Operationalizing Integrated Immunization and Family Planning Services in Rural Liberia: Lessons Learned From Evaluating Service Quality and Utilization

How interventions to maintain services during the COVID-19 pandemic strengthened systems for delivery of maternal and child health services: a case-study of Wakiso District, Uganda

BACKGROUND

Health systems are resilient if they absorb, adapt, and transform in response to shocks. Although absorptive and adaptive capacities have been demonstrated during the COVID-19 response, little has been documented about their transformability and strengthened service delivery systems. We aimed to describe improvements in maternal and child health service delivery as a result of investments during the COVID-19 response.

METHODS

This was a descriptive case study conducted in Wakiso District in central Uganda. It included 21 nurses and midwives as key informants and 32 mothers in three focus group discussions. Data were collected using an interview guide following the Systems Engineering Initiative for Patient Safety theoretical framework for service delivery.

RESULTS

Maternal and child health service delivery during the pandemic involved service provision without changes, service delivery with temporary changes and outcomes, and service delivery that resulted into sustained changes and outcomes. Temporary changes included patient schedule adjustments, community service delivery and negative outcomes such as increased workload and stigma against health workers. Sustained changes that strengthened service delivery included new infrastructure and supplies such as ambulances and equipment, new roles involving infection prevention and control, increased role of community health workers and outcomes such as improved workplace safety and teamwork.

CONCLUSIONS

In spite of the negative impact the COVID-19 pandemic had on health systems, it created the impetus to invest in system improvements. Investments such as new facility infrastructure and emergency medical services were leveraged to improve maternal and child health services delivery. The inter-departmental collaboration during the response to the COVID-19 pandemic resulted into an improved intra-hospital environment for other service delivery. However, there is a need to evaluate lessons beyond health facilities and whether these learnings are deliberately integrated into service delivery. Future responses should also address the psychological and physical impacts suffered by health workers to maintain service delivery.

The effect of integration of family planning education with infant vaccination visits on the uptake of postpartum family planning in Ile-Ife, Nigeria

Integration of maternal and child health services can improve service utilisation. An operations research was conducted in a Nigerian tertiary hospital. A pilot study was conducted at three family planning (FP) and vaccination sites. A formative assessment was carried out using client records and key-informant interviews. Pre- and post-integration questionnaires were administered to 715 women attending the infant vaccination clinics. Themes were developed from the qualitative data and some verbatim quotes were reported. The quantitative data were analysed using Stata, version 17. Univariate and multivariate analyses were done to compare associations between categorical independent and outcome variables where applicable, with level of significance set at <0.05 and 95% confidence interval.The health care workers were willing to integrate the two services but inadequate training and time constraint were key barriers. Significant increases in the knowledge of contraception (25.7% vs 34.7%, p = 0.001), intention to use contraception (31.2% vs 38.2%, p = 0.001), and number of new acceptors of FP (487 vs 664, p = 0.001), were recorded post-integration, even though it was difficult to determine whether the observed increase in new FP acceptors was due to increased patronage from the study participants and not from other clients who were not part of the study. Integration of FP education and infant vaccination services is a feasible and acceptable strategy for increasing contraceptive use among postpartum women, as vaccination clinic staff were willing to take on FP education along with their current duties.Impact statementWhat is already known on this subject? Few studies have reported on the outcomes related to FP and vaccination integration.What the results of this study add? A simple model of FP education and infant vaccination services integration is a feasible and acceptable strategy for increasing contraceptive use among postpartum women. However, inadequate training and time constraint were major concerns for healthcare providers.Implications of these findings for clinical practice and/or further research? Targeted family planning education and referral should be encouraged during infant vaccination visits. There is a need for further research to determine the providers' skills necessary for integration and whether integration poses a risk to either service.

Immunization as an entry point for primary health care and beyond healthcare interventions-process and insights from an integrated approach in Lebanon

Integrated healthcare systems are continually pitched as major contributors towards better distribution of health outcomes and enhanced well-being. Under emergency conditions, integrated healthcare services can guarantee better access to the target population. In recent years, several crises, i.e., economic collapse, the fuel crisis, the Beirut blast, a large refugee population, and the COVID-19 pandemic, in Lebanon have led to a major shift in the health-seeking behavior of the communities, with preventive services being downprioritized despite being available and curative healthcare services being sought out as late as possible. An extensive drop in immunization coverage and an overstretched public health system presents the risk of Vaccine-Preventable Disease outbreaks and urgent intervention is needed to bridge the immunity gap. The Ministry of Public Health, Lebanon, and UNICEF Lebanon successfully demonstrated the use of an immunization platform as an entry point to reach communities for service delivery, identification and referral, screening, awareness generation, and a host of other services that can be copied for other programs including but not limited to those for Maternal and Child health, nutrition, early childhood development, COVID-19, children with disabilities, social protection, education, health emergencies like cholera, etc., and these can provide bi-directional support to each other. UNICEF along with the MoPH (Ministry of Public Health) has been working towards reaching the most vulnerable population with a bouquet of services through existing immunization touchpoints for favorable healthcare outcomes.

Prevalence and factors associated with the intention to use contraception among women of reproductive age who are not already using a contraceptive method in Liberia: findings from a secondary analysis of the 2019-2020 Liberia Demographic Health Survey

OBJECTIVE

Contraception constitutes a vital aspect of sexual and reproductive healthcare. However, the high prevalence of non-use has become a great public health concern globally. This study examined the intention to use contraceptives and its associated factors among women of reproductive age who were not using any method in Liberia.

DESIGN AND SETTING

A cross-sectional population-based study was conducted. We used data from the 2019-2020 Liberia Demographic and Health Survey. The research framework used the theory of planned behaviour to identify the factors that influence women's intention to use contraception.

PARTICIPANTS

The study analysed a weighted sample of 4504 women aged 15-49 who were not currently using any form of contraception.

DATA ANALYSIS

The outcome variable was the intention to use a contraceptive method. A binary logistic regression was used to identify factors associated with the intention to use contraceptives in Stata V.13.0.

RESULTS

Of the 4504 women, 39.42% intended to use contraception. Contraception intention was significantly lower in married women than in never married women (adjusted OR (aOR) 0.78; 95% CI 0.62 to 0.98). Additionally, women aged 25-34 (aOR 0.434; 95% CI 0.339 to 0.556) and 35-49 (aOR 0.120; 95% CI 0.088 to 0.163) had a reduced intent to use contraceptives than those aged 15-24. However, women with at least one child, those with prior contraception experience and those who had their first sexual encounter at the age of 13 or older were more likely to intend to use contraception. Notably, Muslim and wealthy women displayed a lower likelihood of intending to use contraception.

CONCLUSION

These findings highlight that attitudes, subjective norms and perceived behavioural control significantly influence women's intentions to use contraception. Understanding and addressing these factors are crucial for promoting effective contraceptive use among women, facilitating informed reproductive choices.

Integration measurement and its applications in low- and middle-income country health systems: a scoping review

BACKGROUND

Despite growing interest in and commitment to integration, or integrated care, the concept is ill-defined and the resulting evidence base fragmented, particularly in low- and middle-income countries (LMICs). Underlying this challenge is a lack of coherent approaches to measure the extent of integration and how this influences desired outcomes. The aim of this scoping review is to identify measurement approaches for integration in LMICs and map them for future use.

METHODS

Arksey and O'Malley's framework for scoping reviews was followed. We conducted a systematic search of peer-reviewed literature measuring integration in LMICs across three databases and screened identified papers by predetermined inclusion and exclusion criteria. A modified version of the Rainbow Model for Integrated Care guided charting and analysis of the data.

RESULTS

We included 99 studies. Studies were concentrated in the Africa region and most frequently focused on the integration of HIV care with other services. A range of definitions and methods were identified, with no single approach for the measurement of integration dominating the literature. Measurement of clinical integration was the most common, with indicators focused on measuring receipt of two or more services provided at a single point of time. Organizational and professional integration indicators were focused on inter- and intra-organizational communication, collaboration, coordination, and continuity of care, while functional integration measured common information systems or patient records. Gaps were identified in measuring systems and normative integration. Few tools were validated or publicly available for future use.

CONCLUSION

We identified a wide range of recent approaches used to measure integration in LMICs. Our findings underscore continued challenges with lack of conceptual cohesion and fragmentation which limits how integration is understood in practice.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning, a mixed-methods systematic review

BACKGROUND

Post pregnancy family planning includes both postpartum and post-abortion periods. Post pregnancy women remain one of the most vulnerable groups with high unmet need for family planning. This review aimed to describe and assess the quality of the evidence on implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning.

METHODS

Electronic bibliographic databases (MEDLINE, PubMed, Scopus, the Cochrane Library, and Global Index Medicus) were searched from inception to October 2022 for primary quantitative, qualitative, and mixed method reports on scaling up post pregnancy family planning. Abstracts, titles, and full-text papers were assessed according to the inclusion criteria to select studies regardless of country, language, publication status, or methodological limitations. Data were extracted and methodological quality assessed using the Mixed Methods Appraisal Tool. The convergent integrated approach and a deductive thematic synthesis were used to identify themes and sub-themes of strategies to scale up post pregnancy family planning. The health system building blocks were used to summarize barriers and facilitators. GRADE-CERQual was used to assess our confidence in the findings.

RESULTS

Twenty-nine reports (published 2005-2022) were included: 19 quantitative, 7 qualitative, and 3 mixed methods. Seven were from high-income countries, and twenty-two from LMIC settings. Sixty percent of studies had an unclear risk of bias. The included reports used either separate or bundled strategies for scaling-up post pregnancy family planning. These included strategies for healthcare infrastructure, policy and regulation, financing, human resource, and people at the point of care. Strategies that target the point of care (women and / or their partners) contributed to 89.66% (26/29) of the reports either independently or as part of a bundle. Point of care strategies increase adoption and coverage of post pregnancy contraceptive methods.

CONCLUSION

Post pregnancy family planning scaling up strategies, representing a range of styles and settings, were associated with improved post pregnancy contraceptive use. Factors that influence the success of implementing these strategies include issues related to counselling, integration in postnatal or post-abortion care, and religious and social norms.

TRIAL REGISTRATION

Center for Open Science, OSF.IO/EDAKM.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Frequency and impact of long wait times for family planning in public-sector healthcare facilities in Western Kenya

BACKGROUND

Long wait times for family planning services are a barrier to high quality care and client satisfaction. Existing literature examining family planning wait times has methodological limitations, as most studies use data collected during exit interviews, which are subject to recall, courtesy, and selection bias.

OBJECTIVE

We sought to employ a mixed methods approach to capture the prevalence, length, causes, and impacts of wait times for family planning services in Western Kenya.

METHODS

We used mystery clients, focus groups, key informant interviews, and journey mapping workshops to measure and describe family planning wait times. Fifteen mystery clients visited 60 public-sector facilities to quantitatively capture wait times. We conducted eight focus group discussions with 55 current or former family planning clients and 19 key informant interviews to understand facility-level barriers to family planning and feasible solutions. Finally, we visualized the process of seeking and providing family planning with journey mapping workshops with nine clients and 12 providers.

RESULTS

Mystery clients waited, on average, 74 minutes to be seen for family planning services. In focus group discussions and key informant interviews, three themes emerged: the nature of wait times, the impact of wait times, and how to address wait times. Clients characterized long wait times as a barrier to achieving their reproductive desires. Key informants perceived provider shortages to cause long wait times, which reduced quality of family planning services. Both providers and family planning clients suggested increasing staffing or offering specialization to decrease wait times and increase quality of care.

CONCLUSION

Our mixed methods approach revealed that wait times for family planning services were common, could be extensive, and were viewed as a barrier to high quality of care by clients, providers, and key informants. Across the board, participants felt that addressing workforce shortages would enhance service delivery and thus promote reproductive autonomy among women in Kenya.

Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review

Objective

As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC.

Design and methods

We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007-2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned.

Results

Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners.

Conclusions

IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.

Designing for Impact and Institutionalization: Applying Systems Thinking to Sustainable Postpartum Family Planning Approaches for First-Time Mothers in Bangladesh

Integrated service delivery approaches have shown promise to increase use of services including postpartum family planning (PPFP) by young, first-time mothers (FTMs) but have proven challenging to scale and institutionalize. Integration adds complexity, requiring careful assessment of effects on a range of key system functions from demand creation and service delivery to oversight and governance. Through an innovative design process, we selected approaches to increase FTMs' PPFP use through existing health systems. We generated programmatic options and then sought to select approaches based on (1) potential impact on FTMs' PPFP uptake and (2) potential to institutionalize in the health system. The latter represented an innovation in addressing management systems' drivers of scalability and sustainability; to accomplish it, we developed a participatory design process to assess the potential of an approach to be institutionalized in a specific context.We adapted a management systems theory, the Viable System Model (VSM), which presents 5 essential organizational functions and the relations required between them to improve the viability (performance and institutionalization) of organizational systems. Drawing from the VSM, we developed a process for reviewing the effects of proposed approaches on provider workload, client flow, infrastructure, revisions to guidelines and job descriptions, coordination and management, and information systems. The VSM provided a structure to identify potential displacement of capacity in the health system and mitigate often neglected organizational challenges that compromise institutionalization. The process informed the elimination of approaches with potential for impact but that had deal-breakers to institutionalization, such as increased workload or shifted job descriptions, in the Bangladeshi context. For the selected approaches, consideration of systems elements fostered discussion of expected risks to institutionalization, highlighting needed mitigation efforts and monitoring during implementation.

Lessons Learned From Integrating Infant and Young Child Feeding Counseling and Iron-Folic Acid Distribution Into Routine Immunization Services in Ethiopia

Immunization programs reach more children and communities than any other health intervention, thus making immunization a promising platform for integrating other essential health services. There is a dearth of literature on integrating nutrition interventions, such as infant and young child feeding (IYCF) counseling and iron-folic acid (IFA) supplementation, into routine immunization services.To address this evidence gap, a 15-month pilot study (August 2019 to November 2020) tested the feasibility of integrating IYCF counseling and IFA supplement distribution into immunization service delivery in Ethiopia. The interventions focused on joint microplanning for integrated services (including estimating target populations for all services), revising client flows for service delivery, and providing on-the-job support to HWs for implementing and monitoring integrated service delivery.Findings suggest that planning for and delivering IYCF counseling and IFA supplementation with immunization services is feasible. Integrating these services provided opportunities for collaborative planning and enabled health workers (HWs) to offer multiple services to clients through 1 interaction. However, HWs felt that additional human resources were needed to manage integrated services, especially during integrated outreach and mobile service delivery. HWs also reported that communities appreciated accessing 2 services in 1 visit but expressed reservations about the longer wait times.Countries may consider expanding fixed and outreach immunization services to provide integrated service delivery provided that it is feasible, sustainable, of high quality, and incorporates the careful planning, follow-up, and increased human and financial resources needed to reinforce new practices and expand access to a broader array of health services.

Influence of family planning and immunization services integration on contraceptive use and family planning information and knowledge among clients: A cross-sectional analysis in urban Nigeria

Reproductive autonomy necessitates that women have access to high quality family planning information and services. Additionally, closely spaced pregnancies increase maternal and infant morbidity and mortality. Although integrating family planning into child immunization services may increase access to information and services and postpartum contraceptive use, evidence on how integration affects service delivery and health outcomes is scarce. One limitation of previous studies is the use of binary integration measures. To address this limitation, this study applied Provider and Facility Integration Index scores to estimate associations between integration and contraceptive use, receipt of family planning information, and knowledge of family planning services availability. This study leveraged pooled cross-sectional health facility client exit interview data collected from 2,535 women in Nigeria. Provider and Facility Integration Index scores were calculated (0–10, 0 = low, 10 = high) for each facility (N = 94). The Provider Integration Index score measures provider skills and practices that support integrated service delivery; the Facility Integration Index score measures facility norms that support integrated service delivery. Logistic regression models identified associations between Provider and Facility Integration Index scores and (a) contraceptive use among postpartum women, (b) receipt of family planning information during immunization visits, and (c) correct identification of family planning service availability. Overall, 46% of women were using any method of contraception, 51% received family planning information during the immunization appointment, and 83% correctly identified family planning service availability at the facility. Mean Provider and Facility Integration Index scores were 6.46 (SD = 0.21) and 7.27 (SD = 0.18), respectively. Provider and Facility Integration Index scores were not significantly associated with postpartum contraceptive use. Facility Integration Index scores were negatively associated with receipt of family planning information. Provider Integration Index scores were positively associated with correct identification of family planning service availability. Our results challenge the position that integration provides a clear path to improved outcomes. The presence of facility and provider attributes that support integration may not result in the delivery of integrated care.

Effect of integrating maternal and child health services, nutrition and family planning services on postpartum family planning uptake at 6 months post-partum in Burkina Faso, Cote d’Ivoire and Niger: a quasi-experimental study protocol

Background

Although several interventions integrating maternal, neonatal, child health and nutrition with family planning have been implemented and tested, there is still limited evidence on their effectiveness to guide program efforts and policy action on health services integration. This study aims to assess the effectiveness of a service delivery model integrating maternal and child health services, nutrition and family planning services, compared with the general standard of care in Burkina Faso, Cote d'Ivoire, and Niger.

Methods

This is a quasi experimental study with one intervention group and one control group of 3 to 4 health facilities in each country. Each facility was matched to a control facility of the same level of care that had similar coverage on selected reproductive health indicators such as family planning and post-partum family planning. The study participants are pregnant women (up to 28 weeks of gestational age) coming for their first antenatal care visit. They will be followed up to 6 months after childbirth, and will be interviewed at each antenatal visit and also during visits for infant vaccines. The analyzes will be carried out by intention to treat, using generalized linear models (binomial log or log Poisson) to assess the effect of the intervention on the ratio of contraceptive use prevalence between the two groups of the study at a significance level of 5%, while taking into account the cluster effect and adjusting for potential confounding factors (socio-demographic characteristics of women unevenly distributed at inclusion).

Discussion

This longitudinal study, with the provision of family planning services integrated into the whole maternal care continuum, a sufficiently long observation time and repeated measurements, will make it possible to better understand the timeline and the factors influencing women’s decision-making on the use of post-partum family planning services. The results will help to increase the body of knowledge regarding the impact of maternal and child health services integration on the utilization of post-partum family planning taking into account the specific context of sub-Saharan Africa French speaking countries where such information is very needed.

One strategy to improve the utilization of health services by mothers and their children is the integration of maternal and child health services. For instance, a pregnant woman coming for an antenatal care visit would also receive counseling on post-partum family planning services and maternal nutrition. Similarly, a woman coming for her infant’s vaccines would be offered counseling on post-partum family planning, maternal nutrition and breastfeeding. Although several interventions have been implemented and tested, there is still limited evidence on the conditions and factors required for successful maternal and child health services integration strategies. This study aims to assess the effectiveness of an intervention integrating maternal and child health services, nutrition and family planning services. For the purpose of the evaluation, 2 distincts groups of health facilities will be selected in each country, one group of 3 or 4 health facilities where the intervention will be implemented, and another group of 3 or 4 health facilities with the general standard of care. The study participants are pregnant women (up to 28 weeks of gestational age), coming for their first antenatal care visit, who will be followed up to 6 months after childbirth.The analyzes will be carried out to assess the effect of the intervention on contraceptive use prevalence between the two groups of health facilities. This study will make it possible to better understand the timeline and the factors influencing women’s decision-making on the use of post-partum family planning services.

Perceptions of quality and the integrated delivery of family planning with childhood immunisation services in Kenya and Uganda

The integration of family planning (FP) with childhood immunisations is considered a promising approach to addressing postpartum women’s unmet need for FP in resource limited settings. This study set out to examine client and health provider perceptions of the quality of FP services that were integrated with childhood immunisations in Kenya and Uganda. Semi-structured interviews with clients (n = 30) and health providers (n = 27) were conducted in 16 rural health facilities. Interviews centred on the respondents’ experiences receiving/delivering FP services, their interactions with providers/clients, and their views on the quality of FP services. Client and provider perceptions of quality were compared through a thematic analysis of interview transcripts, and findings were synthesised using Jain and Hardee’s revised FP Quality of Care Framework. Using audit data, health facility characteristics and resources were also summarised through descriptive statistics to contextualise the qualitative findings. The dignity and respect experienced by clients was central to the respondents’ perceptions of quality. These two dimensions were not conceptualised as distinct facets of quality, but were instead perceived to be a product of the 1) access to needed services, 2) choice of contraceptives, 3) interpersonal communication, 4) information, and 5) confidentiality afforded to clients. Additionally, clients and providers alike believed that the integration of FP services with childhood immunisations had a positive effect on clients’ access to needed services and on the confidentiality they experienced in a context where modern contraceptive use was stigmatised and where a lack of support from some husbands impeded access to FP services. Understanding clients’ and providers’ conceptualisation of quality is critical to the design of high quality and client-centred integrated FP services.

Integrated delivery of family planning and childhood immunisation services: a mixed methods assessment of service responsiveness

Background

Postpartum women represent a considerable share of the global unmet need for modern contraceptives. Evidence suggests that the integration of family planning (FP) with childhood immunisation services could help reduce this unmet need by providing repeat opportunities for timely contact with FP services. However, little is known about the clients’ experiences of FP services that are integrated with childhood immunisations, despite being crucial to contraceptive uptake and repeat service utilisation.

Methods

The responsiveness of FP services that were integrated with childhood immunisations in Malawi was assessed using cross-sectional convergent mixed methods. Exit interviews with clients (n=146) and audits (n=15) were conducted in routine outreach clinics. Responsiveness scores across eight domains were determined according to the proportion of clients who rated each domain positively. Text summary analyses of qualitative data from cognitive interviewing probes were also conducted to explain responsiveness scores. Additionally, Spearman rank correlation and Pearson’s chi-squared test were used to identify correlations between domain ratings and to examine associations between domain ratings and client, service and clinic characteristics.

Results

Responsiveness scores varied across domains: dignity (97.9%); service continuity (90.9%); communication (88.7%); ease of access (77.2%); counselling (66.4%); confidentiality (62.0%); environment (53.9%) and choice of provider (28.4%). Despite some low performing domains, 98.6% of clients said they would recommend the clinic to a friend or family member interested in FP. The choice of provider, communication, confidentiality and counselling ratings were positively associated with clients’ exclusive use of one clinic for FP services. Also, the organisation of services in the clinics and the providers’ individual behaviours were found to be critical to service responsiveness.

Conclusions

This study establishes that in routine outreach clinics, FP services can be responsive when integrated with childhood immunisations, particularly in terms of the dignity and service continuity afforded to clients, though less so in terms of the choice of provider, environment, and confidentiality experienced. Additionally, it demonstrates the value of combining cognitive interviewing techniques with Likert questions to assess service responsiveness.

Effects of Integrating Family Planning With Maternal, Newborn, and Child Health Services on Uptake of Voluntary Modern Contraceptive Methods in Rural Pakistan: Protocol for a Quasi-experimental Study

Background

The uptake of modern contraceptive methods (MCMs) remains low, with 25% of women reporting their use in Pakistan. The overarching interventions covering service delivery platforms at facility and community levels necessitate the integration of family planning (FP) with maternal, newborn, and child health (MNCH) services.

Objective

The main aim of this study is to evaluate the impact of an integrated FP-MNCH service delivery model to increase coverage of MCMs in rural Pakistan. Moreover, we aim to measure the level of effectiveness of interventions regarding the uptake of MCMs.

Methods

A quasi-experimental, sequential, mixed methods study design with pre- and postevaluation will be adopted to evaluate the impact of integration of FP with MNCH services. The interventions include the following: (1) capacity strengthening of health care providers, including technical trainings; training in counseling of women who attend immunization centers, antenatal care (ANC) clinics, and postnatal care (PNC) clinics; and provision of job aids; (2) counseling of women and girls attending ANC, PNC, and pediatric clinics; (3) ensuring sustained provision of supplies and commodities; (4) community engagement, including establishing adolescent-friendly spaces; and (5) use of District Health Information System data in decision-making. Descriptive statistics will be used to estimate prevalence (ie, proportions) and frequencies of outcome indicators. A univariate difference-in-difference analytical approach will be used to estimate the effect of the interventions. In addition, a Blinder-Oaxaca decomposition analysis will be conducted to identify and quantify determinants of the modern contraceptive prevalence rate.

Results

The intervention phase began in July 2021 and will run until June 2022. The impact assessment will be conducted from July to September 2022.

Conclusions

This project will evaluate the impact of integrating FP with MNCH services. Furthermore, this study will identify the drivers and barriers in uptake of MCMs and will simultaneously help in modifying the interventional strategies that can be scaled up through existing service delivery platforms within the public and private sectors, according to the local sociocultural and health system context.

Trial Registration

ClinicalTrials.gov NCT05045599; https://clinicaltrials.gov/ct2/show/NCT05045599

International Registered Report Identifier (IRRID)

DERR1-10.2196/35291

Facility-level characteristics associated with family planning and child immunization services integration in urban areas of Nigeria: a longitudinal analysis

Background

Unmet need for postpartum contraception is high. Integration of family planning with routine child immunization services may help to satisfy unmet need. However, evidence about the determinants and effects of integration has been inconsistent, and more evidence is required to ascertain whether and how to invest in integration. In this study, facility-level family planning and immunization integration index scores are used to: (1) determine whether integration changes over time and (2) identify whether facility-level characteristics, including exposure to the Nigerian Urban Reproductive Health Initiative (NURHI), are associated with integration across facilities in six urban areas of Nigeria.

Methods

This study utilizes health facility data collected at baseline (n = 400) and endline (n = 385) for the NURHI impact evaluation. Difference-in-differences models estimate the associations between facility-level characteristics, including exposure to NURHI, and Provider and Facility Integration Index scores. The two outcome measures, Provider and Facility Integration Index scores, reflect attributes that support integrated service delivery. These indexes, which range from 0 (low) to 10 (high), were constructed using principal component analysis. Scores were calculated for each facility. Independent variables are (1) time period, (2) whether the facility received the NURHI intervention, and (3) additional facility-level characteristics.

Results

Within intervention facilities, mean Provider Integration Index scores were 6.46 at baseline and 6.79 at endline; mean Facility Integration Index scores were 7.16 (baseline) and 7.36 (endline). Within non-intervention facilities, mean Provider Integration Index scores were 5.01 at baseline and 6.25 at endline; mean Facility Integration Index scores were 5.83 (baseline) and 6.12 (endline). Provider Integration Index scores increased significantly (p = 0.00) among non-intervention facilities. Facility Integration Index scores did not increase significantly in either group. Results identify facility-level characteristics associated with higher levels of integration, including smaller family planning client load, family planning training among providers, and public facility ownership. Exposure to NURHI was not associated with integration index scores.

Conclusion

Programs aiming to increase integration of family planning and immunization services should monitor and provide targeted support for the implementation of a well-defined integration strategy that considers the influence of facility characteristics and concurrent initiatives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11436-x.

Postpartum long-acting contraception uptake and service delivery outcomes after a multilevel intervention in Kigali, Rwanda

INTRODUCTION

Postpartum family planning (PPFP) is critical to reduce maternal-child mortality, abortion and unintended pregnancy. As in most countries, the majority of PP women in Rwanda have an unmet need for PPFP. In particular, increasing use of the highly effective PP long-acting reversible contraceptive (LARC) methods (the intrauterine device (IUD) and implant) is a national priority. We developed a multilevel intervention to increase supply and demand for PPFP services in Kigali, Rwanda.

METHODS

We implemented our intervention (which included PPFP promotional counselling for clients, training for providers, and Ministry of Health stakeholder involvement) in six government health facilities from August 2017 to October 2018. While increasing knowledge and uptake of the IUD was a primary objective, all contraceptive method options were discussed and made available. Here, we report a secondary analysis of PP implant uptake and present already published data on PPIUD uptake for reference.

RESULTS

Over a 15-month implementation period, 12 068 women received PPFP educational counselling and delivered at a study facility. Of these women, 1252 chose a PP implant (10.4% uptake) and 3372 chose a PPIUD (27.9% uptake). On average providers at our intervention facilities inserted 83.5 PP implants/month and 224.8 PPIUDs/month. Prior to our intervention, 30 PP implants/month and 8 PPIUDs/month were inserted at our selected facilities. Providers reported high ease of LARC insertion, and clients reported minimal insertion anxiety and pain.

CONCLUSIONS

PP implant and PPIUD uptake significantly increased after implementation of our multilevel intervention. PPFP methods were well received by clients and providers.

Development of integration indexes to determine the extent of family planning and child immunization services integration in health facilities in urban areas of Nigeria

Background

Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities.

Methods

This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high).

Results

Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high.

Conclusion

Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.

Integrated Family Planning and Immunization Service Delivery at Health Facility and Community Sites in Dowa and Ntchisi Districts of Malawi: A Mixed Methods Process Evaluation

The Government of Malawi’s Health Sector Strategic Plan II highlights the importance of service integration; however, in practice, this has not been fully realized. We conducted a mixed methods evaluation of efforts to systematically implement integrated family planning and immunization services in all health facilities and associated community sites in Ntchisi and Dowa districts during June 2016–September 2017. Methods included secondary analysis of service statistics (pre- and postintervention), focus group discussions with mothers and fathers of children under age one, and in-depth interviews with service providers, supervisors, and managers. Results indicate statistically significant increases in family planning users and shifts in use of family planning services from health facilities to community sites. The intervention had no effect on immunization doses administered or dropout rates. According to mothers and fathers, benefits of service integration included time savings, convenience, and improved understanding of services. Provision and use of integrated services were affected by availability of human resources and commodities, community linkages, data collection procedures and availability, sociocultural barriers, organization of services, and supervision and commitment of health surveillance assistants. The integration approach was perceived to be feasible and beneficial by clients and providers.