Provision of DMPA by community health workers: what the evidence shows

Leveraging community health workers as vaccinators: a case study exploring the role of Malawi's Health Surveillance Assistants in delivering routine immunization services

BACKGROUND

Global chronic health worker shortages and stagnating routine immunization rates require new strategies to increase vaccination coverage and equity. As trained, trusted members of their local communities, community health workers (CHWs) are in a prime position to expand the immunization workforce and increase vaccination coverage in under-reached communities. Malawi is one of only a few countries that relies on CHWs-called Health Surveillance Assistants (HSAs) in Malawi-to administer routine immunizations, and as such offers a unique example of how this can be done.

CASE PRESENTATION

We sought to describe the operational and programmatic characteristics of a functional CHW-led routine immunization program by conducting interviews with HSAs, HSA supervisors, ministry of health officials, and community members in Malawi. This case study describes how and where HSAs provide vaccinations, their vaccination-related responsibilities, training and supervision processes, vaccine safety considerations, and the community-level vaccine supply chain. Interview participants consistently described HSAs as a high-functioning vaccination cadre, skilled and dedicated to increasing vaccine access for children. They also noted a need to strengthen some aspects of professional support for HSAs, particularly related to training, supervision, and supply chain processes. Interviewees agreed that other countries should consider following Malawi's example and use CHWs to administer vaccines, provided they can be sufficiently trained and supported.

CONCLUSIONS

This account from Malawi provides an example of how a CHW-led vaccination program operates. Leveraging CHWs as vaccinators is a promising yet under-explored task-shifting approach that shows potential to help countries maximize their health workforce, increase vaccination coverage and reach more zero-dose children. However, more research is needed to produce evidence on the impact of leveraging CHWs as vaccinators on patient safety, immunization coverage/vaccine equity, and cost-effectiveness as compared to use of other cadres for routine immunization.

Community Health Workers as Vaccinators: A Rapid Review of the Global Landscape, 2000-2021

INTRODUCTION

Community health workers (CHWs) could expand immunization access in under-reached communities by administering vaccines. This rapid review identifies countries where CHWs administered vaccines and synthesizes health systems factors that may contribute to or detract from the feasibility of CHWs administering vaccines.

METHODS

We conducted a rapid review of peer-reviewed literature from 3 databases and gray literature identified through web searches and by CHW subject matter experts. We treated extracted data on conditions related to vaccine administration by CHWs as qualitative data and conducted deductive content analysis.

RESULTS

We retained 32 documents from 497 initial records and identified 23 CHW cadres that vaccinated in 20 countries, ranging from long-established national programs delivering routine immunizations to pilot projects delivering 1 specific vaccine. CHWs who vaccinate face the following challenges: (1) inadequate supply chain training, (2) inadequate cold chain equipment, (3) transportation for supplies and to communities, (4) heavy existing workload, (5) inadequate or irregular remuneration, (6) inadequate or irregular supervision.

CONCLUSION

To improve immunization coverage in underimmunized and zero-dose communities, countries where CHWs vaccinate should provide CHWs with adequate remuneration, supervision, supply chain support and management, and formal integration within the health system. CHWs administered vaccines in 20 of the 75 countries with documented CHW programs, suggesting the majority of an estimated 3.3 million CHWs globally do not yet administer vaccines. In light of health care workforce shortages and immunization equity gaps, further exacerbated by the COVID-19 pandemic, policymakers should consider task-shifting vaccine administration to CHWs to bolster immunization access for under-reached communities. Additional systematic documentation is needed to further explore best practices to support CHWs as vaccinators, especially related to supply chain, policy, safety, and efficacy.

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

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

Provision of injectable contraceptives by community health workers in sub-Saharan Africa: a systematic review of safety, acceptability and effectiveness

BACKGROUND

Injectable contraceptives are the most popular method of contraception in sub-Saharan Africa (SSA), but their availability in clinical settings has been severely limited, despite the scarcity of health care providers and limited access to health facilities. WHO and USAID have endorsed the community-based distribution of injectable contraceptives as a promising option for improving access to family planning services and expanding the method mix for women who want to limit the number of births. Studies have shown that community health workers (CHWs) can provide women with injectable contraceptives that meet acceptable quality standards. The goal of this study is to identify, evaluate and synthesize evidence supporting the use of community-based administration of injectable contraceptives in SSA.

METHODS

This review's guidance was based on a previously developed protocol. Nine international electronic databases and the websites of organizations known to support community-based reproductive health initiatives in SSA were searched systemically. Experts in this area were also contacted for the identification of unpublished literature and ongoing studies. The reference lists of eligible studies were reviewed. The Effective Public Practice Project tool was used to assess the quality and risk of bias in eligible studies. Data were extracted and analysed using a custom data extraction form and a narrative synthesis.

RESULTS

The search strategy identified a total of 1358 studies with 12 studies meeting the inclusion criteria. One unpublished study was provided by an expert making a total of 13 studies. The results showed that irrespective of the study designs, well-trained CHWs can competently administer injectable contraceptives safely and community-based delivery of injectable contraceptives is acceptable in SSA. Also, the use of community health workers in the provision of depot-medroxyprogesterone acetate expanded access to inhabitants of hard-to-reach areas and led to an overall uptake of injectable contraceptives as well as family planning. Studies that compared CHWs to clinic-based providers revealed equivalent or higher levels of performance in favour of CHWs.

CONCLUSIONS

The CHWs can competently provide injectable contraceptives within SSA communities if appropriately trained and supervised. Hence, SSA policymakers should give this initiative due consideration as a way of improving access to family planning services.

Knowledge, attitudes and practices of community treatment supporters administering multidrug-resistant tuberculosis injections: A cross-sectional study in rural Eswatini

Background

This study assessed knowledge, attitudes and practices (KAP) of lay community treatment supporters (CTSs) delegated with directly observed treatment (DOT) supervision and administration of intramuscular multidrug-resistant tuberculosis (MDR-TB) injections in the Shiselweni region in Eswatini.

Methodology

A cross-sectional survey among a purposive sample of 82 CTSs providing DOT and administering injections to MDR-TB patients was conducted in May 2017. Observations in the patients’ homes were undertaken to verify CTSs’ self-reported community-based MDR-TB management practices.

Results

Out of 82 respondents, 78 (95.1%) were female and half (n = 41; 50.0%) had primary education or lower. Over one-tenth (n = 12; 14.6%) had not attended a MDR-TB training workshop, but were administering injections. The overall KAP scores were satisfactory. Good self-reported community-based MDR-TB practices were largely verified through observation. However, substantial proportions of respondents incorrectly defined MDR-TB, were unaware of the treatment regimen, stigmatised patients, and underreported needlestick injuries. There was no statistically significant association between duration administering intramuscular injections, MDR-TB training, knowledge and attitudes, and good community-based MDR-TB management practices.

Conclusions

The gaps in the current KAP of CTSs in this setting raise questions about the timing, adequacy, design and content of community-based MDR-TB management training. Nonetheless, with appropriate training, lay CTSs in this region can be an option to complement an overstretched professional health workforce in providing DOT and MDR-TB injections at community level.

US foreign aid restrictions and maternal and children's health: Evidence from the "Mexico City Policy"

Although family planning services are crucial for global health and achievement of the Sustainable Development Goals, their funding remains controversial. We document the health consequences of the “Mexico City Policy” (MCP), which restricts US funding for abortion-related activities worldwide. Since its enactment in 1985, the MCP has been enforced only under Republican administrations and quickly rescinded when a Democrat wins the presidency. Our analysis shows that the MCP makes it harder for women to get information on and support for reproductive health and is associated with higher maternal and child mortality rates and HIV rates worldwide. We estimate that reinstating the MCP between 2017 and 2021 resulted in approximately 108,000 maternal and child deaths and 360,000 new HIV infections.

This paper analyzes the link between foreign aid for family planning services and a broad set of health outcomes. More specifically, it documents the harmful effects of the so-called “Mexico City Policy” (MCP), which restricts US funding for nongovernmental organizations that provide abortion-related services abroad. First enacted in 1985, the MCP is implemented along partisan lines; it is enforced only when a Republican administration is in office and quickly rescinded when a Democrat wins the presidency. Although previous research has shown that MCP causes significant disruption to family planning programs worldwide, its consequences for health outcomes, such as mortality and HIV rates, remain underexplored. The independence of the MCP’s implementation from the situation in recipient countries allows us to systematically study its impact. Using country-level data from 134 countries between 1990 and 2015, we first show that the MCP is associated with higher maternal and child mortality and HIV incidence rates. These effects are magnified by dependence on US aid while mitigated by funds from non-US donors. Next, we complement these results using individual-level data from 30 low- and middle-income countries and show that, under the MCP, women have less access to modern contraception and are less exposed to information on family planning and AIDS via in-person channels. Moreover, pregnant women are more likely to report that their pregnancy is not desired. Our findings highlight the importance of mitigating the harmful effects of MCP by redesigning or counteracting this policy.

Fear of infertility limits contraceptive usage among first-time mothers in Ghana: A cross-sectional study

OBJECTIVES

This study aimed to determine postpartum modern contraceptive use among first-time young mothers attending child welfare clinics in the Eastern Region of Ghana and explore factors that influence family planning uptake after the first delivery, including fear of infertility.

METHODS

This facility-based, cross-sectional study used interviewer-administered structured questionnaires. The study recruited 422 first-time young mothers aged 15-24 years, with 6- to 18-month-old babies attending child welfare clinics.

RESULTS

Overall, less than half (44%) of first-time mothers used modern contraceptives within 18 months after delivery. Fear of infertility after contraceptive use (56%) is the main barrier reported as the reason for women's non-use of modern contraceptives. Mothers with tertiary education have higher odds of using postpartum contraceptives (adjusted odds ratio =1.6, 95% confidence interval: 0.4-2.0). Compared to mothers with younger children, those with children older than 6 months have higher odds of postpartum contraceptive use (adjusted odds ratio = 1.3, 95% confidence interval: 0.3-1.7). Nonspousal communication (adjusted odds ratio = 0.1, 95% confidence interval: 0.1-0.3) as compared to communication among partners about contraception and those in formal employment (adjusted odds ratio = 0.3, 95% confidence interval: 0.1-0.7), were less likely to use postpartum contraceptives.

CONCLUSION

Considering that there is low postpartum contraceptive utilization, mostly due to concerns about fear of infertility after use, it is paramount to intensify education on actual side effects and reformulate policies that address specific concerns of infertility among mothers and contraceptive use.

Task Sharing of Injectable Contraception Services in Pakistan: A Randomized Controlled Trial

Provision of injectable contraceptive services by lay health workers is endorsed by normative bodies, but support for this practice is not universal. We assessed whether lay providers (lady health workers, LHWs) could perform as well as clinically trained providers (family welfare workers, FWWs) on appropriate screening, counseling, and injection of intramuscular and subcutaneous depot medroxyprogesterone acetate (DMPA) using a randomized controlled trial. In the urban sample (n = 355), 88 percent of FWW DMPA clients were appropriately screened versus 77 percent of LHW clients (noninferiority test p = 0.88). In rural facilities (n = 105), over 90 percent of both providers' clients were screened appropriately. Appropriate counseling was low overall, but LHWs were significantly noninferior to FWWs (p = 0.003). Notably, LHWs demonstrated better injection technique than FWWs. We could not conclude that LHWs screened new DMPA users as well as FWWs from an urban sample of providers but results from the rural sample suggests that service delivery context played an important role.

Patient satisfaction with directly observed treatment and multidrug-resistant tuberculosis injection administration by lay health workers in rural Eswatini

Background

The human resources for health crisis in rural Eswatini led to a novel community-based multidrug-resistant tuberculosis (MDR-TB) treatment strategy based on task-shifting, that is delegation of directly observed treatment (DOT) and administration of MDR-TB injections, traditionally restricted to professional nurses, to lay community treatment supporters (CTSs).

Aim

This study assessed the level of patient satisfaction with receiving community-based MDR-TB care from a CTS.

Setting

The study was conducted at three MDR-TB-treating facilities in the mostly rural Shiselweni region.

Methods

A cross-sectional survey of a purposive sample of 78 patients receiving DOT and intramuscular MDR-TB injections from CTSs was carried out in 2017. Descriptive statistics and regressions were calculated.

Results

A high overall general patient satisfaction score for receiving community-based MDR-TB care from a CTS was observed. Adherence counselling, confidentiality, provider selection and treatment costs significantly (p < 0.05) influenced satisfaction. A large majority (n = 62; 79.5%) of patients indicated that they would likely recommend their significant others to receive MDR-TB care from a CTS. Respondents identified the need to provide CTSs with adequate training, regular supervision and sufficient incentives and also to broaden the scope of their services.

Conclusion

This study observed that task-shifting of DOT and MDR-TB injection administration to CTSs was supported from a patient perspective. However, adherence counselling, confidentiality, provider selection and treatment costs should be taken into account in community-based MDR-TB care programming. Further to the patients, community-based tuberculosis care could be enhanced by improving CTSs’ training, supervision and incentives, and broadening the scope of their services.

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

Background

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

Methods

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

Findings

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

Conclusions

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

Evaluation of a pilot program for task sharing short and long-acting contraceptive methods in Burkina Faso

Background: The Family Health Directorate of the Ministry of Health  and Marie Stopes Burkina Faso, with implementing partners, Association Burkinabè pour le Bien-être Familial  and Equilibres & Populations  collaboratively conducted a pilot project in Burkina Faso focused on “increasing access to family planning (FP) services through task-sharing short- and long-acting family planning methods to primary care cadres.” Four cadres of providers  provided intrauterine devices (IUDs) and implants, while community health workers (CHWs)  provided pills and subcutaneous injectables. FHI 360 and the Institut Supérieur des Sciences de la Population  evaluated the project’s impact on method uptake, client satisfaction, safety, acceptability and the feasibility of task sharing.

Methods: The evaluation employed FP service statistics on new users and conducted 425 client exit interviews  and 27 in-depth interviews . New FP clients, community representatives, MoH officials, and pilot project-trained FP providers from Dandé and Tougan districts participated in these interviews.

Results: Providers, community representatives and government officials all spoke favorably of the pilot project and considered it a boon to women and the communities in which they lived. FP clients were satisfied with their methods and the services they received from their respective providers, and they reported no safety concerns. However, service statistics did not show a clear and steady increase in method uptake for the four methods beyond spikes coinciding with pre-existing free contraceptive weeks.

Conclusions:  A scale-up plan for 2020-2022 is in place and will purposefully implement sensitization and demand generation activities to improve FP uptake beyond free contraceptive weeks.

A process evaluation of the Communication for Healthy Communities adolescent health program in Uganda

This study is a process evaluation of an adolescent-focused intervention of the USAID Communication for Healthy Communities program, in Uganda. We used mixed methods including observation, consultations and review of program documents to collect data on program coverage, reach and factors influencing implementation. Findings show that program activities were successfully implemented through collaborative partnerships with service partners and the community. Interpersonal communication complemented by mass-media messaging was effective in reaching and empowering adolescents with health information to make informed choices for behavior change. The program used theoretical frameworks to guide targeted interventions through audience segmentation and community empowerment. Targeted mass-media messaging and placement was found to be pertinent for program reach. Working through existing community structures is important for an effective reach of health promotion programs. Lessons identified for scaling-up adolescent health programs include the need to harmonize training and deployment of community champions by development partners, recruit audience-specific influential champions and link income-generating activities to health education interventions. There is thus need to collaboratively develop and institutionalize effective monitoring and evaluation strategies during program inception and design phases for appropriate accountability, ownership and a continuation of gains.

Development assistance for community health workers in 114 low- and middle-income countries, 2007-2017

OBJECTIVE

To estimate the level and trend of development assistance for community health worker-related projects in low- and middle-income countries between 2007 and 2017.

METHODS

We extracted data from the Organisation for Economic Co-operation and Development's creditor reporting system on aid funding for projects to support community health workers (CHWs) in 114 countries over 2007-2017. We produced estimates for projects specifically described by relevant keywords and for projects which could include components on CHWs. We analysed the pattern of development assistance by purpose, donors, recipient regions and countries, and trends over time.

FINDINGS

Between 2007 and 2017, total development assistance targeting CHW projects was around United States dollars (US$) 5 298.02 million, accounting for 2.5% of the US$ 209 277.99 million total development assistance for health. The top three donors (Global Fund to Fight AIDS, Tuberculosis and Malaria, the government of Canada and the government of the United States of America) provided a total of US$ 4 350.08 million (82.1%) of development assistance for these projects. Sub-Saharan Africa received a total US$ 3 717.93 million, the largest per capita assistance over 11 years (US$ 0.39; total population: 9 426.25 million). Development assistance to projects that focused on infectious diseases and child and maternal health received most funds during the study period.

CONCLUSION

The share of development assistance invested in the CHW projects was small, unstable and decreasing in recent years. More research is needed on tracking government investments in CHW-related projects and assessing the impact of investments on programme effectiveness.

Innovation diffusion: how homogenous networks influence the uptake of community-based injectable contraceptives

Background

Studies have shown that social networks influence health behaviors, including the adoption of health innovations. This study explored the potential for early adopters of community health worker-delivered injectable contraceptives (CHWDIC) to influence the uptake of this innovation by women in their social networks.

Methods

This Social Network Analysis (SNA) study was conducted in Gombe, Nigeria. Twenty women who were early adopters of the CHWDIC were recruited. Each participant (ego) listed ten women of reproductive age (alters) with whom they related. An interviewer-administered questionnaire was used to collect from each ego, data about the nature of her relationship with each alter (ego-alter relationship), whether she talked about CHWDIC with each alter, and whether her listed alters talked to each other about CHWDIC (alter-alter relationship). Data were also collected on age, marital status and education level for each ego and alter. Data were analyzed with UCINET social network analysis software. Variables of interest include homophilia (similarity), density (number of ties as a proportion of possible ties), degree (popularity) and betweeness (frequency of connecting actor pairs who otherwise might not communicate).

Results

There were 20 egos and 200 alters. Between two thirds (alters) and three quarters (egos) of the women were 30 years or older. All of the egos and 196 (98%) of alters were married. Most of the networks had similar (homophilic) actors according to certain sociodemographic characteristics - ethnicity, age, education and type of marriage. More than 90% of the networks had density greater than 50%, suggesting high cohesion in most networks. The majority of actors in these networks used injectable contraceptives. In some of the networks, few actors with the highest prominence (betweeness centrality) were not users of injectable contraceptives.

Conclusion

The study illustrates the application and feasibility of ego SNA in identifying champions and opinion leaders among women of reproductive age group. It also shows the influence of social networks on the diffusion of community-based injectable contraceptives, and how homophilic and dense networks may have positive health externality. The interrelatedness of network members’ decision to adopt a health innovation was also demonstrated by the findings of this study.

A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda

Background: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention.

Methods: We collected data from two program districts: Busia (learning site) and Oyam (scale-up). We used a descriptive mixed-methods process evaluation design: desk review of program documents, program monitoring data and in-depth interviews and focus group discussions.

Results: The quality improvement (QI) process strengthened linkages between health services provided in communities and health centers. Routine interaction of VHTs, clients and midwives generated improvement ideas. Participants reported increased learning through midwife mentorship of VHTs, supportive supervision, monthly meetings, data interpretation and learning sessions. Three areas for potential sustainability and institutionalization of the QI efforts were identified: the integration of QI into other services, district-level plans and support for the QIC and motivation of QI teams. Challenges in the replication of this model include the community-level capacity for data recording and interpretation, the need to simplify QI terminology and tools for VHTs and travel reimbursements for meetings. We found positive trends in the number of women on an FP method, the number of returning clients and the number of couples counseled.

Conclusions: A QIC can be a positive approach to improve VHT service delivery. Working with VHTs on QI presents specific challenges compared to working at the facility level. To strengthen the implementation of this CBFP QIC and other community-based QICs, we provide program-relevant recommendations.

The effects of community-based distribution of family planning services on contraceptive use: The case of a national scale-up in Malawi

RATIONALE

Although many sub-Saharan African countries have scaled-up pilot projects of community-based distribution (CBD) of family planning services, the effects of the scaled-up CBDs on contraceptive use remain unclear.

OBJECTIVE

We leveraged a national scale-up of Malawi's Learning and Innovation Population and Family Planning pilot to evaluate the effects of a scale-up of CBDs on contraceptive use. We also investigated whether education and income, two important determinants of contraceptive use behaviors, moderate the effects of the scaled-up CBDs.

METHOD

We used the 2000/2004 and 2010/2016 Malawi Demographic and Health Surveys (N = 57,978) and difference-in-differences analyses to estimate the effects of the 2005 national scale-up of CBDs on modern contraceptive use. We used rural and urban communities as the intervention and comparison groups because the national CBDs were implemented only in rural communities. Contraceptive use is defined as the current use of any modern contraceptive method (e.g., pills) and was modelled using multilevel logistic regression.

RESULTS

Prior to the implementation of the national scale CBDs (2000/2004), the probability of using contraceptives was 21.5% in rural communities and 26.3% in urban communities. After the scale-up (2010/2016), the probability of using contraceptives increased in both rural and urban communities but was greater in rural communities (44.9% vs. 42.9%). The effect attributable to the national scale CBDs was 6.8 percentage points (95% CI [3.3, 9.7]). The effects of the national CBDs were greater among uneducated and low-income women.

CONCLUSIONS

These findings suggest that national CBDs increase overall contraceptive use, particularly in rural communities, and that poor and uneducated women benefit more from family planning interventions that reduce communication and financial barriers.

Accessing DMPA-SC through the public and private sectors in Nigeria: users’ characteristics and their experiences

Background: Beginning in 2015, subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was added to the contraceptive method mix in Nigeria, primarily through social marketing in the private sector and community-based distribution in the public sector. We compare user experiences in acquiring DMPA-SC across sectors during this national scale-up. Methods: From October 2017 to February 2018, 459 women (Npublic=235; Nprivate=224) completed a phone survey from a convenience sample of 1,444 women (Npublic=912; Nprivate=532) who obtained DMPA-SC from participating providers and agreed to be contacted. We examined the sociodemographic predictors of attending a public vs. private provider and analyzed differences in care-seeking across sectors (becoming aware of DMPA-SC, choosing a provider, choosing DMPA-SC, quality of care). Results: Respondents obtaining DMPA-SC from public providers were younger and less educated than those attending private providers. Both program respondents were comprised of similar percentages of new users of modern contraception (58.7-60.3%), although most respondents became aware of DMPA-SC through a friend/family member (43.1%) or a provider (41.5%). Relatively more public sector respondents also heard about DMPA-SC through community outreaches whereas relatively more private sector respondents became aware through media. Convenience was the most common reason for choosing a provider—43.8% among all respondents (higher among public sector respondents). Private sector respondents were also more likely to choose a past or usual provider. Having overall higher quality interactions were more likely among clients who attended private providers than public providers, but responses to individual quality item measures show specific areas of poor quality for providers in each sector. Conclusions: Training emphasizing technical thoroughness, sensitivity toward younger women, and client choice may help improve women’s experiences with obtaining DMPA-SC, ultimately contributing to accelerating demand for and uptake of DMPA-SC specifically and contraception in general.

Evaluation of a pilot program for task sharing short and long-acting contraceptive methods in Burkina Faso

Background: The Family Health Directorate of the Ministry of Health (MoH/FHD) and Marie Stopes Burkina Faso (MS BF), with implementing partners, Association Burkinabé pour le Bien-être Familial (ABBEF) and Equilibres & Populations (Equipop) collaborated to conduct a pilot project in Burkina Faso focused on “increasing access to family planning (FP) services through task-sharing short- and long-acting family planning methods to primary care cadres.” Four cadres of providers were trained to provide intrauterine devices (IUDs) and implants, while community health workers (CHWs) were trained to provide pills and subcutaneous injectables. FHI 360 and the Institut Supérieur des Sciences de la Population (ISSP) evaluated the project’s impact on method uptake, client satisfaction, safety, acceptability and the feasibility of task sharing. Methods: The evaluation employed service statistics, client exit interviews (quantitative) and in-depth interviews (qualitative). New FP clients, community representatives, MoH officials, and pilot project-trained FP providers from Dandé and Tougan districts participated in these interviews. Results: Providers, community representatives and government officials all spoke favorably of the pilot project and considered it a boon to women and the communities in which they lived. FP clients were satisfied with their methods and the services they received from their respective providers, and they reported no safety concerns. However, service statistics did not show a clear and steady increase in method uptake for the four methods beyond spikes coinciding with pre-existing free contraceptive weeks. Conclusions: Results of the evaluation were largely positive. These evaluation findings are being used to guide decisions about scale-up.

A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda

Background: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention.Methods:We collected data from two program districts: Busia (learning site) and Oyam (scale-up). We used a descriptive mixed-methods process evaluation design: desk review of program documents, program monitoring data and in-depth interviews and focus group discussions.Results:The quality improvement (QI) process strengthened linkages between health services provided in communities and health centers. Routine interaction of VHTs, clients and midwives generated improvement ideas. Participants reported increased learning through midwife mentorship of VHTs, supportive supervision, monthly meetings, data interpretation and learning sessions. Three areas for potential sustainability and institutionalization of the QI efforts were identified: the integration of QI into other services, district-level plans and support for the QIC and motivation of QI teams. Challenges in the replication of this model include the community-level capacity for data recording and interpretation, the need to simplify QI terminology and tools for VHTs and travel reimbursements for meetings. We found positive trends in the number of women on an FP method, the number of returning clients and the number of couples counseled.Conclusions:A QIC can be a positive approach to improve VHT service delivery. Working with VHTs on QI presents specific challenges compared to working at the facility level. To strengthen the implementation of this CBFP QIC and other community-based QICs, we provide program-relevant recommendations.

Accessing DMPA-SC through the public and private sectors in Nigeria: users’ characteristics and their experiences

Background: Beginning in 2015, subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was added to the contraceptive method mix in Nigeria, primarily through social marketing in the private sector and community-based distribution in the public sector. We compare user experiences in acquiring DMPA-SC across sectors during this national scale-up. Methods: From October 2017 to February 2018, 459 women (Npublic=235; Nprivate=224) completed a phone survey from a convenience sample of 1,444 women (Npublic=912; Nprivate=532) who obtained DMPA-SC from participating providers and agreed to be contacted. We examined the sociodemographic predictors of attending a public vs. private provider and analyzed differences in care-seeking across sectors (becoming aware of DMPA-SC, choosing a provider, choosing DMPA-SC, quality of care). Results: Respondents obtaining DMPA-SC from public providers were younger and less educated than those attending private providers. Both program respondents were comprised of similar percentages of new users of modern contraception (58.7-60.3%), although most respondents became aware of DMPA-SC through a friend/family member (43.1%) or a provider (41.5%). Relatively more public sector respondents also heard about DMPA-SC through community outreaches whereas relatively more private sector respondents became aware through media. Convenience was the most common reason for choosing a provider—43.8% among all respondents (higher among public sector respondents). Private sector respondents were also more likely to choose a past or usual provider. Having overall higher quality interactions were more likely among clients who attended private providers than public providers, but responses to individual quality item measures show specific areas of poor quality for providers in each sector. Conclusions: Training emphasizing technical thoroughness, sensitivity toward younger women, and client choice may help improve women’s experiences with obtaining DMPA-SC, ultimately contributing to accelerating demand for and uptake of DMPA-SC specifically and contraception in general.

"Family planning in Rwanda is not seen as population control, but rather as a way to empower the people": examining Rwanda's success in family planning from the perspective of public and private stakeholders

Background

Rwanda has made significant strides in improving the health of its people, including increasing access to and use of family planning. Contraceptive use has increased from 17% to 53% in just one decade, from 2005 to 2015.

Methods

The data consist of 13 in-depth interviews conducted with family planning program experts in Rwanda to better understand the mechanisms for success, elucidate remaining challenges, speculate on the future of the program, and discuss potential applicability for translating aspects of the program in other settings.

Results

All respondents first noted the positive aspects of government will, leadership, and management of the family planning program when asked to describe the reasons for success. The challenges that loomed the largest for the program were service accessibility for rural Rwandans, adolescent access to and use of contraceptives, opposition from religious institutions, as well as inadequate human resources and funding. These challenges were openly acknowledged and are in the process of being addressed.

Conclusion

The importance of government leadership and focus in the success of Rwanda’s family planning program was prominent. All positive aspects of the program are based upon the strong foundation the government has built and nurtured. Since innovation is welcomed and program evaluation is considered essential, the outlook for Rwanda’s family planning program is favorable. The issues that remain are common and persistent challenges for family planning programs. Other nations could learn tangible practices from Rwanda’s success and follow Rwanda’s efforts to mitigate the remaining challenges.

Acceptability of the distribution of DMPA-SC by community health workers among acceptors in the rural province of Lualaba in the Democratic Republic of the Congo: a pilot study

OBJECTIVES

The objective of this research is to assess the acceptability of the provision of subcutaneously administered depo medroxyprogesterone acetate (DMPA-SC) by nonclinically trained community health workers (CHWs) among acceptors in the rural province of Lualaba in the Democratic Republic of the Congo (DRC).

STUDY DESIGN

In 2017, 34 CHWs received training in provision of DMPA-SC. Among other methods, DMPA-SC by CHWs was offered during household visits and at community outreach events. The initial survey included questions on acceptors' demographic characteristics, contraceptive use history and experience with provision of DMPA-SC by a CHW. The follow-up included questions about side effects experienced and continuation of DMPA-SC by a CHW.

RESULTS

Seventy-four percent of initial acceptors of DMPA-SC (N=252) were first-time contraception users. Almost all (96.0%) felt very comfortable with a CHW performing the injection rather than a physician or nurse, and 97.6% perceived that the CHW was very comfortable performing the injection. A total of 239 women were interviewed at follow-up. Most expressed satisfaction with the method despite some side effects experienced. Almost all acceptors (97.9%) were satisfied with the information provided by CHWs, and 93.8% were satisfied with the overall service. Most (96.4%) would choose to continue receiving DMPA-SC by a CHW rather than in a health clinic, and 95.2% would recommend DMPA-SC by a CHW to a friend.

CONCLUSIONS

Overall, administration of DMPA-SC by CHWs is acceptable to users in Lualaba. DMPA-SC can be safely provided within the community after proper training.

IMPLICATIONS

This study validates the use of CHWs (without clinical training) to provide DMPA-SC in a rural sub-Saharan African setting. It also represents an important step in obtaining official MOH authorization for the scale-up of this mechanism of distribution to other underserved regions in the DRC.

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

OBJECTIVE

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

METHODS

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

FINDINGS

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

CONCLUSION

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

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

Background

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

Methods

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

Findings

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

Conclusions

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

Delivery arrangements for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions.

AUTHORS' CONCLUSIONS

A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.

The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014

BACKGROUND

There has been a substantial increase in publications and interest in community health workers (CHWs) in low- and middle-income countries (LMIC) over the last years. This paper examines the growth, geographical distribution and programmatic orientations of the indexed literature on CHWs in LMIC over a 10-year period.

METHODS

A scoping review of publications on CHWs from 2005 to 2014 was conducted. Using an inclusive list of terms, we searched seven databases (including MEDLINE, CINAHL, Cochrane) for all English-language publications on CHWs in LMIC. Two authors independently screened titles/abstracts, downloading full-text publications meeting inclusion criteria. These were coded in an Excel spreadsheet by year, type of publication (e.g. review, empirical), country, region, programmatic orientation (e.g. maternal-child health, HIV/AIDS, comprehensive) and CHW roles (e.g. prevention, treatment) and further analysed in Stata14. Drawing principally on the subset of review articles, specific roles within programme areas were identified and grouped.

FINDINGS

Six hundred seventy-eight publications from 46 countries on CHWs were inventoried over the 10-year period. There was a sevenfold increase in annual number of publications from 23 in 2005 to 156 in 2014. Half the publications were reporting on initiatives in Africa, a third from Asia and 11 % from the Americas (mostly Brazil). The largest single focus and driver of the growth in publications was on CHW roles in meeting the Millennium Development Goals of maternal, child and neonatal survival (35 % of total), followed by HIV/AIDS (16 %), reproductive health (6 %), non-communicable diseases (4 %) and mental health (4 %). Only 17 % of the publications approached CHW roles in an integrated fashion. There were also distinct regional (and sometimes country) profiles, reflecting different histories and programme traditions.

CONCLUSIONS

The growth in literature on CHWs provides empirical evidence of ever-increasing expectations for addressing health burdens through community-based action. This literature has a strong disease- or programme-specific orientation, raising important questions for the design and sustainable delivery of integrated national programmes.

Community health worker knowledge and management of pre-eclampsia in southern Mozambique

Background

Mozambique has drastically improved an array of health indicators in recent years, including maternal mortality rates which decreased 63 % from 1990–2013 but the rates still high. Pre-eclampsia and eclampsia constitute the third major cause of maternal death in the country. Women in rural areas, with limited access to health facilities are at greatest risk. This study aimed to assess the current state of knowledge and the regular practices regarding pre-eclampsia and eclampsia by community health workers in southern Mozambique.

Methods

This mixed methods study was conducted from 2013 to 2014, in Maputo and Gaza Provinces, southern Mozambique. Self-administered questionnaires, in-depth interviews and focus group discussions were conducted with CHWs, district medical officers, community health workers’ supervisors, Gynaecologists-Obstetricians and matrons. Quantitative data were entered into a database written in REDCap and subsequently analyzed using Stata 13. Qualitative data was imported into NVivo10 for thematic analysis.

Results

Ninety-three percent of CHW had some awareness of pregnancy complications. Forty-one percent were able to describe the signs and symptoms of hypertension. In cases of eclampsia, CHWs reported to immediately refer the women. The vast majority of the CHWs surveyed reported that they could neither measure blood pressure nor proteinuria (90 %). Fewer reported confidence in providing oral antihypertensives (14 %) or injections in pregnancy (5 %). The other community health care providers are matrons. They do not formally offer health services, but assists pregnant women in case of an emergency. Regarding pre-eclampsia and eclampsia, matrons were unable to recognise these biomedical terms.

Conclusions

Although CHWs are aware of pregnancy complications, they hold limited knowledge specific to pre-eclampsia and eclampsia. There is a need to promote studies to evaluate the impact of enhancing their training to include additional content related to the identification and management of pre-eclampsia and eclampsia.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-016-0220-2) contains supplementary material, which is available to authorized users.

Safety and Acceptability of Community-Based Distribution of Injectable Contraceptives: A Pilot Project in Mozambique

Trained community health workers, including traditional birth attendants (TBAs), safely and effectively administered injectables in northern Mozambique; two-thirds of the women choosing injectables had never used contraception before. Including TBAs in the Ministry of Health’s recent task sharing strategy can improve rural women’s access to injectables and help meet women’s demand for contraception.

Mozambique has witnessed a climbing total fertility rate in the last 20 years. Nearly one-third of married women have an unmet need for family planning, but the supply of family planning services is not meeting the demand. This study aimed to explore the safety and effectiveness of training 2 cadres of community health workers—traditional birth attendants (TBAs) and agentes polivalentes elementares (APEs) (polyvalent elementary health workers)—to administer the injectable contraceptive depot-medroxyprogesterone acetate (DMPA), and to provide evidence to policy makers on the feasibility of expanding community-based distribution of DMPA in areas where TBAs and APEs are present. A total of 1,432 women enrolled in the study between February 2014 and April 2015. The majority (63% to 66%) of women in the study started using contraception for the first time during the study period, and most women (over 66%) did not report side effects at the 3-month and 6-month follow-up visits. Very few (less than 0.5%) experienced morbidities at the injection site on the arm. Satisfaction with the performance of TBAs and APEs was high and improved over the study period. Overall, the project showed a high continuation rate (81.1%) after 3 injections, with TBA clients having significantly higher continuation rates than APE clients after 3 months and after 6 months. Clients’ reported willingness to pay for DMPA (64%) highlights the latent demand for modern contraceptives. Given Mozambique’s largely rural population and critical health care workforce shortage, community-based provision of family planning in general and of injectable contraceptives in particular, which has been shown to be safe, effective, and acceptable, is of crucial importance. This study demonstrates that community-based distribution of injectable contraceptives can provide access to family planning to a large group of women that previously had little or no access.

An evaluation of a family planning mobile job aid for community health workers in Tanzania

OBJECTIVES

The global rapid growth in mobile technology provides unique opportunities to support community health workers (CHWs) in providing family planning (FP) services. FHI 360, Pathfinder International and D-tree International developed an evidence-based mobile job aid to support CHW counseling, screening, service provision and referrals, with mobile forms for client and service data, and text-message reporting and reminders. The purpose of this study is to evaluate the acceptability and potential benefits to service quality from the perspective of CHWs and their clients.

STUDY DESIGN

The mobile job aid was piloted in Dar es Salaam, Tanzania. Data collection tools included a demographic survey of all 25 CHWs trained to use the mobile job aid, in-depth interviews with 20 of the CHWs after 3 months and a survey of 176 clients who received FP services from a CHW using the mobile job aid after 6 months.

RESULTS

Both CHWs and their clients reported that the mobile job aid was a highly acceptable FP support tool. CHWs perceived benefits to service quality, including timelier and more convenient care; better quality of information; increased method choice; and improved privacy, confidentiality and trust with clients. Most clients discussed multiple FP methods with CHWs; only 1 in 10 clients reported discussion of all 9 methods.

CONCLUSIONS

This research suggests that mobile phones can be effective tools to support CHWs with FP counseling, screening and referrals, data collection and reporting, and communication. Challenges remain to support informed contraceptive choice. Future research should focus on implementation, including scale-up and sustainability.

IMPLICATIONS

Mobile job aids can uniquely enhance FP service provision at the community level through adherence to standard protocols, real-time feedback and technical assistance, and provision of confidential care. This study can inform future efforts to support and expand the role of CHWs in increasing FP access and informed contraceptive choice.

Medroxyprogesterone acetate levels among Kenyan women using depot medroxyprogesterone acetate in the FEM-PrEP trial

Objective

To describe medroxyprogesterone acetate (MPA) levels among Kenyan depot medroxyprogesterone acetate (DMPA) users in the FEM-PrEP HIV prevention trial, and to compare MPA levels between ARV for HIV prevention (treatment) and placebo groups.

Study Design

We measured MPA in previously collected plasma samples from 63 Kenyan trial participants who used DMPA for one or two complete intervals. We separately assessed MPA levels among the nine DMPA users who became pregnant at this site.

Results

Mean MPA levels at the end of each 12 week injection interval were 0.37 ng/ml (95% CI: 0.25, 1.99) and 0.28 ng/ml (95% CI: 0.19, 1.22) among participants assigned TDF/FTC and 0.49 (95% CI: 0.40, 1.27) and 0.39 (95% CI: 0.31, 1.17) among those assigned placebo. The difference between groups was not statistically significant overall, or in an analysis which adjusted for the observed low adherence to TDF/FTC. Unanticipated findings of this analysis were low 12-week MPA levels among DMPA users in both study arms. Of 61 women who contributed data for the first DMPA injection interval, 26.2% had MPA levels < 0.1 ng/ml and 9.8% had levels below the detection level (0.02 ng/ml) at 12 weeks post-injection. Levels were similar at the end of the second injection interval. Five of nine women who became pregnant had levels below 0.15 ng/mL at the time of their last negative pregnancy test.

Conclusions

Use of TDF/FTC did not appear to affect serum MPA levels, however we found lower than expected MPA concentrations at the end of the dosing interval among DMPA users in the FEM-PrEP trial, the cause of which are unknown.

Implications

This study presents some of the few available data on MPA levels among DMPA users in Africa. The low levels among users described here, together with a number of pregnancies among DMPA users, are potentially concerning and require further investigation.

Implementation Research for the Prevention of Mother-to-Child HIV Transmission in Sub-Saharan Africa: Existing Evidence, Current Gaps, and New Opportunities

Tremendous gains have been made in the prevention of mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa. Ambitious goals for the "virtual elimination" of pediatric HIV appear increasingly feasible, driven by new scientific advances, forward-thinking health policy, and substantial donor investment. To fulfill this promise, however, rapid and effective implementation of evidence-based practices must be brought to scale across a diversity of settings. The discipline of implementation research can facilitate this translation from policy into practice; however, to date, its core principles and frameworks have been inconsistently applied in the field. We reviewed the recent developments in implementation research across each of the four "prongs" of a comprehensive PMTCT approach. While significant progress continues to be made, a greater emphasis on context, fidelity, and scalability-in the design and dissemination of study results-would greatly enhance current efforts and provide the necessary foundation for future evidence-based programs.

Cost of providing injectable contraceptives through a community-based social marketing program in Tigray, Ethiopia

OBJECTIVE

To provide a cost analysis of an injectable contraceptive program combining community-based distribution and social marketing in Tigray, Ethiopia.

METHODS

We conducted a cost analysis, modeling the costs and programmatic outcomes of the program's initial implementation in 3 districts of Tigray, Ethiopia. Costs were estimated from a review of program expense records, invoices, and interviews with health workers. Programmatic outcomes include number of injections and couple-year of protection (CYP) provided. We performed a sensitivity analysis on the average number of injections provided per month by community health workers (CHWs), the cost of the commodity, and the number of CHWs trained.

RESULTS

The average programmatic CYP was US $17.91 for all districts with a substantial range from US $15.48-38.09 per CYP across districts. Direct service cost was estimated at US $2.96 per CYP. The cost per CYP was slightly sensitive to the commodity cost of the injectable contraceptives and the number of CHWs. The capacity of each CHW, measured by the number of injections sold, was a key input that drove the cost per CYP of this model.

CONCLUSION

With a direct service cost of US $2.96 per CYP, this study demonstrates the potential cost of community-based social marketing programs of injectable contraceptives. The findings suggest that the cost of social marketing of contraceptives in rural communities is comparable to other delivery mechanisms with regards to CYP, but further research is needed to determine the full impact and cost-effectiveness for women and communities beyond what is measured in CYP.

Balancing workload, motivation and job satisfaction in Rwanda: assessing the effect of adding family planning service provision to community health worker duties

Background

Task shifting from higher cadre providers to CHWs has been widely adopted to address healthcare provider shortages, but the addition of any service can potentially add to an already considerable workload for CHWs. Objective measures of workload alone, such as work-related time and travel may not reflect howCHWs actually perceive and react to their circumstances. This study combined perception and objectivemeasures of workload to examine their effect on quality of services, worker performance, and job and clientsatisfaction.

Methods

Three hundred eighty-three CHWs from control and intervention districts, where the intervention group was trained to provide contraceptive resupply, completed diaries of work-related activities for one month. Interviews were also conducted with a subset of CHWs and their clients.

Results

CHW diaries did not reveal significant differences between intervention and control groups in time spent on service provision or travel. Over 90 % of CHWs reported workload manageability, job satisfaction, and motivation to perform their jobs. Clients were highly satisfied with CHW services and most stated preference for future services from CHWs.

Conclusion

The study demonstrated that adding resupply of hormonal contraceptives to CHWs’ tasks would not place undue burden on them. Accordingly, the initiative was scaled up in all 30 districts in the country.

Accuracy of Assessment of Eligibility for Early Medical Abortion by Community Health Workers in Ethiopia, India and South Africa

OBJECTIVE

To assess the accuracy of assessment of eligibility for early medical abortion by community health workers using a simple checklist toolkit.

DESIGN

Diagnostic accuracy study.

SETTING

Ethiopia, India and South Africa.

METHODS

Two hundred seventeen women in Ethiopia, 258 in India and 236 in South Africa were enrolled into the study. A checklist toolkit to determine eligibility for early medical abortion was validated by comparing results of clinician and community health worker assessment of eligibility using the checklist toolkit with the reference standard exam.

RESULTS

Accuracy was over 90% and the negative likelihood ratio <0.1 at all three sites when used by clinician assessors. Positive likelihood ratios were 4.3 in Ethiopia, 5.8 in India and 6.3 in South Africa. When used by community health workers the overall accuracy of the toolkit was 92% in Ethiopia, 80% in India and 77% in South Africa negative likelihood ratios were 0.08 in Ethiopia, 0.25 in India and 0.22 in South Africa and positive likelihood ratios were 5.9 in Ethiopia and 2.0 in India and South Africa.

CONCLUSION

The checklist toolkit, as used by clinicians, was excellent at ruling out participants who were not eligible, and moderately effective at ruling in participants who were eligible for medical abortion. Results were promising when used by community health workers particularly in Ethiopia where they had more prior experience with use of diagnostic aids and longer professional training. The checklist toolkit assessments resulted in some participants being wrongly assessed as eligible for medical abortion which is an area of concern. Further research is needed to streamline the components of the tool, explore optimal duration and content of training for community health workers, and test feasibility and acceptability.

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

This systematic review evaluates the strength of the evidence that community health workers' (CHW) provision of family planning (FP) services in low- and middle-income countries is effective. In a search of eight databases, articles were screened by study design and outcome measure and ranked by strength of evidence. Only randomized trials, longitudinal studies with a comparison group, and pre-test/post-test studies met inclusion criteria. A total of 56 studies were included. Of those studies with relevant data, approximately 93 percent indicated that CHW FP programs effectively increased the use of modern contraception, while 83 percent reported an improvement in knowledge and attitudes concerning contraceptives. Based on these findings, strong evidence exists for promoting CHW programs to improve access to FP services. We recommend a set of best practice guidelines that researchers and program managers can use to report on CHW FP programs to facilitate the translation of research to practice across a wide range of settings.

Behaviour change techniques and contraceptive use in low and middle income countries: a review

We aimed to identify effective behaviour change techniques to increase modern contraceptive use in low and middle income countries (LMICs). Literature was identified in Global Health, Web of Science, MEDLINE, PsycINFO and Popline, as well as peer reviewed journals. Articles were included if they were written in English, had an outcome evaluation of contraceptive use, modern contraceptive use, contraceptive initiation/uptake, contraceptive adherence or continuation of contraception, were a systematic review or randomised controlled trial, and were conducted in a low or middle income country. We assessed the behaviour change techniques used in each intervention and included a new category of male partner involvement. We identified six studies meeting the inclusion criteria. The most effective interventions were those that involve male partner involvement in the decision to initiate contraceptive use. The findings also suggest that providing access to contraceptives in the community promotes their use. The interventions that had positive effects on contraceptive use used a combination of behaviour change techniques. Performance techniques were not used in any of the interventions. The use of social support techniques, which are meant to improve wider social acceptability, did not appear except in two of the interventions. Our findings suggest that when information and contraceptives are provided, contraceptive use improves. Recommendations include reporting of behaviour change studies to include more details of the intervention and techniques employed. There is also a need for further research to understand which techniques are especially effective.

D. Integrating family planning into HIV care in western Kenya: HIV care providers' perspectives and experiences one year following integration

With high rates of unintended pregnancy in sub-Saharan Africa, integration of family planning (FP) into HIV care is being explored as a strategy to reduce unmet need for contraception. Perspectives and experiences of healthcare providers are critical in order to create sustainable models of integrated care. This qualitative study offers insight into how HIV care providers view and experience the benefits and challenges of providing integrated FP/HIV services in Nyanza Province, Kenya. Sixteen individual interviews were conducted among healthcare workers at six public sector HIV care facilities one year after the implementation of integrated FP and HIV services. Data were transcribed and analyzed qualitatively using grounded theory methods and Atlas.ti. Providers reported a number of benefits of integrated services that they believed increased the uptake and continuation of contraceptive methods. They felt that integrated services enabled them to reach a larger number of female and male patients and in a more efficient way for patients compared to non-integrated services. Availability of FP services in the same place as HIV care also eliminated the need for most referrals, which many providers saw as a barrier for patients seeking FP. Providers reported many challenges to providing integrated services, including the lack of space, time, and sufficient staff, inadequate training, and commodity shortages. Despite these challenges, the vast majority of providers was supportive of FP/HIV integration and found integrated services to be beneficial to HIV-infected patients. Providers' concerns relating to staffing, infrastructure, and training need to be addressed in order to create sustainable, cost-effective FP/HIV integrated service models.

Task Shifting Provision of Contraceptive Implants to Community Health Extension Workers: Results of Operations Research in Northern Nigeria

BACKGROUND

Contraceptive use remains low in Nigeria, with only 11% of women reporting use of any modern method. Access to long-acting reversible contraceptives (LARCs) is constrained by a severe shortage of human resources. To assess feasibility of task shifting provision of implants, we trained community health extension workers (CHEWs) to insert and remove contraceptive implants in rural communities of Bauchi and Sokoto states in northern Nigeria.

METHODS

We conducted 2- to 3-week training sessions for 166 selected CHEWs from 82 facilities in Sokoto state (September 2013) and 84 health facilities in Bauchi state (December 2013). To assess feasibility of the task shifting approach, we conducted operations research using a pretest-posttest design using multiple sources of information, including surveys with 151 trained CHEWs (9% were lost to follow-up) and with 150 family planning clients; facility observations using supply checklists (N = 149); direct observation of counseling provided by CHEWs (N = 144) and of their clinical (N = 113) skills; as well as a review of service statistics (N = 151 health facilities). The endline assessment was conducted 6 months after the training in each state.

RESULTS

CHEWs inserted a total of 3,588 implants in 151 health facilities over a period of 6 months, generating 10,088 couple-years of protection (CYP). After practicing on anatomic arm models, most CHEWs achieved competency in implant insertions after insertions with 4-5 actual clients. Clinical observations revealed that CHEWs performed implant insertion tasks correctly 90% of the time or more for nearly all checklist items. The amount of information that CHEWs provided clients increased between baseline and endline, and over 95% of surveyed clients reported being satisfied with CHEWs' services in both surveys. The study found that supervisors not only observed and corrected insertion skills, as needed, during supervisory visits but also encouraged CHEWs to conduct more community mobilization to generate client demand, thereby promoting access to quality services. CHEWs identified a lack of demand in the communities as the major barrier for providing services.

CONCLUSION

With adequate training and supportive supervision, CHEWs in northern Nigeria can provide high-quality implant insertion services. If more CHEWs are trained to provide implants and greater community outreach is conducted to generate demand, uptake of LARCs in Nigeria may increase.

Lessons from a geospatial analysis of depot medroxyprogesterone acetate sales by licensed chemical sellers in Ghana

OBJECTIVES

To map access to depot medroxyprogesterone acetate (DMPA) from licensed chemical sellers (LCS); to estimate the proportion of women of reproductive age in areas with access; and to examine affordability and variability of costs.

METHODS

A geospatial analysis was conducted using data collected from 298 women who purchased DMPA from 49 geocoded LCS shops in the Amansie West and Ejisu-Juabeng districts of Ghana from June 4 to August 31, 2012. The women reported on cost and average distance traveled to purchase DMPA.

RESULTS

In Amansie West, 21.1% of all women of reproductive age lived within average walking distance and 80.4% lived within average driving distance of an LCS. In Ejisu-Juabeng, 41.9% and 60.1% of women lived within average walking and driving distance, respectively. Distribution of affordability varied across each district.

CONCLUSIONS

Access to LCS shops is high, and training LCS to administer DMPA would increase access to family planning in Ghana, with associated time and cost savings.

Workforce interventions to improve access to emergency contraception pills: a systematic review of current evidence in low- and middle-income countries and recommendations for improving performance

BACKGROUND

Emergency contraceptive pills (ECP) are one of the 13 essential commodities addressed by the UN Commission on Life-Saving Commodities for Women and Children. Although ECP have been available for 20 years, a number of barriers still limit women's access ECP in low and middle-income countries (LMIC). The workforce who prescribe or dispense ECP are diverse reflecting the varied contexts where ECP are available across the health, commercial and justice sectors and in the community. No reviews currently exist that examine the roles and experiences of the workforce that provide ECP in LMIC.

METHOD

We present a narrative synthesis of research to: identify provider factors that facilitate and constraint access to ECP; assess the effectiveness of associated interventions and; explore associated health system issues in LMIC. A search of bibliographic databases, meta-indexes and websites was undertaken to retrieve peer reviewed and grey literature. Literature was screened and identified documents examined to appraise quality.

RESULTS

Thirty-seven documents were included in the review. Studies focused on formal health workers revealing knowledge gaps concerning the role of private sector and non-health providers who increasingly provide ECP. Data from the findings section in the documents were coded under 4 themes: provider knowledge; provider attitudes and beliefs; provider practice and provider training. The analysis revealed provider knowledge gaps, less than favourable attitudes and practice issues. The findings provide limited insight into products prescribed and/or dispensed, the frequency of provision, and information and advice offered to consumers. Pre and in-service training needs were noted.

CONCLUSION

As the provision of ECPs shifts from the clinic-based health sector to increasing provision by the private sector, the limited understanding of provider performance and the practice gaps revealed in this review highlight the need to further examine provider performance to inform the development of appropriate workforce interventions. A standardized approach to assessing performance using agreed outcomes measures may serve to ensure a systematic way forward that is inclusive of the diverse workforce that deliver ECP. Recommendations are outlined to enhance the performance of providers to improve access to ECP. A framework is offered to help guide this process with indicators.

Optimizing the delivery of contraceptives in low- and middle-income countries through task shifting: a systematic review of effectiveness and safety

Objective

To assess the effectiveness and safety of task shifting for the delivery of injectable contraceptives, contraceptive implants, intrauterine devices (IUDs), tubal ligation and vasectomy in low- and middle-income countries.

Methods

Multiple electronic databases were searched up to 25 May 2012 for studies which had assessed the delivery of contraceptives by health workers with lower levels of training, compared to delivery by health workers usually assigned this role, or compared to no organized provision of contraceptives. We included randomized controlled trials, non-randomized controlled trials, controlled before-after studies, and interrupted time series. Data were extracted using a standard form and the certainty of the evidence found was assessed using GRADE.

Results

We identified six randomized controlled trials published between 1977 and 1995 that assessed the safety and effectiveness of task shifting for the delivery of long-term contraceptives. Two studies assessed IUD insertion by nurses compared to doctors, two assessed IUD insertion by auxiliary nurse-midwives compared to doctors, one assessed tubal ligation by midwives compared to doctors, and one assessed the delivery of vasectomy by medical students compared to doctors. In general, little or no difference was found in contraceptive outcomes between cadres. Study design limitations and the low number of eligible studies, however, allow only limited conclusions to be drawn.

Conclusions

The findings indicate that task shifting for the delivery of long-term contraceptives may be a safe and effective approach to increasing access to contraception. Further research is needed because the certainty of the evidence identified is variable.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-015-0002-2) contains supplementary material, which is available to authorized users.

Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review

Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review.

A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance.

When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.

A better future for injectable contraception?

Provision of injectables though drug shops appears practicable and can contribute a marked share of family planning services.

A potential longer-acting injectable providing at least 6 months of protection appeals to programmatic professionals.

Subcutaneous administration of DMPA offers major injectable improvements over the current intramuscular approach.

Ironically, while injectable use will inevitably grow, better choice and wider availability of other methods—especially of long-acting and permanent methods—will reduce injectables′ overall share.

Getting closer to people: family planning provision by drug shops in Uganda

BACKGROUND

Private-sector drug shops are often the first point of health care in sub-Saharan Africa. Training and supporting drug shop and pharmacy staff to provide a wide range of contraceptive methods and information is a promising high-impact practice for which more information is needed to fully document implementation experience and impact.

METHODS

Between September 2010 and March 2011, we trained 139 drug shop operators (DSOs) in 4 districts of Uganda to safely administer intramuscular DMPA (depot medroxyprogesterone acetate) contraceptive injections. In 2012, we approached 54 of these DSOs and interviewed a convenience sample of 585 of their family planning clients to assess clients' contraceptive use and perspectives on the quality of care and satisfaction with services. Finally, we compared service statistics from April to June 2011 from drug shops, community health workers (CHWs), and government clinics in 3 districts to determine the drug shop market share of family planning services.

RESULTS

Most drug shop family planning clients interviewed were women with low socioeconomic status. The large majority (89%) were continuing family planning users. DMPA was the preferred contraceptive. Almost half of the drug shop clients had switched from other providers, primarily from government health clinics, mostly as a result of more convenient locations, shorter waiting times, and fewer stock-outs in drug shops. All clients reported that the DSOs treated them respectfully, and 93% trusted the drug shop operator to maintain privacy. Three-quarters felt that drug shops offered affordable family planning services. Most of the DMPA clients (74%) were very satisfied with receiving their method from the drug shop and 98% intended to get the next injection from the drug shop. Between April and June 2011, clinics, CHWs, and drug shops in 3 districts delivered equivalent proportions of couple-years of protection, with drug shops leading marginally at 36%, followed by clinics (33%) and CHWs (31%).

CONCLUSION

Drug shops can be a viable and convenient source of short-acting contraceptive methods, including DMPA, serving as a complement to government services. Family planning programs in Uganda and elsewhere should consider including drug shops in the network of community-based family planning providers.

Family planning since ICPD--how far have we progressed?

The 1994 International Conference on Population and Development (ICPD) was a pivotal global event. It established voluntary family planning as a fundamental human right. We describe the progress made and challenges faced by the family planning field in the 20 years since ICPD. We present case studies from three African countries to highlight factors affecting the evolution of family planning during the past 2 decades. Measurable progress has been made in the key family planning indicators over this interval. However, improvement has slowed in recent years, and demographic forecasts predict a greater unmet need for effective contraception in the future. With a rights-based lens, we need to better understand the nuances of fertility intentions as we offer women and couples contraceptive choices pertinent to their stage of life. With a public-health lens, we need better metrics to reflect the realities of contraceptive effectiveness. Now is the time to build on two decades of family planning progress after ICPD.

Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International

Contraceptive implants offer promising opportunities for addressing the high and growing unmet need for modern contraceptives in sub-Saharan Africa. Marie Stopes International (MSI) offers implants as one of many family planning options. Between 2008 and 2012, MSI scaled up voluntary access to implants in 15 sub-Saharan African countries, from 80,041 implants in 2008 to 754,329 implants in 2012. This 9-fold increase amounted to more than 1.7 million implants delivered cumulatively over the 5-year period. High levels of client satisfaction were attained alongside service provision scale up by using existing MSI service delivery channels-mobile outreach, social franchising, and clinics-to implement strategies that broadened access for underserved clients and maintained service quality. Use of adaptive and context-specific service delivery models and attention to key operational components, including sufficient numbers of trained providers, strong supply chains, diverse financing mechanisms, and implant removal services, underpinned our service delivery efforts. Accounting for 70% of the implants delivered by MSI in 2012, mobile outreach services through dedicated MSI provider teams played a central role in scale-up efforts, fueled in part by the provision of free or heavily subsidized services. Social franchising also demonstrated promise for future program growth, along with MSI clinics. Continued high growth in implant provision between 2011 and 2012 in all sub-Saharan African countries indicates the region's capacity for further service delivery expansion. Meeting the expected rising demand for implants and ensuring long-term sustainable access to the method, as part of a comprehensive method mix, will require continued use of appropriate service delivery models, effective operations, and ongoing collaboration between the private, public, and nongovernmental sectors. MSI's experience can be instructive for future efforts to ensure contraceptive access and choice in sub-Saharan Africa, especially as the global health community works to achieve its Family Planning 2020 (FP2020) commitments to expand family planning access to 120 million new users.