programmes.

Measuring family planning quality and its link with contraceptive use in public facilities in Burkina Faso, Ethiopia, Kenya and Uganda

The individual impacts of several components of family planning service quality on contraceptive use have been studied, but the influence of a composite measure synthesizing these components has not been often investigated. We (1) develop a composite score for family planning service quality based on health facility data from Burkina Faso, Ethiopia, Kenya and Uganda and (2) examine the influence of structural quality on contraceptive practice in these four countries. We used nationally representative cross-sectional survey data of health facilities and women of reproductive age. First, we constructed quality scores for facilities using principal component analysis to integrate 18 variables. Second, we linked women to their closest facility using geo-coordinates. Third, we estimated multivariable logistic regression models to calculate women's odds ratios for modern contraceptive use adjusting for facilities' quality and other factors. In Burkina Faso, Ethiopia and Uganda, the odds of using a modern method of contraception was greater if the nearest facility provided high- or medium-quality services compared with low quality in the univariable model. After controlling for possible confounders, the adjusted odds ratios were significant for high quality (aOR: 3.12, P value: 0.005) and medium quality (aOR: 2.57, P value: 0.009) in Ethiopia and in the hypothesized direction but not statistically significant in Uganda or Burkina Faso, and in the opposite direction in Kenya. A process quality measure-having been visited by a community health worker-was statistically significantly associated with modern contraceptive use in three of the four countries (Burkina Faso aOR: 2.18, P value: 0.000; Ethiopia aOR: 1.78, P value: 0.000; Uganda aOR: 1.96, P value: 0.012). These results suggest that service quality in public facilities may be less relevant to contraceptive use in environments where the universe and reach of providers changes actively. Programs promoting contraception therefore need to consider quality within facility types and their service environments.

What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers

OBJECTIVE

To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems.

METHODS

We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards.

FINDINGS

We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance.

CONCLUSION

Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.

Impact of a "Diagonal" Intervention on Uptake of Sexual and Reproductive Health Services by Female Sex Workers in Mozambique: A Mixed-Methods Implementation Study

Background

Female sex workers (FSWs) have high risks for adverse sexual and reproductive health (SRH) outcomes, yet low access to services. Within an implementation research project enhancing uptake of SRH services by FSWs, we piloted a “diagonal” intervention, which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal), and tested its effect.

Methods

The study applied a convergent parallel mixed-methods design to assess changes in access to SRH services. Results of structured interviews with FSWs pre-intervention (N = 311) and thereafter (N = 404) were compared with the findings of eight post-intervention focus group discussions (FGDs) with FSWs and two with FSW-peer educators (PEs).

Results

Marked and statistically significant rises occurred in consistent condom use with all partners (55.3–67.7%), ever use of female condoms (37.9–54.5%), being tested for HIV in the past 6 months (56.0–76.6%), using contraception (84.5–95.4%), ever screened for cervical cancer (0.0–16.9%) and having ≥10 contacts with a PE in the past year (0.5–24.45%). Increases mostly resulted from FSW-targeted outreach, with no rise detected in utilization of public health facilities. FGD participants reported that some facilities had become more FSW-friendly, but barriers such as stock-outs, being asked for bribes and disrespectful treatment persisted.

Conclusion

The combination of expanding FSW-targeted SRH services with improving access to the public health services resulted in an overall increased uptake of services, but almost exclusively because of the strengthened targeted (vertical) outreach services. Utilization of public SRH services had not yet increased and many barriers to access remained. Our diagonal approach was thus only successful in its vertical component. Improving access to the general health services remains nevertheless important and further research is needed how to reduce barriers. Ideally, the combination approach should be maintained and more successful approaches to increase utilization of public services should be explored.

Efficacy of Communication Training of Community Health Workers on Service Delivery to People Who Inject Drugs in Vietnam: A Clustered Randomized Trial

OBJECTIVES

To evaluate the efficacy of an intervention targeted to commune health workers (CHWs) who deliver services to people who inject drugs (PWID) in Vietnam.

METHODS

From 2014 to 2016, we conducted a cluster randomized controlled trial of 300 CHWs and 900 PWID in 60 communes in 2 provinces of Vietnam. Intervention CHWs participated in training sessions to enhance their communication skills. Trained CHWs were asked to deliver individual sessions to PWID. We assessed the outcomes at baseline and at 3-, 6-, 9-, and 12-month follow-ups.

RESULTS

Intervention CHWs showed greater improvement in provider-client interactions than did control CHWs at all follow-ups (range of difference = 3.33-5.18; P < .001). Intervention CHWs showed greater reduction in negative attitudes toward PWID at the 12-month follow-up (mean ±SD = 1.75 ±0.50; P < .001). PWID in the intervention group exhibited greater improvement in drug avoidance than did those in the control group from the 6-month follow-up on (range of difference = 1.21-1.65; P < .001). We observed no intervention effect on heroin use as measured by urinalysis.

CONCLUSIONS

This intervention targeting CHWs could lead to desired outcomes for both CHWs and PWID. ClinicalTrials.gov: NCT0213092.1.

Expanding the population coverage of evidence-based interventions with community health workers to save the lives of mothers and children: an analysis of potential global impact using the Lives Saved Tool (LiST)

Background

Evidence has been accumulating that community health workers (CHWs) providing evidence–based interventions as part of community–based primary health care (CBPHC) can lead to reductions in maternal, neonatal and child mortality. However, investments to strengthen and scale–up CHW programs still remain modest.

Methods

We used the Lives Saved Tool (LiST) to estimate the number of maternal, neonatal and child deaths and stillbirths that could be prevented if 73 countries effectively scaled up the population coverage of 30 evidence–based interventions that CHWs can deliver in these high–burden countries. We set population coverage targets at 50%, 70%, and 90% and summed the country–level results by region and by all 73 high–burden countries combined. We also estimated which specific interventions would save the most lives.

Findings

LiST estimates that a total of 3.0 (sensitivity bounds 1.8–4.0), 4.9 (3.1–6.3) and 6.9 (3.7–8.7) million deaths would be prevented between 2016 and 2020 if CBPHC is gradually scaled up during this period and if coverage of key interventions reaches 50%, 70%, and 90% respectively. There would be 14%, 23%, and 32% fewer deaths in the final year compared to a scenario assuming no intervention coverage scale up. The Africa Region would receive the most benefit by far: 58% of the lives saved at 90% coverage would be in this region. The interventions contributing the greatest impact are nutritional interventions during pregnancy, treatment of malaria with artemisinin compounds, oral rehydration solution for childhood diarrhea, hand washing with soap, and oral antibiotics for pneumonia.

Conclusions

Scaling up CHW programming to increase population–level coverage of life–saving interventions represents a very promising strategy to achieve universal health coverage and end preventable maternal and child deaths by 2030. Numerous practical challenges must be overcome, but there is no better alternative at present. Expanding the coverage of key interventions for maternal nutrition and treatment of childhood illnesses, in particular, may produce the greatest gains. Recognizing the millions of lives of mothers and their young offspring that could be achieved by expanding coverage of evidence–based interventions provided by CHWs and strengthening the CBPHC systems that support them underscores the pressing need for commitment from governments and donors over the next 15 years to prioritize funding, so that robust CHW platforms can be refined, strengthened, and expanded.

The Senegal urban reproductive health initiative: a longitudinal program impact evaluation

Objectives

This paper presents the impact of key components of the Senegal Urban Reproductive Health Initiative, including radio, television, community-based activities, Muslim religious-leader engagement and service quality improvement on modern contraceptive use by all women and the sub-sample of poor women.

Study design

This study uses baseline (2011) and endline (2015) longitudinal data from a representative sample of urban women first surveyed in 2011 to examine the impact of the Initiative's demand- and supply-side activities on modern contraceptive use.

Results

By endline, there was increased exposure to radio and television programming, religious leaders speaking favorably about contraception, and community-based initiatives. In the same period, modern contraceptive use increased from 16.9% to 22.1% with a slightly larger increase among the poor (16.6% to 24.1%). Multivariate analyses demonstrate that women exposed to community-based activities were more likely to use modern contraception by endline (marginal effect (ME): 5.12; 95% confidence interval (CI): 2.50–7.74) than those not exposed. Further, women living within 1 km of a facility with family planning guidelines were more likely to use (ME: 3.54; 95% CI: 1.88–5.20) than women without a nearby facility with guidelines. Among poor women, community-based activities, radio exposure (ME: 4.21; 95% CI: 0.49–7.93), and living close to program facilities (ME: 4.32; 95% CI: 0.04–8.59) impacted use.

Conclusions

Community-based activities are important for reaching urban women, including poor women, to achieve increased contraceptive use. Radio programming is also an important tool for increasing demand, particularly among poor women. Impacts of other program activities on contraceptive use were modest.

Implications

This study demonstrates that community-based activities led to increased modern contraceptive use among all women and poor women in urban Senegal. These findings can inform future programs in urban Senegal and elsewhere in francophone Africa.

Contraceptive Practice in Sub-Saharan Africa

Forty eight of the African continent's 54 sovereign states are located in the Sub-Saharan Africa (SSA) region, with the government of each defining and shaping its own health services and delivery systems. This paper reviews the trends and patterns of contraceptive practice in the region. Using survey data available from the Demographic and Health Surveys and Performance Monitoring and Accountability 2020, the study finds modern contraceptive practice to be on the rise overall but with much geographic variation. The contraceptive methods most frequently used are injectables and, more recently, implants. Higher levels of use are observed among unmarried sexually active than married females. Although use is rising, contraceptive discontinuation rates are also high. Recent program initiatives discussed include expanding long-acting contraceptive options, promoting and delivering contraceptive methods in the postpartum period, and relying on community health workers for contraceptive outreach and service delivery. SSA's family planning situation remains challenged by weak health systems which must address competing priorities to manage disease prevention as well as primary health care. Increasing investments in family planning delivery in many SSA countries, however, augur for continued rapid uptake of modern contraception, possibly matching if not outpacing the record of other regions.