Factors influencing adoption of sexual and reproductive health intervention for adolescents in Ebonyi, Nigeria

BACKGROUND

School and Community-embedded reproductive health interventions have been implemented in developing countries, with evidence that they led to improved sexual and reproductive health among adolescents. However, this type of intervention is rarely evaluated for its potential adoption and use. This study evaluated the constraints and enablers of the adoption of a school and community-embedded intervention that used community engagement, capacity building, partnerships and collaborations to deliver sexual and reproductive health services to adolescents.

METHODS

The intervention was implemented between 2019 and 2021 in six local government areas in Ebonyi State. The results on adoption presented here were collected four months into the mid-phase of the project, targeting adolescents, parents, adult family members, healthcare providers, local authorities, and community members. Sixteen in-depth interviews were conducted with policymakers, 14 with health service providers and 18 Focus Group Discussions (FGDs) with parents, community leaders and adolescents who were part of the implementation process. The coding reliability approach, a type of thematic data analysis was used, that involves early theme development and the identification of evidence for the themes.

RESULTS

The adoption of school and community-embedded reproductive health intervention was strong among stakeholders at the early stages of the implementation process. Multi-stakeholder involvement and its multi-component approach made the intervention appealing, thereby enabling its adoption. However, at the later stage, the adoption was constrained by beliefs and norms about sexual and reproductive health (SRH) and the non-incentivisation of stakeholders who acted as advocates at the community level. The sustainability of the intervention may be threatened by the non-incentivisation of stakeholders and the irregular supply of materials and tools to facilitate SRH advocacy at the community level.

CONCLUSIONS

The inclusive community-embedded reproductive health intervention was adopted by stakeholders because of the enablers which include timely stakeholder engagement. However, for it to be sustainable, implementers must address the non-incentivising of community-level advocates which serve as constraints.

Policy action points and approaches to promote fertility care in The Gambia: Findings from a mixed-methods study

INTRODUCTION

In the Global South, (in)fertility care is scarcely recognized as a priority, yet the government of The Gambia has recently included it as one of the key priorities in its reproductive health strategic plan. This inclusion appears to be the result of years of engagement between policy actors, academic researchers, and activists in the field of reproductive health and specifically of infertility. However, the operationalization of the strategic plan may be hampered by multiple factors. The research aims to identify and analyze challenges that may impede the effective implementation of the strategic plan, thereby providing policy action points and practical guidance into the operationalization of (in)fertility care in the context of The Gambia's health system.

METHODS

This is a mixed-methods study with data from a survey and semi-structured interviews collected between 2020 and 2021 in The Gambia that were separately published. In this paper, we present the triangulation of quantitative and qualitative data using a convergence coding matrix to identify relevant policy action points.

RESULTS

Six fertility care policy action points, driven by data, arose from the triangulation and interpretation process, specifically: (i) establishing and maintaining political commitment and national priority for fertility care; (ii) creating awareness and increasing the involvement of men in SRH and fertility; (iii) ensuring data-driven health policymaking; (iv) offering and regulating affordable IVF alternatives; (v) improving knowledge of and means for fertility care provision; and (vi) enhancing the collaboration among stakeholders and building links with the private healthcare sector.

CONCLUSION

This study found the implementation of the fertility care-related activities in the reproductive health strategic plan may face challenges that require careful mitigation through a holistic approach. Such an approach conceptualizes infertility not just as a biomedical issue but as a broader one that incorporates educational and socio-emotional aspects, including male and (not only) female involvement in sexual and reproductive health. Moreover, it is supported by a comprehensive health management information system that includes capturing data on the demand for, and access to, infertility services in The Gambia health system.

Sexual and reproductive health implementation research in humanitarian contexts: a scoping review

BACKGROUND

Meeting the health needs of crisis-affected populations is a growing challenge, with 339 million people globally in need of humanitarian assistance in 2023. Given one in four people living in humanitarian contexts are women and girls of reproductive age, sexual and reproductive health care is considered as essential health service and minimum standard for humanitarian response. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on appropriate methods and analytical frameworks is limited.

METHODS

A scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Peer-reviewed papers published from 2013 to 2022 were identified through relevant systematic reviews and a literature search of Pubmed, Embase, PsycInfo, CINAHL and Global Health databases. Papers that presented primary quantitative or qualitative data pertaining to a sexual and reproductive health intervention in a humanitarian setting were included.

RESULTS

Seven thousand thirty-six unique records were screened for inclusion, and 69 papers met inclusion criteria. Of these, six papers explicitly described the use of an implementation research framework, three citing use of the Consolidated Framework for Implementation Research. Three additional papers referenced other types of frameworks used in their evaluation. Factors cited across all included studies as helping the intervention in their presence or hindering in their absence were synthesized into the following Consolidated Framework for Implementation Research domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process.

CONCLUSION

This review found a wide range of methodologies and only six of 69 studies using an implementation research framework, highlighting an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization. Three hundred thirty-nine million people globally were in need of humanitarian assistance in 2023, and meeting the health needs of crisis-affected populations is a growing challenge. One in four people living in humanitarian contexts are women and girls of reproductive age, and provision of sexual and reproductive health care is considered to be essential within a humanitarian response. Implementation research can help to better understand how real-world contexts affect health improvement efforts. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on how best to do so is limited. This scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Of 69 papers that met inclusion criteria for the review, six of them explicitly described the use of an implementation research framework. Three used the Consolidated Framework for Implementation Research, a theory-based framework that can guide implementation research. Three additional papers referenced other types of frameworks used in their evaluation. This review summarizes how factors relevant to different aspects of implementation within the included papers could have been organized using the Consolidated Framework for Implementation Research. The findings from this review highlight an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

Transsexual men and pregnancy: an integrative literature review

Promoting sexual and reproductive health in the context of transmasculinity constitutes a new issue for health service organisation. This integrative review sought to understand the current evidence on pregnancy in transsexual men in the context of sexual and reproductive health care. From a search of the BVS, PubMed, Science Direct, Scopus, Capes, SciELO and PEPSIC databases, from 2010 to 2020, a sample of 11 articles was selected, treated by content analysis and grouped into four analytical categories: health services - positive experiences; cis heteronormative health services; implications of pregnancy for transsexual bodies; and repercussions of gender-affirming therapy and pregnancy. A cis heteronormative logic was found to predominate in health care, leading to negative experiences during antenatal care and childbirth among transsexual men. Their unique health needs during the pregnancy-puerperium cycle should include mental health care. It is suggested that strategies be adopted to build capacity in health professionals with a view to respectful, inclusive perinatal care for this population group, as well as further studies on the subject.

Organizing Primary Care Clinicians to Expand Reproductive Health Access: A Qualitative Program Evaluation

BACKGROUND AND OBJECTIVES

Comprehensive sexual reproductive health care (SRH) in the United States, including abortion, is siloed from primary care, making it more difficult to access. The crisis in access has drastically worsened following the overturning of Roe v Wade, 410 US 113 (1973). Primary care clinicians (PCC) are well-positioned to protect and expand SRH access but do not receive sufficient training or support. The Reproductive Health Access Network ("Network") was created to connect like-minded clinicians to engage in advocacy, training, and peer support to enhance access to SRH in their communities and practices. This evaluation explores PCC leaders' experiences within this SRH organizing network.

METHODS

In 2021, we conducted 34 semistructured phone interviews with a purposive sample of current (n=27) and former (n=7) PCC leaders in the Network (N=87). The program's theory of change and network evaluation framework guided reflexive thematic analysis.

RESULTS

Participants viewed Network support as critical to ending isolation through three mechanisms: connecting to a supportive community of like-minded peers, empowering leadership, and providing infrastructure for local organizing. They viewed mentorship as critical in building a sustainable and equitable pipeline of PCC leaders. Participants identified challenges to engaging fully, such as burnout and discrimination experienced both within and outside the Network.

CONCLUSIONS

Community-building, peer support, and mentorship are critical to building and sustaining PCC leadership in SRH-organizing communities. Efforts are needed to mitigate burnout, support SRH education and mentorship for PCCs, and transform into a truly inclusive community. The Network structure is promising for amplifying efforts to enhance SRH access through clinician leadership.

Biocolonial pregnancies: Louise Erdrich's Future Home of the Living God (2017)

This article argues that the health humanities must examine biocolonialism (and representations thereof) if it is to attend to Native American experiences of reproductive healthcare in the USA. Reproductive healthcare abuses are brought into dialogue with Native American resistance to Western biomedical sciences in Future Home of the Living God (2017) by Louise Erdrich (Ojibwe). Written over the course of two reinstatements of the Mexico City Policy, Erdrich's novel invites a consideration of biocolonialism in relation to the exploitation and policing of female bodies.After a discussion of bioprospecting and female bodies, I frame unethical practices of reproductive healthcare and sterilisation as biocolonial acts. The experience of the novel's protagonist, Cedar Hawk Songmaker, will be situated alongside the broader ways in which Native Americans are subjected to surveillance. Second, this article proposes that speculative fiction allows for a temporal reframing of the colonial histories of Indigenous healthcare. As she narrates a world in which evolution 'is running backward', Cedar employs narrative reversals to resist the linear narrative of progress and 'discovery' associated with biomedical sciences.The radically changing structures of a dystopian state, as well as the revelation of her biological inheritance, complicate the cultural and medical frameworks within which Cedar narrates her pregnancy. A challenge faced by the health humanities is how the discipline might theorise ongoing, interrelated forms of domination such as those which position female Indigenous bodies as 'new colonies'. But, as I will argue, the mobilisation of Indigenous narrative forms and cultural frameworks offer productive directions for future work within the global health humanities.

Individual and contextual factors affect the implementation fidelity of youth-friendly services, northwest Ethiopia: A multilevel analysis

BACKGROUND

The evaluation of all potential determinants of implementation fidelity of Youth-Friendly Services (YFS) is crucial for Ethiopia. Previous studies overlooked investigating the determinants at different levels. Therefore, this study aimed to assess the determinants of implementation fidelity of YFS considering individual and contextual levels.

METHODS

This study was conducted among 1,029 youths, from 11 health centers that are implementing the YFS in Central Gondar Zone. Data were collected by face to face interview and facility observation using a semi-structured questionnaire. A Bivariable multi-level mixed effect modelling was employed to assess the main determinants. Four separate models were fitted to reach the full model. The fitness of the model was assessed using Akaike Information Criterion (AIC) and level of significance was declared at p-values < 0.05. The results of fixed effects were presented as adjusted odds ratio (AOR) at their 95% CI.

RESULTS

Four hundred one (39.0%) of the respondents got the YFS with high level of fidelity. Had high level of involvement in the YFS provision (AOR = 1.35, 95% CI: 1.15, 1.57), knew any peer educator trained in YFS (AOR = 1.60, 95% CI: 1.36, 1.86), and involved as a peer educator (AOR = 1.46, 95% CI: 1.24, 1.71), were the individual level determinants. Whereas, got capacity building training; (AOR = 1.93, 95% CI (1.12, 3.48), got supportive supervision, (AOR 2.85, 95% CI (1.99, 6.37), had a separate waiting room (AOR = 9.84, 95%CI: 2.14, 17.79), and system in place to provide continuous support to staff (AOR = 2.81, 95%CI: 1.25, 6.34) were the contextual level determinants.

CONCLUSIONS

The level of implementation fidelity remains low. Both individual and contextual level determinants affect the implementation fidelity of YFS. Therefore, policy makers, planners, managers and YFS providers could consider both individual and contextual factors to improve the implementation fidelity.

A comparison of contraceptive services for adolescents at school-based versus community health centers in Oregon

OBJECTIVE

To compare Oregon school-based health centers (SBHCs) with community health centers (CHCs) as sources of adolescent contraceptive services.

DATA SOURCES

Oregon electronic health record data, 2012-2016.

STUDY DESIGN

We compared clinic-level counseling rates and long-acting reversible contraception (LARC) provision, adolescent populations served, and visit-level LARC provision time trends. We evaluated adjusted associations between LARC provision and Title X participation by clinic type.

DATA COLLECTION/EXTRACTION METHODS

We used diagnosis and procedure codes to identify contraceptive counseling and provision visits, excluding visits for adolescents not at risk of pregnancy.

PRINCIPAL FINDINGS

CHCs were more likely to provide LARC on-site than SBHCs (67.2% vs. 36.4%, respectively). LARC provision increased more at SBHCs (5.8-fold) than CHCs (2-fold) over time. SBHCs provided more counseling visits per clinic (255 vs. 142) and served more young and non-White adolescents than CHCs. The adjusted probability of LARC provision at Title X SBHCs was higher than non-Title X SBHCs (4.4% [3.9-4.9] vs. 1.7% [1.4-2.0]), but there was no significant association at CHCs.

CONCLUSIONS

In Oregon, CHCs and SBHCs are both important sources of adolescent contraceptive services, and Title X plays a crucial role in SBHCs. Compared with CHCs, SBHCs provided more counseling, showed a larger increase in LARC provision over time, and served more younger and non-White adolescents.

Associations of serum estradiol level, serum estrogen receptor-alpha level, and estrogen receptor-alpha polymorphism with male infertility: A retrospective study

Estradiol regulates spermatogenesis partly via estrogen receptor-alpha (ESRα). This study aimed to analyze the associations of serum estradiol level, serum ESRα level, and ESRα gene polymorphisms with sperm quality.This retrospective study included infertile men attending the Reproductive Center, Affiliated Hospital of Youjiang Medical University for Nationalities, and a control group without a history of fertility (October, 2016 to March, 2017). Data regarding sperm quality, serum levels of estradiol and ESRα, and rs2234693C/T genotype were extracted from the medical records. Pearson/Spearman correlations (as appropriate) between estradiol level, ESRα level, and sperm quality parameters were evaluated.The analysis included 215 men with infertility and 83 healthy controls. The infertile group had higher serum levels of estradiol (147.57 ± 35.3 vs 129.62 ± 49.11 pg/mL, P < .05) and ESRα (3.02 ± 2.62 vs 1.33 ± 0.56 pg/mL, P < .05) than the control group. For the infertile group, serum estradiol level was negatively correlated with sperm concentration, percentage of progressively motile sperm, and percentage of sperm with normal morphology (r = 0.309, 0.211, and 0.246, respectively; all P < .05). Serum estradiol and ESRα levels were lower in infertile men with normozoospermia than in those with azoospermia, oligozoospermia, mild azoospermia, or malformed spermatozoa (all P < .05). Sperm concentration, percentage of progressively motile sperm, serum ESRα level, and serum estradiol level did not differ significantly among the rs2234693 CC, CT, and TT genotypes.Elevated serum levels of estradiol and possibly ESRα might have a negative impact on sperm quality and fertility, whereas single nucleotide polymorphisms at rs2234693 of the ESRα gene had little or no effect.

Utilization of a mobile phone application to increase access to sexual and reproductive health information, goods, and services among university students in Uganda

BACKGROUND

Innovations to increase access to sexual and reproductive health (SRH) information, goods, and services are needed, particularly in low-income settings. This study assessed the utilization of a mobile phone application (MPA) to increase access to SRH information, goods, and services among university students in Uganda.

METHODS

We conducted a cross-sectional analysis of data from: (1) an endline survey performed as a consequence of a randomized controlled trial (RCT) of the effectiveness of the MPA, and (2) data from use of the MPA for accessing information, goods, and services over the 6-month time period of the RCT, obtained from in-MPA data collection service providers. We performed descriptive analysis of participant characteristics and their association with the utilization of the MPA using logistic regression; analyses of MPA use for accessing different types of information, goods, and services by gender; and analyses of functionality attributes of the MPA and related services.

RESULTS

In the study population of young (median 22 years) predominantly female (61%) students, the utilization of the MPA by those who downloaded it was high (81% overall, 82% female, and 82% male). The most popular information portal was the frequently asked questions (71% utilization); the most popular goods were condoms for males (77% utilization) and sanitary pads for females (94% utilization); and the most popular service was HIV testing and counseling (60% utilization). The MPA demonstrated predominantly positive (responsiveness, non-distracting in-app advertisements, and ease of use) attributes.

CONCLUSION

A mobile phone app to increase access to SRH information, goods, and services among university students in Uganda demonstrated high utilization. The results of this study support ongoing and future technical improvement efforts and research on effectiveness, economic efficiency, and scalability, along the continuum of activities to scale this intervention in order to improve SRH in low-income settings.

TRIAL REGISTRATION

MUREC1/7 No. 07/05-18. Registered; June 29, 2018.

Applying a Nursing Perspective to Address the Challenges Experienced by Cisgender Women in the HIV Status Neutral Care Continuum: A Review of the Literature

ABSTRACT

The field of HIV research has grown over the past 40 years, but there remains an urgent need to address challenges that cisgender women living in the United States experience in the HIV neutral status care continuum, particularly among women such as Black women, who continue to be disproportionately burdened by HIV due to multiple levels of systemic oppression. We used a social ecological framework to provide a detailed review of the risk factors that drive the women's HIV epidemic. By presenting examples of effective approaches, best clinical practices, and identifying existing research gaps in three major categories (behavioral, biomedical, and structural), we provide an overview of the current state of research on HIV prevention among women. To illustrate a nursing viewpoint and take into account the diverse life experiences of women, we provide guidance to strengthen current HIV prevention programs. Future research should examine combined approaches for HIV prevention, and policies should be tailored to ensure that women receive effective services that are evidence-based and which they perceive as important to their lives.

Performance of a tool to identify different types of self-reported sexual risk among women attending a contraception and sexual health clinic: results of a cross-sectional survey

INTRODUCTION

A clinical prediction rule (CPR) using psychosocial questions was previously derived to target sexual healthcare in general practice by identifying women at risk of unintended pregnancy (UIP) and sexually transmitted infections (STIs). This psychosocial CPR may help target resources within contraception and sexual health (CASH) services. This study investigated how well it predicted recent self-reported risk of UIP and STI acquisition among women attending a CASH clinic.

METHODS

Female patients aged 16-44 years attending a CASH clinic in South-East England were offered a questionnaire on arrival. This comprised psychosocial questions, and others addressing three sexual risks: (1) two or more male sexual partners in the last year (2+P), (2) risk of STI acquisition through most recent partner and (3) risk of UIP in the last 6 months. A CPR score was calculated for each participant and cross-tabulated against self-report of each sexual risk to estimate CPR sensitivity and specificity.

RESULTS

The psychosocial questions predicting 2+P had sensitivity 83.2% (95% CI 79.3% to 86.5%) and specificity 56.1% (95% CI 51.3%-60.6%). Those predicting combined 2+P and/or risk of STI acquisition through most recent partner had a sensitivity of 89.1% (95% CI 85.7%-91.8%) and specificity of 43.7% (95% CI 39.0%-48.5%). Questions predicting risk of UIP in the last 6 months had a sensitivity of 82.5% (95% CI 78.6%-86.0%) and specificity of 48.3% (95% CI 43.4%-53.1%).

CONCLUSIONS

The CPR demonstrated good sensitivity but low specificity, so may be suited to triaging or stratifying which interventions to offer CASH patients and by which mode (eg, online vs face-to-face). Further investigation of causal links between psychosocial factors and sexual risk is warranted to support development of psychosocial interventions for this patient group.

Reproductive health interventions for Inuit youth in the north: a scoping review

BACKGROUND

Inuit have thrived in the northern regions of Canada and Alaska for thousands of years. Recent evidence suggests that Inuit in this region have experienced systemic barriers to reproductive health with resulting disparities in reproductive health-related outcomes including those among youth. Northern youth-focused reproductive health intervention research or evaluations have not to date been well summarized. The objective of this scoping review was to summarize the literature over the past twenty years focusing on reproductive health interventions for adolescents in northern Inuit communities.

METHODS

English-language articles from 2000 to 2020 were identified from seven scientific databases, a general internet search and a review of relevant websites. Two reviewers screened titles, abstracts and full texts and included articles if they mentioned a reproductive health intervention and pertained, directly or indirectly, to reproductive health for Inuit aged 10-19 in northern communities.

RESULTS

Seventeen articles met the inclusion criteria, across six themes: (1) Barriers to reproductive health interventions in the north; (2) Northern midwifery; (3) Northern birthing centres; (4) Fetal fibronectin tests for identifying high-risk pregnancies; (5) Prenatal education classes; and (6) Interventions to improve access to and quality of reproductive health supports.

CONCLUSION

Overall there is relatively limited evidence base specific to reproductive health interventions and northern Inuit youth. What does exist largely focuses on maternal health interventions and is inclusive of but not specific to youth. There is some evidence that youth specific educational programs, participatory action research approaches and the promotion of northern birthing centres and midwifery can improve reproductive health for adolescents and young mothers in northern Inuit communities. Future initiatives should focus on the creation and evaluation of culturally relevant and youth specific interventions and increasing community and youth participation in intervention research for better reproductive health.

Breaking Barriers to Healthcare Access: A Multilevel Analysis of Individual- and Community-Level Factors Affecting Women's Access to Healthcare Services in Benin

Background: In low-income countries such as Benin, most people have poor access to healthcare services. There is scarcity of evidence about barriers to accessing healthcare services in Benin. Therefore, we examined the magnitude of the problem of access to healthcare services and its associated factors. Methods: We utilized data from the 2017–2018 Benin Demographic and Health Survey (n = 15,928). We examined the associations between the demographic and socioeconomic characteristics of women using multilevel logistic regression. The outcome variable for the study was problem of access to healthcare service. Adjusted odds ratios (AORs) with 95% confidence intervals (95% CI) were estimated. Results: Overall, 60.4% of surveyed women had problems in accessing healthcare services. Partner’s education (AOR = 0.70; 95% CI; 0.55–0.89), economic status (AOR = 0.59; 95% CI; 0.47–0.73), marital status (AOR = 0.44; 95% CI; 0.39–0.51), and parity (AOR = 1.85; 95% CI; 1.45–2.35) were significant individual-level factors associated with problem of access to healthcare. Region (AOR = 5.24; 95% CI; 3.18–8.64) and community literacy level (AOR = 0.69; 95% CI; 0.51–0.94) were the main community-level risk factors. Conclusions: Enhancing husband education through adult education programs, economic empowerment of women, enhancing national education coverage, and providing priority for unmarried and multipara women need to be considered. Additionally, there is the need to ensure equity-based access to healthcare services across regions.

Situation analysis for delivering integrated comprehensive sexual and reproductive health services for displaced population of Kasaï, Democratic Republic of Congo: Protocol for a mixed method study

Introduction

Delivering integrated sexual and reproductive health services (SRHS) in emergencies is important in order to save lives of the most vulnerable as well as to combat poverty, reduce inequities and social injustice. More than 60% of preventable maternal deaths occur in conflict areas and especially among the internally displaced persons (IDP). Between 2016 and 2018, unprecedented violence erupted in the Kasaï’s region, in the Democratic Republic of Congo (DRC), called the Kamuina Nsapu Insurgency. During that period, an estimated three million of adolescent girls and women were forced to flee; and have faced growing threat to their health, safety, security, and well-being including significant sexual and reproductive health challenges. Between August 2016 and May 2017, the “Sous-Cluster sur les violences basées sur le genre (SC-VBG)” in DRC (2017) reported 1,429 Gender Based Violence (GBV) incidents in the 49 service delivery points in the provinces of Kasaï, Kasaï Central and Kasaï Oriental. Rape cases represented 79% of reported incidents whereas sexual assault and forced marriage accounted for respectively 11% and 4% of Gender Based Violence (GBV) among women and adolescent girls. This study aims to assess the availability of SRHS in the displaced camps in Kasaï; to evaluate the SRHS needs of young girls and women in the reproductive age (12–49). Studies of sexual and reproductive health (SRH) in the Democratic Republic of Congo (DRC) have often included adolescent girls under the age of 15 because of high prevalence of child marriage and early onset of childbearing, especially in the humanitarian context. According to the 2013 Demographic and Health Survey (DHS), about 16% of surveyed women got married by age 14 while the prevalence of early child marriage (marriage by 15) was estimated at 30%; to assess the use of SRHS services and identify barriers as well as challenges for SRH service delivery and use. Findings from this study will help provide evidence to inform towards more needs-based and responsive SRH service delivery. This is hoped for ultimately improve the quality and effectiveness of services, when considering service delivery and response in humanitarian settings.

Data and methods

We will conduct a mixed-methods study design, which will combine quantitative and qualitative approaches. Based on the estimation of the sample size, quantitative data will be drawn from the community-based survey (500 women of reproductive age per site) and health facility assessments will include assessments of 45 health facilities and 135 health providers’ interviews. Qualitative data will comprise materials from 30 Key Informant Interviews (KII) and 24 Focus Group Discussions (FGDs), which are believed to achieve the needed saturation levels. Data analysis will include thematic and content analysis for the KIIs and FGDs using ATLAS.ti software for the qualitative arm. For the quantitative arm, data analysis will combine frequency and bivariate chi-square analysis, coupled with multi-level regression models, using Stata 15 software. Statistic differences will be established at the significance level of 0.05. We submitted this protocol to the national ethical committee of the ministry of health in September 2019 and it was approved in January 2020. It needs further approval from the Scientific Oversee Committee (SOC) and the Provincial Ministry of Health. Prior to data collection, informed consents will be obtained from all respondents.

How to adapt sexual and reproductive health services to the needs and circumstances of trans people- a qualitative study in Colombia

BACKGROUND

People living a trans-life require access to equitable healthcare services, policies and research that address their needs. However, trans people have experienced different forms of violence, discrimination, stigma, and unfair access barriers when dealing with healthcare providers. Therefore, adapting sexual and reproductive health services with the purpose of providing more equitable, inclusive and discrimination-free healthcare services is an urgent need. The article presents an example of how operative research can be used in order to adjust sexual and reproductive healthcare services to trans people's needs, identities and circumstances.

METHODS

This is a qualitative study written from a constructivist perspective, and it is based on the voices and experiences of trans people in four major cities in Colombia. The research used a combination of focus groups of discussion (n = 6) and in-depth interviews with trans people (n = 13) in Barranquilla, Bogota, Cali and Medellin. This research had two specific objectives: i) identifying the main sexual and reproductive health needs of people living a trans-life; and ii) generating new evidence in order to guide the adaptation of sexual and reproductive health services centered to trans people's needs, identities, and circumstances. Qualitative data codification and analysis was using NVivo.

RESULTS

Once access barriers to sexual and reproductive health services, unmet sexual and reproductive health needs were identified, the research helped define strategies to adapt sexual and reproductive health services to the needs, identities, and circumstances of people living a trans-life in Colombia. Amongst the main barriers found were healthcare costs, lack of insurance, stigmatization, discrimination and abuse by health care providers. Perhaps among the most notable sexual and reproductive health needs presented were trans-specific services such as sensitive assistance for the transition process, endocrinology appointments, and sex reaffirmation surgeries.

CONCLUSIONS

The evidence obtained from this research allowed Profamilia, a Colombian healthcare provider, to adapt the sexual and reproductive health services it provides to people living a trans-life in Colombia. Furthermore, it was possible for Profamilia to design and implement an inclusive sexual and reproductive health program that specifically addresses trans people's needs, identities, and circumstances.

Adaptation and validation of social accountability measures in the context of contraceptive services in Ghana and Tanzania

BACKGROUND

Changes in the values, attitudes, and interactions of both service users and health care providers are central to social accountability processes in reproductive health. However, there is little consensus on how best to measure these latent changes. This paper reports on the adaptation and validation of measures that capture these changes in Tanzania and Ghana.

METHODS

The CaPSAI theory of change determined the dimensions of the measure, and we adapted existing items for the survey items. Trained data collectors used a survey to collect data from 752 women in Tanzania and 750 women in Ghana attending contraceptive services. We used reliability analysis, exploratory, and confirmatory factor analysis to assess the validity and reliability of these measures in each country.

RESULTS

The measure has high construct validity and reliability in both countries. We identified several subscales in both countries, 10 subscales in Tanzania, and 11 subscales in Ghana. Many of the domains and items were shared across both settings.

CONCLUSION

The study suggests that the multi-dimensional scales have high construct validity and reliability in both countries. Though there were differences in the two country contexts and in items and scales, there was convergence in the analysis that suggests that this measure may be relevant in different settings and should be validated in new settings.

TRIAL REGISTRATION

ACTRN12619000378123 .

Out of the Freezer and into the Policy Fire: Quandaries in Reproductive Cryopreservation

The field of assisted reproduction is advancing rapidly and is ripe for regulation and guidance. In 2018, over four thousand frozen eggs and embryos were lost to approximately one thousand patients at Ahuja University Hospital in Cleveland, Ohio, due to an accidental thaw of a cryopreservation tank. The precedent that will be set by the Ahuja class-action case is significant for both past events and future possibilities and is core to the discussion of policy involving the cryopreservation of gametes and embryos.

Barriers to and Enablers of Abortion Provision for Family Physicians Trained in Abortion During Residency

CONTEXT

Although some family medicine residency programs include routine opt-out training in early abortion, little is known about abortion provision by trainees after residency graduation. A better understanding of the barriers to and enablers of abortion provision by trained family physicians could improve residency training and shape other interventions to increase abortion provision and access.

METHODS

Twenty-eight U.S. family physicians who had received abortion training during residency were interviewed in 2017, between two and seven years after residency graduation. The doctors, identified using databases of abortion-trained physicians maintained by residency programs, were recruited by e-mail. In phone interviews, they described their postresidency abortion provision experiences. All interviews were transcribed, coded and analyzed using Dedoose, and a social-ecological framework was employed to guide investigation and analysis.

RESULTS

Although many of the physicians were motivated to provide abortion care, only a minority did so. Barriers to and enablers of abortion provision were found on all levels of the social-ecological model-legal, institutional, social and individual-and included state-specific laws and restrictions on federal funding; religious affiliation or policies prohibiting abortion within particular health systems; mentorship, colleagues' support and the stigma of being an abortion provider; and geographic location, time management and individuals' prioritization of abortion provision.

CONCLUSIONS

Clinical training alone may not be sufficient for family medicine physicians to overcome the barriers to postresidency abortion provision. To increase abortion provision and access, organizations and advocates should work to strengthen enablers of provision, such as strong mentorship and support networks.

Capacity assessment for provision of quality sexual reproductive health and HIV-integrated services in Karamoja, Uganda

INTRODUCTION

Sexual and reproductive health (SRH) and Human Immunodeficiency Virus (HIV) are crucial global health issues. Uganda continues to sustain a huge burden of HIV and AIDS.

METHODS

A cross-sectional health facility-based assessment was performed in November and December 2016 in Karamoja Region, northern Uganda. All the 126 health facilities (HFs) in Karamoja, including 5 hospitals and 121 Health Centers (HCs), covering 51 sub-counties of the 7 districts were assessed. We assessed the capacity of a) leadership and governance, b) human resource, c) service delivery, d) SRH and HIV service integration and e) users satisfaction and perceptions.

RESULTS

64% of the established health staffing positions were filled leaving an absolute gap of 704 units in terms of human resources. As for service delivery capacity, on 5 domains assessed, the best performing was basic hygiene and safety measures in which 33% HCs scored "excellent", followed by the presence of basic equipment. The level of integration of SRH/HIV services was 55.56%.

CONCLUSION

HFs in Karamoja have capacity gaps in a number of health system building blocks. Many of these gaps can be addressed through improved planning. To invest in improvements for these services would have a great gain for Uganda.

Availability, accessibility, and quality of adolescent Sexual and Reproductive Health (SRH) services in urban health facilities of Rwanda: a survey among social and healthcare providers

BACKGROUND

Adolescents are still getting pregnant and contracting Human Immunodeficiency Virus (HIV) and Sexually Transmitted Infections (STIs) in Rwanda as elsewhere. Quality and comprehensive SRH services and information for adolescents is valuable for adolescents' wellbeing. This study aimed at understanding SRH services providers' viewpoints on accessibility, availability, and quality of SRH services provided to adolescents in selected cities of Rwanda.

METHOD

The study was a descriptive cross-sectional survey conducted between May 2018 and May 2019 in six selected cities of Rwanda using a mixed-methods approach. A checklist was used to collect data from 159 conveniently selected SRH services providers. The survey tool was validated. SPSS version 20 was used to describe quantitative data and ATLAS TI version 5.2 was used to code and analyze the qualitative data thematically.

RESULTS

Qualitatively, health care providers reported that the availability of adolescent SRHS are satisfactory with access to accurate SRH information, contraceptive methods, prevention and management of STIs and HIV services, and counselling. However, the accessibility of some services remains limited. According to respondents, some products such as female condoms are less in demand and often expire before they can be distributed. One nurse clarified that they render services at a low price if an adolescent has insurance medical coverture. Religious leaders and family members may hinder adolescents from health-seeking behavior by promoting abstinence and discouraging use of protective means. Quantitatively, we found that 94.3% of health facilities provide information to adolescents on SRH services that were available and 51.6% affirmed delivering services at a low cost. Only 57.2% of respondents mentioned that adolescents are involved in designing the feedback mechanisms at their facilities.

CONCLUSION

SRH services in Rwanda are available for the general population and are not specifically designed for adolescents. These SRH services seem to be fairly accessible to adolescents with insufficient quality as adolescents themselves do not get to be fully involved in service provision among other aspects of quality SRH as stated by the World Health Organization (WHO). Therefore, there is a need to improve the present quality of these services to meet adolescents' needs in an urban setting.

Barriers and facilitators for the sexual and reproductive health and rights of young people in refugee contexts globally: A scoping review

BACKGROUND

The need to address sexual and reproductive health and rights (SRHR) in humanitarian settings is more urgent than ever, especially among young refugees. We conducted a scoping review to identify and synthesise the literature on perceived barriers and facilitators to SRHR among young refugees and interventions created to address their needs.

METHODS

We searched three databases (PubMed, Global Health and POPLINE) for peer-reviewed and grey literature published in English between January 2008 and June 2018 that reported on SRHR barriers, facilitators and interventions for young refugees aged 10 to 24 years. We extracted data using standardised templates and assessed the quality of studies according to study design. Data were charted using qualitative content analysis and organised in line with a socio-ecological framework (individual, social and community, institutional and health system, and structural).

FINDINGS

We screened 1,169 records and included 30 publications (qualitative, quantitative, and mixed methods) across 22 countries; 15 were peer-reviewed articles and 15 were from the grey literature. Twenty-two publications reported on young people in refugee camps or alternatives to camps (e.g. sustainable settlements), and eight referred to young refugees who had been resettled to a third country. We identified 19 sub-categories for barriers and 14 for facilitators at the individual, social and community, institutional and health system, and structural levels. No publications discussed the SRHR challenges faced by young homosexual, bisexual, transgender or queer refugees, or those living with HIV. Nine publications described interventions, which tended to focus on the provision of SRHR services and information, and the training of peers, parents, religious leaders and/or service providers.

CONCLUSIONS

Findings highlight that while young refugees experience similar barriers to SRHR as other young people, many of these barriers are exacerbated by the refugee context. The limited number of publications and evidence on interventions underlines the immediate need to invest in and evaluate SRHR interventions in refugee contexts.

COVID-19 and assisted reproductive technology services: repercussions for patients and proposal for individualized clinical management

The prolonged lockdown of health services providing high-complexity fertility treatments -as currently recommended by many reproductive medicine entities- is detrimental for society as a whole, and infertility patients in particular. Globally, approximately 0.3% of all infants born every year are conceived using assisted reproductive technology (ART) treatments. By contrast, the total number of COVID-19 deaths reported so far represents approximately 1.0% of the total deaths expected to occur worldwide over the first three months of the current year. It seems, therefore, that the number of infants expected to be conceived and born -but who will not be so due to the lockdown of infertility services- might be as significant as the total number of deaths attributed to the COVID-19 pandemic. We herein propose remedies that include a prognostic-stratification of more vulnerable infertility cases in order to plan a progressive restart of worldwide fertility treatments. At a time when preventing complications and limiting burdens for national health systems represent relevant issues, our viewpoint might help competent authorities and health care providers to identify patients who should be prioritized for the continuation of fertility care in a safe environment.

Exploring young women's reproductive decision-making, agency and social norms in South African informal settlements

This paper explores reproductive decision-making among young women in South Africa's informal settlements and considers whether and how agency and social norm theory inform their decisions. Understanding whether, when and how young women make decisions about conception and motherhood is critical for supporting women to avoid unplanned, early motherhood. Qualitative data were collected from 15 young women in informal settlements in eThekwini, South Africa at three time points over 18 months, using in-depth interviews, participant observation and photovoice, and were analysed inductively. When the young women were teenagers and into their early twenties, and had not yet had a child, most paid little attention to whether or not they conceived. This shifted as they grew older and/or after having a first child, at which point many of the women began to express, and sometimes act upon, a greater desire to control whether and when they conceived and delay further pregnancies. At different times in their lives, both social norms and reproductive agency, specifically 'distributed agency' played significant roles in influencing their reproductive decision-making. Social norms held the most influence when they were teenagers and experiencing normative pressures to have a baby while young. As they grew older and/or had a first child they began to assert some agentic control around their reproduction. We therefore recommend that in order to improve the effectiveness of services and interventions supporting young women to delay unplanned pregnancies, programmers, researchers and policy makers must develop a better understanding of the role of social norms and agency at different stages of women's lives.

Youth participation in sexual and reproductive health: policy, practice, and progress in Malawi

Objectives

Ensuring youth participation in policymaking that affects their health and well-being is increasingly recognized as a strategy to improve young people’s reproductive health. This paper aimed to describe the policy context and analyze underlying factors that influence youth participation in sexual and reproductive health (SRH) policymaking in Malawi.

Methods

This critical, focused ethnographic study is informed by postcolonial feminism and difference-centered citizenship theory, based on data collected from October 2017 to May 2018. Multiple research methods were employed: document analysis, focus group discussions, and “moderate” participant observation. Semi-structured interviews were conducted with key informants and youth, supplemented by open-ended drawing exercises with youth.

Results

Progressive policies and the presence of youth in some policymaking structures indicate substantial headway in Malawi. However, underlying structural and societal factors circumscribe young people’s lived experiences of participation.

Conclusions

Despite recent progress in involving young people in SRH policymaking, notable gaps remain between policy and practice. Recognizing and integrating young people in all stages of SRH policymaking is critical to catalyzing the social and political changes necessary to ensure their reproductive health and well-being.

Electronic supplementary material

The online version of this article (10.1007/s00038-020-01357-8) contains supplementary material, which is available to authorized users.

Provider perspectives on contraceptive service delivery: findings from a qualitative study in Johannesburg, South Africa

BACKGROUND

Healthcare providers' skills and attitudes are both barriers and facilitators of contraceptive uptake. In South Africa, migration of healthcare workers and the demands of the HIV epidemic have also contributed to inequitable access to sexual and reproductive health (SRH) care. Yet, the country has committed to achieving universal access to SRH services. We explored healthcare provider's opinions and attitudes on provision of contraceptive services in public facilities, their personal use of methods, and their thoughts on the recent integration of new contraceptive methods in their facilities.

METHODS

We conducted a phenomenological, qualitative study in 2017 at an outpatient, public HIV treatment clinic and two primary healthcare clinics (PHCs) in Johannesburg, South Africa. We purposively selected providers who had worked at the facilities for at least six months and were seeing patients for HIV or SRH services. Trained study staff conducted semi-structured interviews. We conducted descriptive analyses for quantitative data, and used an iterative, thematic analysis approach for open-ended responses.

RESULTS

We interviewed 14 healthcare providers (HIV clinic - 5; PHCs - 9). One respondent was a man; all were nurses. All respondents reported having ever personally used a contraceptive method; half (7/14) were currently using a method. Responses on service provision were conflicting. Respondents felt that their clinics currently met the contraceptive needs of their female patients through on-site services or referrals. However, they noted that staff shortages, lack of training, and a limited contraceptive offering meant that women did not always get the counselling or method they wanted. Respondents noted that the 'best' contraceptive methods for women were those that fit with a woman's lifestyle and medical needs; however, providers also felt strongly that injectables were best for all women. Recent introduction of the implant at one PHC and injectable contraceptives at the HIV clinic was not overly challenging, though there were concerns about staffing and demand creation for the new methods.

CONCLUSIONS

Respondents' conflicting responses revealed challenges with current service delivery, particularly contraceptive counselling. Addressing staff workloads and providing refresher training on contraception would contribute to increased contraceptive service capacity and quality in this setting.

Equity of resource flows for reproductive, maternal, newborn, and child health: are those most in need being left behind?

Although equity has improved in recent years, donors and country governments still need to improve the amount and targeting of funding for reproductive, maternal, and child health, say Melisa Martinez-Alvarez and colleagues

Featured counter-trafficking program: The CAREs clinic, a primary care medical home for commercially exploited youth

This invited article is one of several comprising part of a special issue of Child Abuse and Neglect focused on child trafficking and health. The purpose of each invited article is to describe a specific program serving trafficked children. Featuring these programs is intended to raise awareness of innovative counter-trafficking strategies emerging worldwide and facilitate collaboration on program development and outcomes research. This article describes a medical home model of care to serve the complex medical and mental health needs of commercially sexually exploited youth. Located in Washington D.C., US, it provides coordinated ongoing primary, mental health, and reproductive health care in a trauma-informed manner. Serving 62 youth during its first year, the medical home has begun to improve access to high-quality healthcare to a very vulnerable population.

Using Digital Technology for Sexual and Reproductive Health: Are Programs Adequately Considering Risk?

Digital technologies provide opportunities for advancing sexual and reproductive health and services but also present potential risks. We propose 4 steps to reducing potential harms: (1) consider potential harms during intervention design, (2) mitigate or minimize potential harms during the design phase, (3) measure adverse outcomes during implementation, and (4) plan how to support those reporting adverse outcomes.

Understanding Quality of Care and Satisfaction With Sexual and Reproductive Healthcare Among Young Men

OBJECTIVE

Sexual and reproductive healthcare (SRHC) guidelines recommend the delivery of quality preventive SRHC to males beginning in adolescence. A quality of care (QOC) framework was used to examine factors associated with young male's perceptions of QOC and satisfaction with care, which can influence their engagement and use of SRHC.

METHODS

Cross-sectional surveys were conducted from August 2014 to September 2016 with 385 male patients aged 15-24 years, recruited from primary care and sexually transmitted disease (STD) clinics. Surveys measured QOC received, satisfaction with care, and domains of a QOC framework. Poisson regression analyses examined associations between domains of quality and perceived QOC as well as satisfaction with care.

RESULTS

Over half of males reported QOC as excellent (59%) and were very satisfied with the services (56.7%). Excellent QOC and high satisfaction with services was associated with timely care, higher Clinician-Client Centeredness, and being a bisexual male. Excellent QOC was also associated with greater comfort in the clinic, being tested for human immunodeficiency virus/STDs, attending primary care settings, and receipt of higher number of SRHC services.

CONCLUSIONS

Using a QOC framework as part of providing SRHC to young males can be important in improving their perceptions of QOC and satisfaction with services.

Women's Expectation of Receiving Reproductive Health Care at Catholic and Non-Catholic Hospitals

CONTEXT

Catholic hospitals operate under directives that prohibit the provision of contraceptives, sterilization and abortion. Little research has examined women's awareness of these institutions' policies, which affects their ability to make informed decisions about where to seek care.

METHODS

In 2016, some 1,430 women aged 18-45 were recruited from a U.S. probability-based research panel for a survey about hospital care. Respondents were randomized to a hypothetical Catholic or nonreligious hospital group and asked about their expectations for receiving nine specific reproductive services. Multivariable logistic regression analyses were used to evaluate associations between participants' characteristics and their correctly identifying a hospital as Catholic, as well as between characteristics and expecting that birth control pills, tubal ligation or abortion for serious fetal indications would be provided there.

RESULTS

Women randomized to the Catholic hospital group were less likely than those randomized to the nonreligious group to expect provision of birth control pills (77% vs. 86%), tubal ligation (70% vs. 78%) or abortion for serious fetal indications (42% vs. 54%). Income level was associated with correctly identifying the Catholic hospital: Compared with individuals with the lowest income, those in three of the four other income groups were more likely to identify the hospital as Catholic (odds ratios, 1.9-2.2). In comparison with women who misidentified the Catholic hospital, those who identified it as Catholic had lower expectations that the hospital would provide birth control pills (0.3), tubal ligation (0.5) or abortion (0.2).

CONCLUSIONS

Many women do not realize the breadth of restrictions on reproductive health care at Catholic hospitals. Without institutional transparency, patient autonomy and health outcomes may be compromised.

Confidentiality Matters but How Do We Improve Implementation in Adolescent Sexual and Reproductive Health Care?

Confidentiality protections are a key component of high-quality adolescent sexual and reproductive health (SRH) care. Research has shown that adolescents value confidentiality and are more likely to seek care and provide honest information when confidentiality protections are implemented. However, many adolescents do not receive confidential SRH care. We synthesize studies of adolescents, parents, and providers to identify confidentiality-related factors that may explain why adolescents do not seek care or receive confidential services when they do access care. We present themes relevant to each population that address individual-level knowledge, attitudes, and behaviors, as well as clinic-level characteristics such as protocols, billing mechanisms, and clinic type. These findings have the potential to inform intervention efforts to improve the delivery of confidential SRH care for young people.

Exploring the preferences of involved health professionals regarding the implementation of an online decision aid to support couples during reproductive decision-making in hereditary cancer: a mixed methods approach

To support persons having a genetic predisposition to cancer and their partners during reproductive decision-making, an online decision aid was developed and evaluated. To maximize the impact of the support tool, this mixed methods study aims at developing the optimal implementation strategy for the decision aid. A questionnaire to assess the critical determinants that may affect this implementation was completed by health professionals involved in oncogenetic counselling (N = 46). Subsequently, semi-structured focus groups (N = 19) and individual telephonic interviews (N = 15) were performed with a subset of health professionals. All health professionals indicated to be willing to refer couples to the decision aid, preferably at the moment of receiving the genetic test result. They agreed that the primary requirement for implementation in daily practice was ease of referring couples and preferably free online accessibility. Referral to the tool was able to be included in the standard report couples receive after consultation, thereby making the use of additional paper-based materials redundant (e.g. flyers). Furthermore, incorporating the link to the decision aid on patient organization websites was suggested. Health professionals agreed that implementation would benefit more from promoting awareness regarding the decision aid rather than the inclusion of the tool in official clinical guidelines. To foster implementation of the decision aid, the distribution of online newsletters and the designation of a contact person charged with continued implementation in each Clinical Genetic Center were suggested. Based on these preferences and recommendations, the implementation of the online decision aid will be nationally executed to optimize impact.

Integrating community health assistant-driven sexual and reproductive health services in the community health system in Nyimba district in Zambia: mapping key actors, points of integration, and conditions shaping the process

INTRODUCTION

Although large scale public sector community health worker programs have been key in providing sexual and reproductive health (SRH) services in low- and middle-income countries, their integration process into community health systems is not well understood. This study aimed to identify the conditions and strategies through which Community Health Assistants (CHAs) gained entry and acceptability into community health systems to provide SRH services to youth in Zambia. The country's CHA program was launched in 2010.

METHODOLOGY

A phenomenological design was conducted in Nyimba district. All nine CHAs deployed in Nyimba district were interviewed in-depth on their experiences of navigating the introduction of SRH services for youth in community settings, and the data obtained analyzed thematically.

RESULTS

In delivering SRH services targeting youth, CHAs worked with a range of community actors, including other health workers, safe motherhood action groups, community health workers, neighborhood health committees, teachers, as well as political, traditional and religious leaders. CHAs delivered SRH education and services in health facilities, schools, police stations, home settings, and community spaces. They used their health facility service delivery role to gain trust and entry into the community, and they also worked to build relationships with other community level actors by holding regular joint meetings, and acting as brokers between the volunteer health workers and the Ministry of Health. CHAs used their existing social networks to deliver SRH services to adolescents. By embedding the provision of information about SRH into general life skills at community level, the topic's sensitivity was reduced and its acceptability was enhanced. Further, support from community leaders towards CHA-driven services promoted the legitimacy of providing SRH for youth. Factors limiting the acceptability of CHA services included the taboo of discussing sexuality issues, a gender discriminatory environment, competition with other providers, and challenges in conducting household visits.

CONCLUSION

Strengthening CHAs' ability to negotiate and navigate and gain acceptability in the community health system as they deliver SRH, requires support from both the formal health system and community networks. Limitations to the acceptability of CHA-driven SRH services are a product of challenges both in the community and in the formal health system.

Assessing the sustainability of the Nigerian urban reproductive health initiative facility-level programming: longitudinal analysis of service quality

BACKGROUND

To date, there is little information on the sustainability of family planning (FP) service quality after completion of a donor-funded program. This paper examines the sustainability of the Nigerian Urban Reproductive Health Initiative (NURHI) program on quality of FP services in two cities: Ilorin, where the program ended in March 2015 and Kaduna where the program continued.

METHODS

Data come from three time periods: 2011, before program implementation; 2014, near Phase 1 completion; and 2017, two-years post Phase 1. In 2011, we undertook a facility audit and provider surveys in all public sector facilities in each city as well as all private facilities mentioned as the source for FP or maternal, newborn, and child health services in a 2010 women's household survey. In 2014 and 2017, we returned to the same facilities to undertake the facility audit and provider surveys. Quality is measured from principal component analyses of 30 items from the facility audit and provider surveys. Service use outcomes are measured as the ratio of FP clients (total and new) to the number of reproductive health staff members. Multivariate random effect models are estimated to examine changes in the outcomes over time, between NURHI and non-NURHI facilities and by city.

RESULTS

We demonstrate that NURHI facilities had better quality and higher service use than non-NURHI facilities. Further, while quality of services was higher in Ilorin in 2011, by 2014 and three years later (2017), the quality was better in Kaduna where the program continued. In addition, while no difference was found in service utilization between Ilorin and Kaduna in 2014, by 2017, Kaduna had significantly more new FP users than Ilorin.

CONCLUSIONS

In Ilorin, quality of services did not continue its strong upward trend after the program ended. Programs need to consider long-term strategies that support continuation of program components post program implementation. This may include ensuring continued training of providers and addressing equipment and commodity stock-outs through system changes rather than specific facility-level changes. The findings from this study can be used to inform future programs seeking to improve quality of FP services in a sustainable manner.

Situation analysis for delivering integrated comprehensive sexual and reproductive health services in humanitarian crisis condition for Rohingya refugees in Cox's Bazar, Bangladesh: protocol for a mixed-method study

INTRODUCTION

Rohingya diaspora are one of the most vulnerable groups seeking refuge in camps of Cox's Bazar, Bangladesh, arising an acute humanitarian crisis. More than half of the Rohingya refugees are women and adolescent girls requiring quality sexual and reproductive health (SRH) services. Minimum initial service package of SRH are being rendered in the refugee camps; however, WHO is aiming to provide integrated comprehensive SRH services to meet the unmet needs of this most vulnerable group. For sustainable and successful implementation of such comprehensive SRH service packages, a critical first step is to undertake a situation analysis and understand the current dimensions and capture the lessons learnt on their SRH-specific needs and implementation challenges. This situation analysis is pertinent in current humanitarian condition and will provide an overview of the needs, availability and delivery of SRH services for adolescent girls and women, barriers in accessing and providing those services in Rohingya refugee camps in Cox's Bazar, Bangladesh, and similar humanitarian contexts.

METHODS AND ANALYSIS

A concurrent mixed-methods design will be used in this study. A community-based household survey coupled with facility assessments as well as qualitative in-depth interviews, key informant interviews and focus group discussions will be conducted with community people of Rohingya refugee camps and relevant stakeholders providing SRH services to Rohingya population in Cox's Bazar, Bangladesh. Survey data will be analysed using univariate, bivariate and multivariable regression statistics. Descriptive analysis will be done for facility assessment and thematic analysis will be conducted with qualitative data.

ETHICS AND DISSEMINATION

Ethical approval from Institutional Review Board of BRAC James P Grant School of Public Health (2018-017-IR) has been obtained. Findings from this research will be disseminated through presentations in local, national and international conferences, workshops, peer-reviewed publications, policy briefs and interactive project report.

Delivering community-led integrated HIV and sexual and reproductive health services for sex workers: A mixed methods evaluation of the DIFFER study in Mysore, South India

Introduction

Women in developing countries continue to face barriers to accessing sexual and reproductive health (SRH) services, with marginalized women facing increased challenges to accessing care. The Diagonal Interventions to Fast-Forward Enhanced Reproductive Health (DIFFER) project implemented a package of interventions for female sex workers and women from the general population which integrated horizontal health services for the general population with existing vertical targeted interventions aimed at sex workers with an aim to improve SRH and HIV services. We present an outcome evaluation of the DIFFER project in terms of uptake rates for SRH services among sex workers in Mysore, India.

Methods

Ashodaya Samithi, a sex worker-led organization, implemented the DIFFER strategy through their community-based clinic and a Well Women Clinic (WWC), established at a partner private hospital that provided SRH services for women living with HIV. Mixed methods were used to evaluate the intervention that included a baseline (2012–13) and end of project (2015–16) cross sectional surveys (CSS), focus group discussions (FGDs), key informant interviews, and analysis of service statistics from 2013–2016.

Results

The CSS found that condom use, STI testing, and treatment were high before, and throughout the intervention; cervical cancer screening and treatment increased significantly, from 11.5% to 56% (aOR 9.85, p<0.001) and HIV testing in the last 3 months increased from 26.3% to 73.3% (aOR 7.25, p<0.001). The proportion of sex workers using any SRH service in the past year doubled from 25.7% to 51.4% (aOR 2.91, p<0.001). Service statistics showed similar trends. The FGDs and key informant interviews showed that women and stakeholders held high levels of satisfaction with the strategy, and affirmed potential for scale up.

Conclusion

The DIFFER strategy demonstrated that SRH service uptake can occur in conjuction with HIV services offered to sex workers. This model of integrated service delivery has been accepted by policy makers and needs further analysis for scaling up.

Prioritizing the sexual and reproductive health and rights of adolescent girls and young women within HIV treatment and care services in emergency settings: a girl-centered agenda

BACKGROUND

Extensive documentation exists on a range of negative sexual and reproductive health outcomes and rights violations occurring during humanitarian emergencies. We explore two central questions: Do existing policies, services, and research adequately address the SRH rights, priorities and HIV risks of adolescent girls and young women in emergency settings? What are the missed opportunities for holistically addressing the vulnerabilities experienced by those living with HIV during rapid onset disasters and long term, protracted emergencies? Authors review considerations informing real-time decision making, and highlight missed opportunities to apply a gendered lens in the delivery of AGYW-centered SRHR/HIV services.

METHODS

A scoping review identified studies on HIV intervention and outcomes in emergency settings, published in the peer-reviewed literature (2002-2017). This exercise was complemented with a desk review of normative guidance, frameworks, and implementation guidelines on HIV and SRH in emergency responses, and by consultations with subject matter experts.

RESULTS

The existing frameworks and guidance pay scant attention to the sexual reproductive health and rights of young women living with HIV (WLHIV), focusing mainly on prevention of mother to child transmission (PMTCT), antiretroviral therapy (ART), HIV testing services, and linkage to treatment services. Applying a gendered sexual and reproductive health lens to the response offers opportunities to identify critical implementation questions, and highlight promising practices, to better tailor current services for AGYW.

CONCLUSIONS

A plurality of competing needs crowds out dedicated time and space to effectively integrate HIV and sexual and reproductive health interventions in emergency settings. Political will is required to advance multi-sectoral cooperation, through joint planning, rights-informed learning and integrative responses, and to promote creative solutions for ART continuation, drug supply and HIV testing, treatment and care. Recent advancements in policy and practice would suggest that a more AGYW-centered response is feasible.

Integration of HIV testing services into family planning services: a systematic review

BACKGROUND

Despite significant interest in integrating sexual and reproductive health (SRH) services into HIV services, less attention has been paid to linkages in the other direction. Where women and girls are at risk of HIV, offering HIV testing services (HTS) during their visits to family planning (FP) services offers important opportunities to address both HIV and unwanted pregnancy needs simultaneously.

METHODS

We conducted a systematic review of studies comparing FP services with integrated HTS to those without integrated HTS or with a lower level of integration (e.g., referral versus on-site services), on the following outcomes: uptake/counseling/offer of HTS, new cases of HIV identified, linkage to HIV care and treatment, dual method use, client satisfaction and service quality, and provider knowledge and attitudes about integrating HTS. We searched three online databases and included studies published in a peer-reviewed journal prior to the search date of June 20, 2017.

RESULTS

Of 530 citations identified, six studies ultimately met the inclusion criteria. Three studies were conducted in Kenya, and one each in Uganda, Swaziland, and the USA. Most were in FP clinics. Three were from the Integra Initiative. Overall rigor was moderate, with one cluster-randomized trial. HTS uptake was generally higher with integrated sites versus comparison or pre-integration sites, including in adjusted analyses, though outcomes varied slightly across studies. One study found that women at integrated sites were more likely to have high satisfaction with services, but experienced longer waiting times. One study found a small increase in HIV seropositivity among female patients testing after full integration, compared to a dedicated HIV tester. No studies comparatively measured linkage to HIV care and treatment, dual method use, or provider knowledge/attitudes.

CONCLUSIONS

Global progress and success for reaching SRH and HIV targets depends on progress in sub-Saharan Africa, where women bear a high burden of both unintended pregnancy and sexually transmitted infections, including HIV. While the evidence base is limited, it suggests that integration of HTS into FP services is feasible and has potential for positive joint outcomes. The success and scale-up of this approach will depend on population needs and health system factors.

A Web-based review of sexual and reproductive health services available at colleges and universities in Georgia

OBJECTIVE

Although two-thirds of graduating high school seniors attend college or university in the U.S., there is a paucity of national or state specific research regarding SRH services available on or near college and university campuses.

METHODS

A review of websites for all colleges and universities in Georgia was conducted to evaluate sexual health services available on campuses and evidence of referral to community providers.

RESULTS

Of 96 colleges in Georgia, 44 had campus-located health centers, with only 3 at two-year colleges. Overall SRH service provision was low, with great variation between colleges. Distances between colleges and Title X clinics ranged from 0.33 to 35.45 miles.

CONCLUSIONS

Many students lack access to campus health centers, and information on college websites regarding SRH service availability and referrals differs dramatically between campuses. In the absence of robust campus-located services, schools should highlight where students can obtain comprehensive SRH care in the community.

How do Jordanian and Syrian youth living in Jordan envision their sexual and reproductive health needs? A concept mapping study protocol

INTRODUCTION

Youth in Jordan constitute 20.4% of the population, and many face considerable challenges in addressing their sexual and reproductive health (SRH) needs, such as those related to the prevention of unintended pregnancy and sexually transmitted infections, early marriage and sexual coercion and violence. The findings of previous studies indicate that Jordanian youth require reproductive health-related support, information and services; however, there remains very limited data as to how youth envision their SRH challenges and needs. This protocol outlines the design of a qualitative study using a participatory research methodology called concept mapping. This methodology enables participants to develop a conceptual framework for how they envision their sexual and reproductive health needs.

METHODS AND ANALYSIS

This study will use concept mapping, which consists of a structured and iterative participatory research process that engages participants over three data collection sessions in order to generate the information needed to create a visual display of their ideas pertaining their SRH needs, issues and concerns, and how these ideas relate to each other. Each data collection session focuses on a different activity, including brainstorming, pile sorting and interpretation of the results. Data will be analysed using hierarchical cluster analysis and multidimensional scaling. Transcriptions of group discussions will be coded and analysed to add depth to the study results. Two hundred and eighty-eight males and females of Jordanian or Syrian descent living in Jordan will be recruited from four communities across Jordan.

ETHICS AND DISSEMINATION

This study meets the requirements of the Declaration of Helsinki and has been approved by the Institutional Review Boards at the Harvard T.H. Chan School of Public Health and the University of Jordan. Study findings will be presented in peer-reviewed, international journals and made available to local programme managers, policy-makers and stakeholders through local dissemination efforts.

What's Religion Got to Do with It? Exploring College Students' Sexual and Reproductive Health Knowledge and Awareness of Sexual and Reproductive Health Services in Relation to Their Gender and Religiosity

The purpose of this study was to examine the relationship between religiosity and sexual and reproductive health (SRH) knowledge and awareness of campus SRH services among college students on a racially and ethnically diverse college campus. The sample included 996 undergraduate students at a large public university in California. For women, there was a consistent pattern across religious affiliations of more frequent attenders reporting lower SRH knowledge than less frequent attenders. These findings suggest that higher rates of religious attendance among Catholic, Protestant, and Evangelical women pose a risk for lower SRH knowledge. The results suggest the need for SRH outreach and educational materials targeting men in general, who had lower levels of SRH knowledge and awareness of SRH services overall, and taking religiosity into account, particularly with regard to women.

Correlates of the Women's Development Army strategy implementation strength with household reproductive, maternal, newborn and child healthcare practices: a cross-sectional study in four regions of Ethiopia

BACKGROUND

To address the shortfall in human resources for health, Ethiopia launched the Health Extension Program (HEP) in 2004, establishing a health post with two female health extension workers (HEWs) in every kebele (community). In 2011, the Women's Development Army (WDA) strategy was added, using networks of neighboring women to increase the efficiency of HEWs in reaching every household, with one WDA team leader for every 30 households. Through the strategy, women in the community, in partnership with HEWs, share and learn about health practices and empower one another. This study assessed the association between the WDA strategy implementation strength and household reproductive, maternal, newborn and child health care behaviors and practices.

METHODS

Using cross-sectional household surveys and community-level contextual data from 423 kebeles representing 145 rural districts, an internal comparison group design was applied to assess whether HEP outreach activity and household-level care practices were better in kebeles with a higher WDA density. The density of active WDA leaders was considered as WDA strategy implementation strength; higher WDA density in a kebele indicating relatively high implementation strength. Based on this, kebeles were classified as higher, moderate, or lower. Multilevel logit models, adjusted for respondents' individual, household and contextual characteristics, were used to assess the associations of WDA strategy implementation strength with outcome indicators of interest.

RESULTS

Average numbers of households per active WDA team leader in the 25th, 50th and 75th percentiles of the kebeles studied were respectively 41, 50 and 73. WDA density was associated with better service for six of 13 indicators considered (p < 0.05). For example, kebeles with one active WDA team leader for up to 40 households (higher category) had respectively 7 (95% CI, 2, 13), 11 (5, 17) and 9 (1, 17) percentage-points higher contraceptive prevalence rate, coverage of four or more antenatal care visits, and coverage of institutional deliveries respectively, compared with kebeles with one active WDA team leader for 60 or more households (lower category).

CONCLUSION

Higher WDA strategy implementation strength was associated with better health care behaviors and practices, suggesting that the WDA strategy supported HEWs in improving health care services delivery.