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Mnyippembe A, Sheira LA, McCoy SI, Njau PF, Packel LJ, Hassan K, Solorzano-Barrera C, Maokola W, Kang Dufour MS, Sabasaba A, Liu J. Supporting young women's health through girl-friendly drug vendors in Lake Zone, Tanzania: protocol for the AmbassADDOrs for Health cluster-randomised controlled trial. BMJ Open 2024; 14:e078755. [PMID: 38851225 PMCID: PMC11163605 DOI: 10.1136/bmjopen-2023-078755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 05/15/2024] [Indexed: 06/10/2024] Open
Abstract
INTRODUCTION Adverse sexual and reproductive health (SRH) outcomes, such as unplanned pregnancies and HIV infection, disproportionately affect adolescent girls and young women (AGYW; aged 15-24 years) in east Africa. Increasing uptake of preventive SRH services via innovative, youth-centred interventions is imperative to addressing disparities in SRH outcomes. METHODS AND ANALYSIS From 2018 to 2019, we used human-centred design to co-develop a theoretically driven HIV and pregnancy prevention intervention for AGYW at private drug shops called Accredited Drug Dispensing Outlets (ADDOs) in Tanzania. The result, Malkia Klabu (Queen Club), was a customer loyalty programme designed to strengthen ADDOs' role as SRH providers while encouraging uptake of critical SRH prevention products among AGYW. Malkia Klabu members had access to free contraceptives and oral HIV self-test (HIVST) kits and earned punches on a loyalty card for other shop purchases; punches were redeemable for small prizes. Our pilot among 40 shops showed that intervention ADDOs had higher AGYW patronage and distributed more HIVST kits and contraceptives to AGYW relative to business-as-usual (ie, client purchasing) comparison shops. We will conduct a cluster-randomised controlled trial (c-RCT) among 120-140 ADDOs in 40 health catchment areas in Shinyanga and Mwanza Regions (Lake Zone), Tanzania. ADDO shop recruitment includes a 1-month run-in with a tablet-based electronic inventory management system for tracking shop transactions, followed by enrolment, randomisation and a 24-month trial period. Our c-RCT evaluating the human-centred design-derived intervention will assess population impact on the primary outcomes of HIV diagnoses and antenatal care registrations, measured with routine health facility data. We will also assess secondary outcomes focusing on mechanisms of action, evaluate programme exposure and AGYW behaviour change in interviews with AGYW, and assess shop-level implementation strategies and fidelity. ETHICS AND DISSEMINATION Ethical approval was granted from both the University of California, San Francisco and the Tanzanian National Institute for Medical Research. Study progress and final outcomes will be posted annually to the National Clinical Trials website; study dissemination will occur at conferences, peer-reviewed manuscripts and local convenings of stakeholders. TRIAL REGISTRATION NUMBER NCT05357144.
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Affiliation(s)
- Agatha Mnyippembe
- Health for a Prosperous Nation, Dar es Salaam, United Republic of Tanzania
| | - Lila A Sheira
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
- Institute for Health Aging, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Sandra I McCoy
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Prosper F Njau
- Ministry of Health and Social Welfare, Dar es Salaam, United Republic of Tanzania
| | - Laura J Packel
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
- Institute for Health Aging, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Kassim Hassan
- Health for a Prosperous Nation, Dar es Salaam, United Republic of Tanzania
| | - Camila Solorzano-Barrera
- Institute for Health Aging, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Werner Maokola
- Ministry of Health and Social Welfare, Dar es Salaam, United Republic of Tanzania
| | | | - Amon Sabasaba
- Health for a Prosperous Nation, Dar es Salaam, United Republic of Tanzania
| | - Jenny Liu
- Institute for Health Aging, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, California, USA
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Komasawa M, Sato M, Ssekitoleko R, Waiswa P, Gitta S, Nabugoomu J, Honda S, Saito K, Aung MN. Study protocol for a type-II hybrid effectiveness-implementation trial to reach teenagers using mobile money shops to reduce unintended pregnancies in Uganda. BMJ Open 2024; 14:e084539. [PMID: 38582537 PMCID: PMC11002355 DOI: 10.1136/bmjopen-2024-084539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
INTRODUCTION Unintended teenage pregnancies have become a global public health challenge, particularly in sub-Saharan Africa. There is a notably high prevalence of unintended pregnancies among unmarried teenagers in Uganda. This study will develop an intervention programme using mobile money shops (vendors) as a platform to deliver sexual and reproductive health and rights (SRHR) services to teenagers and assess its effectiveness and scalability in Uganda. METHODS AND ANALYSES This hybrid study comprises two integral components: an intervention study to assess the effectiveness of vendor-mediated intervention and implementation research to evaluate the implementation process. 30 vendors will be recruited for both intervention and control arms in 2 municipalities in Eastern Uganda, which have a high unintended pregnancy prevalence rate among unmarried teens aged 15-19 years. A preintervention and postintervention repeated survey involving 600 participants for each arm will be conducted over 4 months. The primary outcome is the rate of condom users among teenage vendor users. The secondary outcomes include the rate of preference for receiving SRHR services at vendors and knowledge regarding SRHR. A difference-in-differences analysis will be used to determine the effectiveness of the intervention. The Bowen model will be employed to evaluate the implementation design. ETHICS AND DISSEMINATION Ethical approval was obtained from the Ethics Review Committee of Uganda Christen University and JICA Ogata Sadako Research Institute for Peace and Development in Japan. The findings will be widely disseminated. This study was registered with the University Hospital Medical Information Network in Japan (UMIN000053332) on 12 January 2024. TRIAL REGISTRATION NUMBER UMIN000053332.
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Affiliation(s)
- Makiko Komasawa
- Ogata Sadako Research Institute for Peace and Development, Japan International Cooperation Agency, Shinjuku-ku, Japan
- Department of Global Health Research, Juntendo University, Bunkyo-ku, Japan
| | - Miho Sato
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | | | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
- Busoga Health Forum, Jinja, Uganda
| | - Sheba Gitta
- School of Public Health, Uganda and Busoga Health Forum, Jinja, Uganda
- Makerere University, Kampala, Uganda
| | | | - Sumihisa Honda
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Kiyoko Saito
- Ogata Sadako Research Institute for Peace and Development, Japan International Cooperation Agency, Shinjuku-ku, Japan
| | - Myo Nyein Aung
- Department of Global Health Research, Juntendo University, Bunkyo-ku, Japan
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Willard-Grace R, Abigail Cabrera F, Bykhovsky C, Douglas K, Hunter LA, Mnyippembe A, Mgunya KH, McCoy SI, Liu JX. "They call me the 'Great Queen'": implementing the Malkia Klabu program to improve access to HIV self-testing and contraception for adolescent girls and young women in Tanzania. Reprod Health 2024; 21:21. [PMID: 38321482 PMCID: PMC10848389 DOI: 10.1186/s12978-024-01744-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/23/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Adolescent girls and young woman (AGYW) comprise a significant proportion of new HIV infections and unintended pregnancies in sub-Saharan Africa yet face many barriers to accessing family planning and reproductive health (FPRH) information and services. Developed via human-centered design, the Malkia Klabu ("Queen Club") program aimed to facilitate access to HIV self-testing (HIVST) and FPRH information and products at privately-owned drug shops. We sought to understand barriers and facilitators to program implementation in a 4-month pilot in Tanzania. METHODS Forty semi-structured interviews were conducted with participants in a cluster randomized trial of the Malkia Klabu program from November 2019 through March 2020, including 11 with AGYW, 26 with drug shopkeepers, and three with counselors at health facilities to whom AGYW were referred. Interviews were audio-recorded, transcribed, coded, and analyzed to identify key themes. The Consolidated Framework for Implementation Research (CFIR) was used to assess barriers and facilitators to program implementation at multiple levels. CFIR considers the outer setting (e.g., culture and systemic conditions), the inner setting where the intervention is implemented (e.g., incentives, relationships, and available resources), the individuals involved, the innovation as it relates to stakeholder needs, and the implementation process. RESULTS The Malkia Klabu program reshaped and directed the role of drug shopkeepers as providers of information and resources rather than FPRH gatekeepers. Key implementation facilitators included the program's adaptability to a wide range of needs and stages of readiness among AGYW, ability to capitalize on AGYW social networks for driving membership, responsiveness to AGYW's need for privacy, and positive contributions to the income and community standing of drug shopkeepers. Components such as HIVST were highly acceptable to both AGYW and shopkeepers, and the introduction of the loyalty program and HIVST kits in shops opened doors to the provision of FPRH products and information, which was further facilitated by program tools such as videos, product displays, and symbol cards. Although some shopkeepers maintained beliefs that certain contraceptive methods were inappropriate for AGYW, most appeared to provide the products as part of the program. CONCLUSIONS The Malkia Klabu intervention's success was due in part to its ability to address key motivations of both AGYW and drug shopkeepers, such as maintaining privacy and increasing access to FPRH products for AGYW and increasing business for shops. Better understanding these implementation barriers and facilitators can inform the program's future adaptation and scale-up. TRIAL REGISTRATION clinicaltrials.gov #NCT04045912.
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Affiliation(s)
- Rachel Willard-Grace
- Center for Excellence in Primary Care, University of California, San Francisco, San Francisco, CA, USA.
| | - F Abigail Cabrera
- Center for Excellence in Primary Care, University of California, San Francisco, San Francisco, CA, USA
| | - Camilla Bykhovsky
- Center for Excellence in Primary Care, University of California, San Francisco, San Francisco, CA, USA
| | - Kayla Douglas
- Center for Excellence in Primary Care, University of California, San Francisco, San Francisco, CA, USA
| | - Lauren A Hunter
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | | | - Sandra I McCoy
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Jenny X Liu
- Institute for Health and Aging, Bixby Center for Global Reproductive Health, University of California, San Francisco, San Francisco, CA, USA
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Liu JX, Vallin J, Chiu C, Cabrera FA, Hunter LA, Rao A, Njau P, McCoy SI. Designing for two: How enhancing human-centered design with behavioral nudges unlocked breakthroughs to promote young women's psychological safety and access to reproductive care in Tanzania. Soc Sci Med 2023; 320:115683. [PMID: 36709692 PMCID: PMC10798268 DOI: 10.1016/j.socscimed.2023.115683] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/16/2023]
Abstract
Adolescent girls and young women (AGYW; ages 15-24) in sub-Saharan Africa face many barriers to accessing preventive sexual and reproductive health (SRH) services. We drew upon the strengths of two complementary approaches, human-centered design and behavioral economics, to craft a holistic, highly-tailored, and empathetic intervention to motivate AGYW to seek contraception and HIV self-test kits at community drug shops. To encourage engagement, we embedded "nudge" strategies at different opportunity points (uncovered during our design research) along the care-seeking and service delivery journey. Our Malkia Klabu intervention is a loyalty program designed to enhance drug shops' role as SRH providers through which AGYW earned punches for shop purchases redeemable for small prizes; free SRH products could be requested at any time. From our 4-month pilot in Shinyanga, Tanzania, we assess the extent to which different behavioral nudge strategies motivated behaviors as predicted by synthesizing findings from (1) in-depth interviews with AGYW and shopkeepers, (2) shop program records, (3) shop observations, and (4) customer exit surveys. Overall, we find that AGYW and shopkeepers were motivated by many intervention features as intended and consistent with hypothesized mechanisms. We found strong evidence of social norms for helping to spread awareness of Malkia Klabu among peers, prize incentives for drawing AGYW back to shops, and the opt-out default membership gift of an HIV self-test kit for encouraging testing uptake and exploration of contraceptives. Shopkeepers in both arms noted increased community status from distributing HIV self-testing kits (ego). Malkia Klabu shopkeepers experienced increased customer traffic and business revenues (incentives), which reduced shopkeepers' gatekeeping tendencies and earned them additional recognition as champions of AGYW well-being. Integrating human-centered design and behavioral economics was effective for developing an innovative and effective intervention that simultaneously met the different needs of economic actors in support of public health priorities.
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Affiliation(s)
- Jenny X Liu
- Institute for Health and Aging; Bixby Center for Global Reproductive Health; University of California, San Francisco, 490 Illinois St. 123J, San Francisco, CA 94158, USA.
| | - Janelli Vallin
- Institute for Health and Aging; Bixby Center for Global Reproductive Health; University of California, San Francisco, 490 Illinois St. 123J, San Francisco, CA 94158, USA.
| | - Calvin Chiu
- School of Public Health; University of California, Berkeley; 2121 Berkeley Way, Berkeley, CA, 94704, USA.
| | - F Abigail Cabrera
- Center for Excellence in Primary Care; University of California, San Francisco; Zuckerberg San Francisco General Hospital; 995 Potrero Ave, Ward 83, San Francisco, CA, 94110, USA.
| | - Lauren A Hunter
- School of Public Health; University of California, Berkeley; 2121 Berkeley Way, Berkeley, CA, 94704, USA.
| | - Aarthi Rao
- Behavioral Insights and Program Design; Cityblock Health; 86 Laws Brook Rd, Concord, MA 01742, USA.
| | - Prosper Njau
- National AIDS Control Programme, Ministry of Health, Community Development, Gender, Elderly and Children; Government City - Mtumba, Afya Road, P.O. Box 743, 40478 Dodoma, United Republic of Tanzania.
| | - Sandra I McCoy
- School of Public Health; University of California, Berkeley; 2121 Berkeley Way, Berkeley, CA, 94704, USA.
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