Tara M. Sullivan

Changes in contraceptive method mix in developing countries

CONTEXT Understanding shifts in contraceptive method mix is key to helping policymakers, program managers and donor agencies meet current contraceptive demand and estimate future needs in developing countries. METHODS Data from Demographic and Health Surveys, Reproductive Health Surveys and other nationally representative surveys were analyzed to describe trends and shifts in method mix among married women of reproductive age from 1980 to 2005. The analysis included 310 surveys from 104 developing countries. RESULTS Contraceptive use among married women of reproductive age increased in all regions of the developing world, reaching 66% in Asia and 73% in Latin America and the Caribbean in 2000-2005, though only 22% in Sub- Saharan Africa. The proportion of married contraceptive users relying on the IUD declined from 24% to 20%, and the proportion using the pill fell from 16% to 12%. The share of method mix for injectables rose from 2% to 8%, and climbed from 8% to 26% in Sub-Saharan Africa, while the share for condoms was 5-7%. The overall proportion of users relying on female sterilization ranged from 29% to 39%, reaching 42-43% in Asia and in Latin America and the Caribbean in 2000-2005; on average, the share of all method use accounted for by male sterilization remained below 3% for all periods. Use of traditional methods declined in all regions; the sharpest drop-from 56% to 31% of users-occurred in Sub-Saharan Africa. CONCLUSIONS To meet the rising demand for modern methods, it is critical that future programmatic efforts provide methods that are both accessible and acceptable to users.

Reaching remote health workers in Malawi: baseline assessment of a pilot mhealth intervention.

mHealth has great potential to change the landscape of health service delivery in less developed countries—expanding the reach of health information to frontline health workers in remote areas. Formative, process, and summative evaluation each play an important role in mHealth interventions. K4Health conducted a Health Information Needs Assessment in Malawi from July to September 2009 (formative evaluation) that found widespread use of cell phones among health workers offering new opportunities for knowledge exchange, especially in areas where access to health information is limited. K4Health subsequently designed an 18-month demonstration project (January 2010 to June 2011) to improve the exchange and use of family planning/reproductive health and HIV/AIDS knowledge among health workers, which included the introduction of a short message service (SMS) network. K4Health conducted a pretest of the mHealth intervention from June to October 2010. A baseline assessment was carried out in November 2010 before expanding the SMS network and included use of qualitative and quantitative measures and comparison groups (summative evaluation). Routinely collected statistics also guide the program (process evaluation). This article describes the approach and main findings of the SMS baseline study and contributes to a growing body of evidence measuring the effectiveness and efficiency of mHealth programs using a strong evaluation design.

Taking knowledge for health the extra mile: participatory evaluation of a mobile phone intervention for community health workers in Malawi

A participatory evaluation process called Net-Map showed that providing community health workers (CHWs) with mobile phones and essential technical information changed CHWs, from passive recipients of information with little influence to active information agents who sought and provided information to improve health services. A participatory evaluation process called Net-Map showed that providing community health workers (CHWs) with mobile phones and essential technical information changed CHWs, from passive recipients of information with little influence to active information agents who sought and provided information to improve health services. In Malawi, where the majority of the population resides in rural areas, community health workers (CHWs) are the first, and often only, providers of health services. An assessment of health information needs, however, found that these frontline workers often lacked essential health information. A pilot project, implemented in 2 rural districts of Malawi between 2010 and 2011, introduced a mobile phone system to strengthen knowledge exchange within networks of CHWs and district staff. To evaluate the mobile phone intervention, a participatory evaluation method called Net-Map was used, an approach built on traditional social network analysis. Together, CHWs and district personnel discussed information needs and gaps and the roles of different actors in their information networks. They then used drawings and 3-dimensional objects to create baseline and endline maps showing the linkages and levels of influence among members of the information network. Net-Map provided them with powerful evidence of differences before and after the mobile phone initiative. At baseline, CHWs were not mentioned as actors in the information network, while at endline they were seen to have significant connections with colleagues, beneficiaries, supervisors, and district health facilities, as both recipients and providers of information. Focus groups with CHWs complemented the Net-Map findings with reports of increased self-confidence and greater trust by their communities. These qualitative results were bolstered by surveys that showed decreases in stockouts of essential medicines, lower communication costs, wider service coverage, and more efficient referrals. As an innovative, participatory form of social network analysis, Net-Map yielded important visual, quantitative, and qualitative information at reasonable cost.

Contraceptive method skew and shifts in method mix in low- and middle-income countries

CONTEXT Method mix-the percentage distribution of contraceptive users in a given country, by method-is one measure that reflects the availability of a range of contraceptive methods. A skewed method mix-one in which 50% or more of contraceptive users rely on a single method-could be cause for concern as a sign of insufficiency of alternative methods or provider bias. Shifts in method mix are important to individual countries, donors and scholars studying contraceptive dynamics. METHODS To determine current patterns and recent changes in method mix, we examined 109 low- and middle-income countries. A variety of statistical methods were used to test four factors as correlates of skewed method mix: geographic region, family planning program effort index, modern contraceptive prevalence rate and human development index. An assessment of changes in reliance on female and male sterilization, the IUD, the implant and the injectable was conducted for countries with available data. RESULTS Of the 109 countries included in this analysis, 30% had a skewed method mix-a modest decrease from 35% in a 2006 analysis. Only geographic region showed any correlation with method skew, but it was only marginally significant. The proportion of users relying on female sterilization, male sterilization or the IUD decreased in far more countries than it increased; the pattern was reversed for the injectable. CONCLUSION Method mix skew is not a definitive indicator of lack of contraceptive choice or provider bias; it may instead reflect cultural preferences. In countries with a skewed method mix, investigation is warranted to identify the cause.

Understanding Health Information Needs and Gaps in the Health Care System in Uttar Pradesh, India

Health information and the channels that facilitate the flow and exchange of this information to and among health care providers are key elements of a strong health system that offers high-quality services,yet few studies have examined how health care workers define, obtain, and apply information in the course of their daily work. To better understand health information needs and barriers across all of levels of the health care system, the authors conducted a needs assessment in Lucknow, Uttar Pradesh, India. Data collection consisted of 46 key informant interviews and 9 focus group discussions. Results of the needs assessment pointed to the following themes: (a) perceptions or definitions of health information related to daily tasks performed at different levels of the health system; (b) information flow in the public health structure; (c) need for practical information; and (d) criteria for usability of information. This needs assessment found that health information needs vary across the health system in Uttar Pradesh. Information needs are dynamic and encompass programmatic and service delivery information. Providing actionable information across all levels is a key means to strengthen the health system and improve the quality of services. An adequate assessment of health information needs, including opportunities, barriers, and gaps, is a prerequisite to designing effective communication of actionable information.

From research to policy and practice: a logic model to measure the impact of knowledge management for health programs

To date, few monitoring and evaluation guidelines exist for knowledge management products and services. One initiative undertaken by the Health Information and Publications Network (HIPNet) (www.hipnet.org), a network of health technical assistance organizations culminated in development of a guide to monitoring and evaluating health information products and services. The guide provides an approach to measuring the function and outcomes of health information programs, suggesting indicators and a logic model linking inputs, processes, and outputs to multiple levels of outcomes. The logic model depicts a way to strategically structure the design, implementation, and evaluation of such programs. This guide represents one of the few efforts to collect, develop, organize, and define indicators related to reach, usefulness and use of knowledge management products and services. It presents a unique logic model and list of indicators that can be used across different knowledge management products and services (e.g. manuals, guidelines, websites, networks, e-learning) to measure reach, usefulness and use. Since its development, the indicators and logic model have been used to guide the monitoring and evaluating (M&E) work of HIPNet member organizations and others. For example, the logic model has formed the foundation of M&E plans and many of the indicators and questions included in the guide have been used as the basis for measuring the reach, usefulness, and use of knowledge management for health programs. This paper discusses the theoretical basis of the logic model in this guide, the components of the logic model, and recommendations for its further development. It concludes that while this logic model based on diffusion of innovations theory fills a gap, knowledge management program designers, implementers, and evaluators will benefit from further testing the logic model and related indicators, better understanding audiences and the role of their networks, expanding the logic model to address multiple levels, further exploring relevant theory, and developing stronger needs assessment, monitoring, and evaluation approaches.

Working Together to Meet the Information Needs of Health Care Providers, Program Managers, and Policy Makers in Low- and Middle-Income Countries

Within the health system policymakers program managers and health care providers require needs-driving and evidence-based information to inform decision making and improve the quality of services delivered. However many international health and development organizations continue to rely on a push model of information dissemination routinely sending information to health care professionals in low- and middle-income countries but failing to fully take into consideration the needs of information consumers in these settings. Over the past decade the world has experienced an information revolution with the exponential growth of information and communication technologies and the surge in Internet and mobile phone users worldwide. These advances have dramatically increased access to health information for many health care professions. However those who live in remote areas work at grassroots level and are most in need of information at the point of care continue to have the least access to these technologies. An adequate assessment of health information needs including opportunities barriers and gaps is necessary for designing effective communication strategies. The articles in this special issue contribute to the evidence base of the information needs of health care professionals working at various levels of the health system. Through an examination of information flow throughout an entire health system the research studies provide concrete findings on the information needs and wants of individual health care professions and document the role of professional networks. The commentary pieces further explore these issues to help design sound programs that improve knowledge management and sharing.

Leveraging the Power of Knowledge Management to Transform Global Health and Development

Good knowledge is essential to prevent disease and improve health. Knowledge management (KM) provides a systematic process and tools to promote access to and use of knowledge among health and development practitioners to improve health and development outcomes. KM tools range from publications and resources (briefs, articles, job aids) and products and services (websites, eLearning courses, mobile applications), to training and events (workshops, webinars, meetings) and approaches and techniques (peer assists, coaching, after-action reviews, knowledge cafés). Good knowledge is essential to prevent disease and improve health. Knowledge management (KM) provides a systematic process and tools to promote access to and use of knowledge among health and development practitioners to improve health and development outcomes. KM tools range from publications and resources (briefs, articles, job aids) and products and services (websites, eLearning courses, mobile applications), to training and events (workshops, webinars, meetings) and approaches and techniques (peer assists, coaching, after-action reviews, knowledge cafés).

Utilizing digital health applications as a means to diffuse knowledge to improve family planning outcomes in Bangladesh

Introduction: Bangladesh’s growing population negatively affects its economic growth. As such, reproductive health programs are critical. Fieldworkers play a critical role in providing family planning services in Bangladesh, and require up-to-date knowledge to counsel their clients to improve family planning outcomes. This study examines the effects of a fieldworker digital health training package on family planning client knowledge and behaviors in Bangladesh through a two-step diffusion model. Methods: This study was part of a knowledge management intervention that sought to improve fieldworkers’ access, comprehension, and application of health resources. Mothers with a child under the age of two (n= 651) reported receiving a home visit from a fieldworker who had a netbook with the package (low exposure); reported receiving a home visit from a fieldworker who had a netbook with the package and were shown a digital resource (high exposure); or reported no home visit from a fieldworker who had a netbook (no exposure). Results: Both levels of exposure were associated with higher odds of mothers reporting that the fieldworker discussed contraceptive choice, contraceptive side effects, and contraceptive side effects management compared to unexposed mothers. Mothers in the high exposure group had higher odds of contraceptive use compared to unexposed mothers (aOR: 1.85). Discussion: The knowledge a fieldworker gains through a digital health training package can be diffused to clients, positively affecting client knowledge and behaviors. Such interventions can empower fieldworkers by providing them relevant information at the point of care, which can enhance their credibility among the communities they serve. Correspondence to: Rupali J. Limaye, PhD, Assistant Scientist, Johns Hopkins Bloomberg School of Public Health, Department of International Health, 111 Market Place Suite 310, Baltimore, MD 21202, USA; E-mail: rlimaye@jhu.edu

Piloting Digitally Enabled Knowledge Management to Improve Health Programs in Rural Bangladesh

Until recently, digitally enabled Knowledge Management (KM) activities in developing countries have more often than not been dismissed as unrealistic given challenges with access to electricity and the internet. However, a number of recent examples of holistic KM activities, including digital elements, have demonstrated a measurable contribution to improved outcomes for some of the world’s poorest people. This chapter focuses on such a case, looking at how a digitally enabled KM program was designed, piloted, and measured in two districts in Bangladesh. The program aimed to help rural community-based health workers be more informed about, and helpful in, providing health and nutrition guidance to some of the world’s poorest people.