Mario Chen

Keeping community health workers in Uganda motivated: key challenges, facilitators, and preferred program inputs

In Uganda, community-based health programs using volunteers should focus on strengthening support systems to address transportation and stockout issues and on improving links with the health structure while reinforcing effort recognition, status, and acquisition of new skills. In Uganda, community-based health programs using volunteers should focus on strengthening support systems to address transportation and stockout issues and on improving links with the health structure while reinforcing effort recognition, status, and acquisition of new skills. Introduction: In the face of global health worker shortages, community health workers (CHWs) are an important health care delivery strategy for underserved populations. In Uganda, community-based programs often use volunteer CHWs to extend services, including family planning, in rural areas. This study examined factors related to CHW motivation and level of activity in 3 family planning programs in Uganda. Methods: Data were collected between July and August 2011, and sources comprised 183 surveys with active CHWs, in-depth interviews (IDIs) with 43 active CHWs and 5 former CHWs, and service statistics records. Surveys included a discrete choice experiment (DCE) to elicit CHW preferences for selected program inputs. Results: Service statistics indicated an average of 56 visits with family planning clients per surveyed CHW over the 3-month period prior to data collection. In the survey, new skills and knowledge, perceived impact on the community, and enhanced status were the main positive aspects of the job reported by CHWs; the main challenges related to transportation. Multivariate analyses identified 2 correlates of CHWs being highly vs. less active (in terms of number of client visits): experiencing problems with supplies and not collaborating with peers. DCE results showed that provision of a package including a T-shirt, badge, and bicycle was the program input CHWs preferred, followed by a mobile phone (without airtime). IDI data reinforced and supplemented these quantitative findings. Social prestige, social responsibility, and aspirations for other opportunities were important motivators, while main challenges related to transportation and commodity stockouts. CHWs had complex motivations for wanting better compensation, including offsetting time and transportation costs, providing for their families, and feeling appreciated for their efforts. Conclusion: Volunteer CHW programs in Uganda and elsewhere need to carefully consider appropriate combinations of financial and nonfinancial inputs for optimal results.

Getting to 70%: Barriers to modern contraceptive use for women in Rwanda

To identify reasons for non‐use of modern family planning in Rwanda, to examine specific barriers to contraception, and to explore psychosocial factors influencing modern contraceptive use.

Effectiveness, safety and acceptability of Sino-implant (II) during the first year of use: results from Kenya and Pakistan.

BACKGROUND Sino-implant (II) is a two-rod subcutaneous contraceptive implant used up to 4 years, containing 150 mg of levonorgestrel. We conducted two observational studies of Sino-implant (II) to evaluate its performance in routine service delivery settings. METHODS We enrolled 1326 women age 18-44 who had Sino-implant (II) inserted at clinics in Pakistan and Kenya. Women were followed-up using either an active or passive follow-up scheme in each study. Study outcomes were: one-year cumulative pregnancy and discontinuation rates; rates of insertion and removal complications; adverse event and side effect rates; reasons for discontinuation; and implant acceptability and satisfaction with clinic services. RESULTS A total of 754 women returned for at least one follow-up visit. The overall Pearl pregnancy rate was 0.4 per 100 woman-years [95% confidence interval (CI) 0.1, 0.9] resulting from 1 confirmed post-insertion pregnancy in Kenya and 4 in Pakistan. Country-specific Pearl rates were 0.2 (95% CI 0.0, 0.9) in Kenya and 0.6 (95% CI 0.2, 1.6) in Pakistan. The total cumulative 12-month probability of removal was 7.6% (95% CI 6.1, 9.1), with country-specific removal probabilities of 3.7% in Kenya (95% CI 2.1, 5.3) and 10.8% in Pakistan (95% CI 8.5, 13.2). Four serious adverse events occurred in Kenya and none occurred in Pakistan; one SAE (an ectopic pregnancy) was possibly related to Sino-implant (II). Most women in both countries said they would recommend the implant to others. CONCLUSION The results from these studies reveal high effectiveness and favorable safety and acceptability during the first year of use of Sino-implant. IMPLICATION The favorable Sino-implant (II) findings from Kenya and Pakistan provide further evidence from disparate regions that Sino-implant (II) is safe, effective and acceptable during routine service delivery.

Evaluating Bang for the Buck A Cost-Effectiveness Comparison Between Individual Interviews and Focus Groups Based on Thematic Saturation Levels

Evaluators often use qualitative research methods, yet there is little evidence on the comparative cost-effectiveness of the two most commonly employed qualitative methods—in-depth interviews (IDIs) and focus groups (FGs). We performed an inductive thematic analysis of data from 40 IDIs and 40 FGs on the health-seeking behaviors of African American men (N = 350) in Durham, North Carolina. We used a bootstrap simulation to generate 10,000 random samples from each data set and calculated the number of data collection events necessary to reach different levels of thematic saturation. The median number of data collection events required to reach 80% and 90% saturation was 8 and 16, respectively, for IDIs and 3 and 5 for FGs. Interviews took longer but were more cost-effective at both levels. At the median, IDIs cost 20–36% less to reach thematic saturation. Evaluators can consider these empirically based cost-effectiveness data when selecting a qualitative data collection method.

Integrating family planning messages into immunization services: a cluster-randomized trial in Ghana and Zambia

OBJECTIVE To determine whether integrating family planning (FP) messages and referrals into facility-based, child immunization services increase contraceptive uptake in the 9- to 12-month post-partum period. METHODS A cluster-randomized trial was used to test an intervention where vaccinators were trained to provide individualized FP messages and referrals to women presenting their child for immunization services. In each of 2 countries, Ghana and Zambia, 10 public sector health facilities were randomized to control or intervention groups. Shortly after the introduction of the intervention, exit interviews were conducted with women 9-12 months postpartum to assess contraceptive use and related factors before and after the introduction of the intervention. In total, there were 8892 participants (Control Group Ghana, 1634; Intervention Group Ghana, 1129; Control Group Zambia, 3751; Intervention Group Zambia, 2468). Intervention effects were evaluated using logistic mixed models that accounted for clustering in data. In addition, in-depth interviews were conducted with vaccinators, and a process assessment was completed mid-way through the implementation of the intervention. RESULTS In both countries, there was no significant effect on non-condom FP method use (Zambia, P = 0.56 and Ghana, P = 0.86). Reported referrals to FP services did not improve nor did womens knowledge of factors related to return of fecundity. Some providers reported having made modifications to the intervention; they generally provided FP information in group talks and not individually as they had been trained to do. CONCLUSION Rigorous evidence of the success of integrated immunization services in resource poor settings remains weak.

Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomised controlled trial

BACKGROUND Injectable contraceptives are popular in sub-Saharan Africa but have high discontinuation rates due partly to the need for provider-administered re-injection. We compared continuation rates of women who self-injected subcutaneous depot medroxyprogesterone acetate (DMPA-SC) and women who received DMPA-SC from a health-care provider, including community health workers (CHWs). METHODS We did an open-label randomised controlled trial based at six Ministry of Health clinics in rural Mangochi District, Malawi. Health-care providers recruited adult women who presented at the six clinics or to CHWs in rural communities in the clinic catchment areas. Participants received DMPA-SC and were randomised (1:1) to receive provider-administered injections or training in how to self-inject DMPA-SC. Randomisation was done via a computer-generated block randomisation schedule with block sizes of four, six, and eight and stratified by study site, generated by an independent statistician. Self-injectors administered the first injection under observation and were sent home with three doses, written instructions, and a calendar. The provider-administered group received a DMPA-SC injection and a calendar, and were asked to return for subsequent injections. Data collectors contacted participants after the 14-week re-injection window at 3, 6, and 9 months to collect continuation data. At 12 months after enrolment or early discontinuation, women had their final interview, which included pregnancy testing. The primary outcome was discontinuation of DMPA-SC, as assessed in the intention-to-treat population. We used Kaplan-Meier methods to estimate the probabilities of continuation and a log-rank test to compare groups. Safety was assessed in the as-treated population, which consisted only of participants who successfully received at least one DMPA-SC injection after randomisation. This trial is registered with ClinicalTrials.gov, number NCT02293694. FINDINGS This study lasted from Sept 17, 2015, to Feb 21, 2017. 731 women underwent randomisation, with 364 assigned to the self-administered group and 367 to the provider-administered group. One woman in the self-injection group withdrew at month 0. Treatment was discontinued by 99 women in the self-administered group and 199 women in the provider-administered group. The 12 month continuation rate was 73% in the self-injection group and 45% in the provider-administered group, giving an incidence rate ratio of 0·40 (95% CI 0·31-0·51; p<0·0001). Adverse events deemed to potentially be treatment-related were reported by ten women (20 events) in the self-administered group and 17 women (28 events) in the provider-administered group. Five serious adverse events were reported during the trial by four women; two events related to DMPA-SC (menorrhagia and anaemia requiring hospital admission) were reported by the same woman in the provider-administered group and resolved without sequelae. The other serious adverse events, including one death, were deemed to be unrelated to DMPA-SC. INTERPRETATION Women who self-injected DMPA-SC had significantly higher rates of continuation than those receiving provider-injected DMPA-SC. Community-based provision of injectable contraception for self-injection in low-resource settings seems to be safe and feasible. Self-administration of DMPA-SC should be made widely available. FUNDING United States Agency for International Development and Childrens Investment Fund Foundation.

Performance of Sino-implant (II) in routine service delivery in Madagascar

BACKGROUND Sino-implant (II) is a low-cost subdermal contraceptive implant containing levonorgestrel that is currently labeled for 4 years of use. Widely used in China and Indonesia, it has been little studied elsewhere. We conducted a prospective study of Sino-implant (II) use by women in Madagascar. METHODS We enrolled a total of 621 women 18 or older who had Sino-implant (II) inserted on day of enrollment, some in fixed clinical sites, and some at outreach sites. Half of the women were scheduled for follow-up visits at 3 months and at 12 months postinsertion (active follow-up cohort); the other half were advised to return if they desired care for any problem, thought they were pregnant or wanted the implants removed (passive surveillance cohort). RESULTS No insertion complications were reported. A total of 384 women returned for an earlier visit, and 351 returned for a later visit, for a total of 419 woman-years of observation. No postinsertion pregnancies or serious adverse events were observed. Twenty-eight implant removals were reported by 12 months, a cumulative removal probability of 7.3 per 100 women. Acceptability of the implants was very high, as was satisfaction with clinic services. CONCLUSIONS This is the first report on the performance of Sino-implant (II) from outside China and Indonesia and among the first in the English-language literature. These initial data from Madagascar indicate a favorable level of safety, effectiveness and acceptability during the first year of use.

The levonorgestrel intrauterine system: cohort study to assess satisfaction in a postpartum population in Kenya.

BACKGROUND The levonorgestrel intrauterine system (LNG IUS) may become the next long-acting contraceptive to be introduced in public sector programs of resource-poor countries. Whereas service provision for subdermal implants and intrauterine devices is growing, little is known about how the LNG IUS might fit in. STUDY DESIGN We conducted a cohort study of 313 women in Kenya who were 6-12 weeks postpartum when they started using these methods: subdermal implant (205), LNG IUS (93), and copper intrauterine device (15). Participants returned for visits at 6 and 12 months to share information on bleeding patterns, side effects, satisfaction, and continued use of the products. We used Kaplan-Meier techniques to estimate method continuation rates and chi-square tests of association to identify differences in experiences with the methods. RESULTS The 12-month continuation rate for the LNG IUS was 89.1 (95% confidence interval [CI] = 86.9-94.9) and statistically equivalent to that of the subdermal implant (91.8: 95% CI = 80.6-94.0). Nearly 87% of LNG IUS users were very satisfied with the method at 6 months compared to 75% of implant users; this gap closed somewhat at 12 months as satisfaction levels of implant users rose. At 12 months 78% of LNG IUS users felt that their bleeding pattern was highly acceptable compared with about 66% of implant users. CONCLUSIONS This study found that the LNG IUS compared favorably to the subdermal implant in terms of satisfaction levels and continued use. The LNG IUS will provide another long-acting option for postpartum women. IMPLICATIONS The LNG IUS may soon be purchased by international donor agencies for use in public sector programs in sub-Saharan Africa and other resource-poor countries. The results of this study suggest that the product will be successful in future introduction activities.

Introduction of the levonorgestrel intrauterine system in Kenya through mobile outreach: review of service statistics and provider perspectives

Limited introduction of the LNG IUS through mobile outreach in Kenya, without any special promotion, resulted in good uptake. And providers viewed it positively, particularly because of its noncontraceptive benefits. Increased provision of the LNG IUS can improve options for women needing highly effective reversible contraception. Limited introduction of the LNG IUS through mobile outreach in Kenya, without any special promotion, resulted in good uptake. And providers viewed it positively, particularly because of its noncontraceptive benefits. Increased provision of the LNG IUS can improve options for women needing highly effective reversible contraception. Background: The levonorgestrel intrauterine system (LNG IUS) was developed over 30 years ago, but the product is currently too expensive for widespread use in many developing countries. In Kenya, one organization has received donated commodities for 5 years, providing an opportunity to assess impact and potential future role of the product. Methods: We reviewed service statistics on insertions of the LNG IUS, copper intrauterine device (IUD), and subdermal implant from 15 mobile outreach teams during the 2011 calendar year. To determine the impact of the LNG IUS introduction, we analyzed changes in uptake and distribution of the copper IUD and subdermal implant by comparing periods of time when the LNG IUS was available with periods when it was not available. In addition, we interviewed 27 clinicians to assess their views of the product and of its future role. Results: When the LNG IUS was not available, intrauterine contraception accounted for 39% of long-acting method provision. The addition of the LNG IUS created a slight rise in intrauterine contraception uptake (to 44%) at the expense of the subdermal implant, but the change was only marginally significant (P = .08) and was largely attributable to the copper IUD. All interviewed providers felt that the LNG IUS would increase uptake of long-acting methods, and 70% felt that the noncontraceptive benefits of the product are important to clients. Conclusions: The LNG IUS was well-received among providers and family planning clients in this population in Kenya. Although important changes in service statistics were not apparent from this analysis (perhaps due to the small quantity of LNG IUS that was available), provider enthusiasm for the product was high. This finding, above all, suggests that a larger-scale introduction effort would have strong support from providers and thus increase the chances of success. Adding another proven and highly acceptable long-acting contraceptive technology to the method mix could have important reproductive health impact.

Understanding the Broader Sexual and Reproductive Health Needs of Female Sex Workers in Dhaka, Bangladesh

CONTEXT Little is known about the sexual and reproductive health care needs of female sex workers in Dhaka, Bangladesh. METHODS Survey data were collected from 354 hotel-based and 323 street-based female sex workers using a venue-based stratified cluster sampling approach. In addition, in-depth interviews were conducted with 20 female sex workers recruited from drop-in centers. We calculated unmet need for family planning and examined fertility desires, use of condoms and other contraceptive methods, experiences with gender-based violence, sexual and reproductive health service needs, and preferences on where to receive services. RESULTS The prevalence of unmet need was 25% among hotel-based female sex workers and 36% among street-based female sex workers. Almost all participants reported having used condoms in the past 30 days, and 44% of hotel-based sex workers and 30% of street-based sex workers reported dual method use during that period. Condom use was inconsistent, however, and condom breakage and nonuse for extra money were common. Many women reported experiencing gender-based violence. Sexual and reproductive health services had been obtained by 64% of hotel-based and 89% of street-based sex workers in the past six months; drop-in centers were their preferred site for receiving health services. CONCLUSIONS Female sex workers in Dhaka need family planning and other sexual and reproductive health services and prefer receiving them from drop-in centers.