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Athey S, Bergstrom K, Hadad V, Jamison JC, Özler B, Parisotto L, Sama JD. Can personalized digital counseling improve consumer search for modern contraceptive methods? SCIENCE ADVANCES 2023; 9:eadg4420. [PMID: 37801502 PMCID: PMC10558117 DOI: 10.1126/sciadv.adg4420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 09/05/2023] [Indexed: 10/08/2023]
Abstract
This paper analyzes a randomized controlled trial of a personalized digital counseling intervention addressing informational constraints and choice architecture, cross-randomized with discounts for long-acting reversible contraceptives (LARCs), such as intrauterine devices (IUDs). The counseling intervention encourages shared decision-making (SDM) using a tablet-based app, which provides a tailored ranking of modern methods to each client according to their elicited needs and preferences. Take-up of LARCs in the status quo regime at full price was 11%, which increased to 28% with discounts. SDM roughly tripled the share of clients adopting a LARC at full price to 35%, and discounts had no incremental impact in this group. Neither intervention affected the take-up of short-acting methods, such as the pill. Consistent with theoretical models of consumer search, SDM clients discussed more methods in depth, which led to higher adoption rates for second- or lower-ranked LARCs. Our findings suggest that low-cost individualized recommendations can potentially be as effective in increasing unfamiliar technology adoption as providing large subsidies.
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Affiliation(s)
- Susan Athey
- Graduate School of Business, Stanford University, Stanford, CA 94305, USA
| | - Katy Bergstrom
- Department of Economics, Tulane University, New Orleans, LA 70118, USA
| | | | - Julian C. Jamison
- Business School, University of Exeter, Exeter EX44PU, UK
- Global Priorities Institute, Oxford University, Oxford OX2 0DJ, UK
| | - Berk Özler
- Development Research Group, The World Bank, Washington DC, DC 20433, USA
| | - Luca Parisotto
- Department of Economics, Bocconi University, Milano, MI 20100, Italy
| | - Julius Dohbit Sama
- Department of Gynaecology-Obstetrics, University of Yaoundé I, Yaoundé, Cameroon
- Yaoundé Gynaecology, Obstetrics and Pediatrics Hospital, Yaoundé, Cameroon
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Neill R, Zia N, Ashraf L, Khan Z, Pryor W, Bachani AM. Integration measurement and its applications in low- and middle-income country health systems: a scoping review. BMC Public Health 2023; 23:1876. [PMID: 37770887 PMCID: PMC10537146 DOI: 10.1186/s12889-023-16724-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 09/08/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Despite growing interest in and commitment to integration, or integrated care, the concept is ill-defined and the resulting evidence base fragmented, particularly in low- and middle-income countries (LMICs). Underlying this challenge is a lack of coherent approaches to measure the extent of integration and how this influences desired outcomes. The aim of this scoping review is to identify measurement approaches for integration in LMICs and map them for future use. METHODS Arksey and O'Malley's framework for scoping reviews was followed. We conducted a systematic search of peer-reviewed literature measuring integration in LMICs across three databases and screened identified papers by predetermined inclusion and exclusion criteria. A modified version of the Rainbow Model for Integrated Care guided charting and analysis of the data. RESULTS We included 99 studies. Studies were concentrated in the Africa region and most frequently focused on the integration of HIV care with other services. A range of definitions and methods were identified, with no single approach for the measurement of integration dominating the literature. Measurement of clinical integration was the most common, with indicators focused on measuring receipt of two or more services provided at a single point of time. Organizational and professional integration indicators were focused on inter- and intra-organizational communication, collaboration, coordination, and continuity of care, while functional integration measured common information systems or patient records. Gaps were identified in measuring systems and normative integration. Few tools were validated or publicly available for future use. CONCLUSION We identified a wide range of recent approaches used to measure integration in LMICs. Our findings underscore continued challenges with lack of conceptual cohesion and fragmentation which limits how integration is understood in practice.
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Affiliation(s)
- Rachel Neill
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA.
| | - Nukhba Zia
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Lamisa Ashraf
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Zainab Khan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Wesley Pryor
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, 3010, Australia
| | - Abdulgafoor M Bachani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
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Thomas D, Wanje G, Eastment MC, McClelland RS, Mwaringa E, Patta S, Jaoko W, Kinuthia J, Abubakar A, Sherr K, Barnabas RV. The cost of implementing the Systems Analysis and Improvement Approach for a cluster randomized trial integrating HIV testing into family planning services in Mombasa County, Kenya. BMC Health Serv Res 2022; 22:1480. [PMID: 36471311 PMCID: PMC9720937 DOI: 10.1186/s12913-022-08828-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 11/10/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Although HIV testing in family planning (FP) clinics is a promising approach for engaging women in HIV treatment and prevention services, HIV testing rates are low in FP clinics in Kenya. In 2018, a cluster randomized trial was implemented in Mombasa, Kenya applying the Systems Analysis and Improvement Approach (SAIA) to integrate HIV testing into FP services (1K24HD088229-01). We estimated the incremental costs and explored cost drivers of the FP HIV SAIA implementation in Mombasa, Kenya. METHODS We conducted a costing evaluation from the payer perspective for the FP HIV SAIA randomized control trial. We identified relevant activities for the intervention including start-up, training, research and FP HIV SAIA. We estimated activity time burden using a time-and motion study. We derived unit costs through staff interviews and programmatic budgets. We present cost estimates for two different scenarios: as-implemented including research and projected costs for a Ministry of Health-supported intervention. All costs are reported in 2018 USD. RESULTS For an annual program output of 36,086 HIV tests administered to new FP clients, we estimated the total annual program cost to be $91,994 with an average cost per new FP client served of $2.55. Personnel and HIV rapid testing kits comprised 55% and 21% of programmatic costs, respectively. Assuming no changes to program outputs and with efficiency gains under the MOH scenario, the estimated cost per new FP client served decreased to $1.30 with a programmatic cost reduction of 49%. CONCLUSION FP HIV SAIA is a low-cost and flexible implementation strategy for facilitating integrated delivery of HIV testing alongside FP services. Although cost implications of the FP HIV SAIA intervention must continue to be evaluated over time, these findings provide context-specific cost data useful for budget planning and decision-making regarding intervention delivery and expansion. TRIAL REGISTRATION The trial was registered on December 15, 2016, with clinicaltrials.gov (NCT02994355).
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Affiliation(s)
- Dorothy Thomas
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 98104-2499, Seattle, USA.
| | - George Wanje
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 98104-2499, Seattle, USA
| | | | - R Scott McClelland
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 98104-2499, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medical Microbiology & Immunology, University of Nairobi, Nairobi, Kenya
| | - Emily Mwaringa
- Department of Health Services, County Government of Mombasa, Mombasa, Kenya
| | - Shem Patta
- Department of Health Services, County Government of Mombasa, Mombasa, Kenya
| | - Walter Jaoko
- Department of Medical Microbiology & Immunology, University of Nairobi, Nairobi, Kenya
| | - John Kinuthia
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 98104-2499, Seattle, USA
- Department of Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Aisha Abubakar
- Department of Health Services, County Government of Mombasa, Mombasa, Kenya
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 98104-2499, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, USA
| | - Ruanne V Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, USA
- Division of Infectious Diseases, Harvard Medical School, Boston, USA
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Long JE, Eastment MC, Wanje G, Richardson BA, Mwaringa E, Mohamed MA, Sherr K, Barnabas RV, Mandaliya K, Jaoko W, McClelland RS. Assessing the sustainability of the Systems Analysis and Improvement Approach to increase HIV testing in family planning clinics in Mombasa, Kenya: results of a cluster randomized trial. Implement Sci 2022; 17:70. [PMID: 36195890 PMCID: PMC9530422 DOI: 10.1186/s13012-022-01242-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Kenya, HIV incidence is highest among reproductive-age women. A key HIV mitigation strategy is the integration of HIV testing and counseling (HTC) into family planning services, but successful integration remains problematic. We conducted a cluster-randomized trial using the Systems Analysis and Improvement Approach (SAIA) to identify and address bottlenecks in HTC integration in family planning clinics in Mombasa County, Kenya. This trial (1) assessed the efficacy of this approach and (2) examined if SAIA could be sustainably incorporated into the Department of Health Services (DOHS) programmatic activities. In Stage 1, SAIA was effective at increasing HTC uptake. Here, we present Stage 2, which assessed if SAIA delivery would be sustained when implemented by the Mombasa County DOHS and if high HTC performance would continue to be observed. METHODS Twenty-four family planning clinics in Mombasa County were randomized to either the SAIA implementation strategy or standard care. In Stage 1, the study staff conducted all study activities. In Stage 2, we transitioned SAIA implementation to DOHS staff and compared HTC in the intervention versus control clinics 1-year post-transition. Study staff provided training and minimal support to DOHS implementers and collected quarterly HTC outcome data. Interviews were conducted with family planning clinic staff to assess barriers and facilitators to sustaining HTC delivery. RESULTS Only 39% (56/144) of planned SAIA visits were completed, largely due to the COVID-19 pandemic and a prolonged healthcare worker strike. In the final study quarter, 81.6% (160/196) of new clients at intervention facilities received HIV counseling, compared to 22.4% (55/245) in control facilities (prevalence rate ratio [PRR]=3.64, 95% confidence interval [CI]=2.68-4.94). HIV testing was conducted with 60.5% (118/195) of new family planning clients in intervention clinics, compared to 18.8% (45/240) in control clinics (PRR=3.23, 95% CI=2.29-4.55). Interviews with family planning clinic staff suggested institutionalization contributed to sustained HTC delivery, facilitated by low implementation strategy complexity and continued oversight. CONCLUSIONS Intervention clinics demonstrated sustained improvement in HTC after SAIA was transitioned to DOHS leadership despite wide-scale healthcare disruptions and incomplete delivery of the implementation strategy. These findings suggest that system interventions may be sustained when integrated into DOHS programmatic activities. TRIAL REGISTRATION ClinicalTrials.gov (NCT02994355) registered on 16 December 2016.
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Affiliation(s)
- Jessica E Long
- Department of Epidemiology, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA. .,Present Address: Department of Medicine, University of Washington, Seattle, WA, USA.
| | - McKenna C Eastment
- Present Address: Department of Medicine, University of Washington, Seattle, WA, USA
| | - George Wanje
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA.,Fred Hutchinson Cancer Research Center, Vaccine and Infectious Disease Division, Seattle, WA, USA
| | | | | | - Kenneth Sherr
- Department of Epidemiology, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
| | - Ruanne V Barnabas
- Department of Epidemiology, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA.,Present Address: Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Walter Jaoko
- Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - R Scott McClelland
- Department of Epidemiology, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA.,Present Address: Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Medical Microbiology, University of Nairobi, Nairobi, Kenya
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Hamon JK, Hoyt J, Krishnaratne S, Barbra AA, Morukileng J, Spilotros N, Mbembe M, Marcus S, Webster J. Perceptions of quality and the integrated delivery of family planning with childhood immunisation services in Kenya and Uganda. PLoS One 2022; 17:e0269690. [PMID: 35666759 PMCID: PMC9170085 DOI: 10.1371/journal.pone.0269690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/25/2022] [Indexed: 11/19/2022] Open
Abstract
The integration of family planning (FP) with childhood immunisations is considered a promising approach to addressing postpartum women's unmet need for FP in resource limited settings. This study set out to examine client and health provider perceptions of the quality of FP services that were integrated with childhood immunisations in Kenya and Uganda. Semi-structured interviews with clients (n = 30) and health providers (n = 27) were conducted in 16 rural health facilities. Interviews centred on the respondents' experiences receiving/delivering FP services, their interactions with providers/clients, and their views on the quality of FP services. Client and provider perceptions of quality were compared through a thematic analysis of interview transcripts, and findings were synthesised using Jain and Hardee's revised FP Quality of Care Framework. Using audit data, health facility characteristics and resources were also summarised through descriptive statistics to contextualise the qualitative findings. The dignity and respect experienced by clients was central to the respondents' perceptions of quality. These two dimensions were not conceptualised as distinct facets of quality, but were instead perceived to be a product of the 1) access to needed services, 2) choice of contraceptives, 3) interpersonal communication, 4) information, and 5) confidentiality afforded to clients. Additionally, clients and providers alike believed that the integration of FP services with childhood immunisations had a positive effect on clients' access to needed services and on the confidentiality they experienced in a context where modern contraceptive use was stigmatised and where a lack of support from some husbands impeded access to FP services. Understanding clients' and providers' conceptualisation of quality is critical to the design of high quality and client-centred integrated FP services.
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Affiliation(s)
- Jessie K. Hamon
- Department of Disease Control, London School of Hygiene &Tropical Medicine, London, United Kingdom
| | - Jenna Hoyt
- Department of Disease Control, London School of Hygiene &Tropical Medicine, London, United Kingdom
| | - Shari Krishnaratne
- Department of Disease Control, London School of Hygiene &Tropical Medicine, London, United Kingdom
| | | | - Job Morukileng
- International Rescue Committee Uganda, Kampala, Uganda
- Uganda Public Health Fellowship Program, Ministry of Health, Kampala, Uganda
| | - Nathaly Spilotros
- International Rescue Committee US, New York, NY, United States of America
| | | | - Seth Marcus
- World Vision US, Monrovia, California, United States of America
| | - Jayne Webster
- Department of Disease Control, London School of Hygiene &Tropical Medicine, London, United Kingdom
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Warren CE, McClair TL, Kirk KR, Ndwiga C, Yam EA. Design, adaptation, and diffusion of an innovative tool to support contraceptive decision-making: Balanced Counseling Strategy Plus. Gates Open Res 2022. [DOI: 10.12688/gatesopenres.13477.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Contraceptive decision-making is highly complex, and family planning (FP) clients choose methods according to a host of personal, interpersonal, and context-specific considerations. These include concerns about side effects, confidence in their ability to adhere to daily or monthly use, efficacy of methods, partner support, and HIV vulnerability. FP decision support tools can support FP clients and providers to engage in a joint decision-making process to ensure clients make informed choices about contraception. For more than two decades, the Balanced Counseling Strategy (BCS) and Balanced Counseling Strategy Plus (BCS+) decision support tools have been used in lower- and middle-income countries, informed by implementation science research and iterative updates and refinements to reflect new developments in contraceptive technology and HIV prevention strategies. To inform the development and scale-up of future FP decision support tools, this article describes the development, evaluation, and proliferation of BCS and BCS+.
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Mannoh I, Amundsen D, Turpin G, Lyons CE, Viswasam N, Hahn E, Ryan S, Baral S, Hansoti B. A Systematic Review of HIV Testing Implementation Strategies in Sub-Saharan African Countries. AIDS Behav 2022; 26:1660-1671. [PMID: 34797449 PMCID: PMC9426653 DOI: 10.1007/s10461-021-03518-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/25/2022]
Abstract
HIV/AIDS remains a looming presence in public health across the world, particularly in Sub-Saharan Africa. The HIV Care Cascade hinges on testing and knowledge of HIV status. Though significant advances have been made in diagnosing people living with HIV (PLHIV), limitations in understanding which strategies are best suited to certain regions or populations have contributed to the uneven distribution in the success of various HIV testing strategies. Here, we present a conceptual framework that outlines effective HIV testing strategies for four target groups. This framework is based on a systematic literature review of articles published from January 1st, 2008, to December 31st, 2019. The effectiveness of HIV testing strategies depends on various factors including the setting, type of test and service providers. Multiple strategies are needed to reach the UNAIDS target of 95% of individuals knowing their HIV status. Expansion of community-based approaches, self-testing and HIV testing services in antenatal care will further improve the state of HIV testing in Sub-Saharan Africa.
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Affiliation(s)
- Ivy Mannoh
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Gnilane Turpin
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Carrie E Lyons
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Nikita Viswasam
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth Hahn
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Sofia Ryan
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Stefan Baral
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Medicine Suite 200, 5801 Smith Avenue, Baltimore, MD, 21209, USA.
- Department of International Health, Bloomberg School of Public Health, Baltimore, MD, USA.
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Warren CE, McClair TL, Kirk KR, Ndwiga C, Yam EA. Design, adaptation, and diffusion of an innovative tool to promote shared contraceptive decision-making: Balanced Counseling Strategy Plus. Gates Open Res 2022. [DOI: 10.12688/gatesopenres.13477.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Contraceptive decision-making is highly complex, and family planning (FP) clients choose methods according to a host of personal, interpersonal, and context-specific considerations. These include concerns about side effects, confidence in their ability to adhere to daily or monthly use, efficacy of methods, partner support, and HIV vulnerability. FP decision support tools can support FP clients and providers to engage in a joint decision-making process to ensure clients make informed choices about contraception. For more than two decades, the Balanced Counseling Strategy (BCS) and Balanced Counseling Strategy Plus (BCS+) decision support tools have been used in lower- and middle-income countries, informed by implementation science research and iterative updates and refinements to reflect new developments in contraceptive technology and HIV prevention strategies. To inform the development and scale-up of future FP decision support tools, as well as share lessons from translating implementation science results to practice, this article describes the development, evaluation, and proliferation of BCS and BCS+.
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Mensah K, Kaboré C, Zeba S, Bouchon M, Duchesne V, Pourette D, DeBeaudrap P, Dumont A. Implementation of HPV-based screening in Burkina Faso: lessons learned from the PARACAO hybrid-effectiveness study. BMC Womens Health 2021; 21:251. [PMID: 34162367 PMCID: PMC8220722 DOI: 10.1186/s12905-021-01392-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/11/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cervical cancer screening in sub-Saharan countries relies on primary visual inspection with acetic acid (VIA). Primary human papillomavirus (HPV)-based screening is considered a promising alternative. However, the implementation and real-life effectiveness of this strategy at the primary-care level in limited-resource contexts remain under explored. In Ouagadougou, Burkina Faso, free HPV-based screening was implemented in 2019 in two primary healthcare centers. We carried out a process and effectiveness evaluation of this intervention. METHODS Effectiveness outcomes and implementation indicators were assessed through a cohort study of screened women, observations in participating centers, individual interviews with women and healthcare providers and monitoring reports. Effectiveness outcomes were screening completeness and women's satisfaction. Logistic regression models and concurrent qualitative analysis explored how implementation variability, acceptability by women and the context affected effectiveness outcomes. RESULTS After a 3-month implementation period, of the 350 women included in the cohort, 94% completed the screening, although only 26% had their screening completed in a single visit as planned in the protocol. The proportion of highly satisfied women was higher after result disclosure (95%) than after sampling (65%). A good understanding of the screening results and recommendations increased screening completeness and women's satisfaction, while time to result disclosure decreased satisfaction. Adaptations were made to fit healthcare workers' workload. CONCLUSION Free HPV-based screening was successfully integrated within primary care in Ouagadougou, Burkina Faso, leading to a high level of screening completeness despite the frequent use of multiple visits. Future implementation in primary healthcare centers needs to improve counseling and reduce wait times at the various steps of the screening sequence.
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Affiliation(s)
- Keitly Mensah
- Centre Population et Développement (Ceped), Inserm ERL 1244, UMR Institut de recherche pour le développement (IRD) et Université de Paris, 45 rue des Saints-Pères, 75006, Paris, France.
| | - Charles Kaboré
- Institut de Recherche en Sciences de La Santé (IRSS), Ouagadougou, Burkina Faso
| | - Salifou Zeba
- Laboratoire de Recherche Interdisciplinaire en Sciences sociales et Santé (LARISS), Université Ouaga 1, Ouagadougou, Burkina Faso
| | - Magali Bouchon
- Pôle Recherche et Apprentissages, Médecins du Monde, Paris, France
| | - Véronique Duchesne
- Centre Population et Développement (Ceped), Inserm ERL 1244, UMR Institut de recherche pour le développement (IRD) et Université de Paris, 45 rue des Saints-Pères, 75006, Paris, France
| | - Dolorès Pourette
- Centre Population et Développement (Ceped), Inserm ERL 1244, UMR Institut de recherche pour le développement (IRD) et Université de Paris, 45 rue des Saints-Pères, 75006, Paris, France
| | - Pierre DeBeaudrap
- Centre Population et Développement (Ceped), Inserm ERL 1244, UMR Institut de recherche pour le développement (IRD) et Université de Paris, 45 rue des Saints-Pères, 75006, Paris, France
| | - Alexandre Dumont
- Centre Population et Développement (Ceped), Inserm ERL 1244, UMR Institut de recherche pour le développement (IRD) et Université de Paris, 45 rue des Saints-Pères, 75006, Paris, France
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Drake AL, Quinn C, Kidula N, Sibanda E, Steyn P, Barr-DiChiara M, Jamil MS, Rodolph M, Gaffield ME, Kiarie J, Baggaley R, Johnson C. A Landscape Analysis of Offering HIV Testing Services Within Family Planning Service Delivery. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:657728. [PMID: 36304029 PMCID: PMC9580748 DOI: 10.3389/frph.2021.657728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 04/01/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: Offering HIV testing services (HTS) within sexual and reproductive health (SRH) services is a priority, especially for women who have a substantial risk. To reach women with HIV who do not know their status and prevent mother-to-child HIV transmission, the World Health Organization (WHO) recommends routinely offering HTS as part of family planning (FP) service delivery in high HIV burden settings. We conducted a landscape analysis to assess HTS uptake and HIV positivity in the context of FP/SRH services. Assessment of Research and Programs: We searched records from PubMed, four gray literature databases, and 13 organization websites, and emailed 24 organizations for data on HTS in FP/SRH services. We also obtained data from International Planned Parenthood Federation (IPPF) affiliates in Eswatini, Kenya, Lesotho, Malawi, Namibia, Uganda, Zambia, and Zimbabwe. Unique programs/studies from records were included if they provided data on, or barriers/facilitators to, offering HTS in FP/SRH. Overall, 2,197 records were screened and 12 unique programs/studies were eligible, including 10 from sub-Saharan Africa. Four reported on co-delivery of SRH services (including FP), with reported HTS uptake between 17 and 94%. Six reported data on HTS in FP services: four among general FP clients; one among couples; and one among female sex workers, adolescent girls, and young women. Two of the six reported HTS uptake >50% (51%, 419/814 Kenya; 63%, 5,930/9,439 Uganda), with positivity rates of 2% and 4.1%, respectively. Uptake was low (8%, 74/969 Kenya) in the one FP program offering pre-exposure prophylaxis. In the IPPF program, seven countries reported HTS uptake in FP services and ranged from 4% in Eswatini to 90% in Lesotho; between 0.6% (Uganda) and 8% (Eswatini) of those tested were HIV positive. Implications: Data on providing HTS in FP/SRH service delivery were sparse and HTS uptake varied widely across programs. Actionable Recommendations: As countries expand HTS in FP/SRH appropriate to epidemiology, they should ensure data are reported and monitored for progress and impact.
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Affiliation(s)
- Alison L. Drake
- Department of Global Health, University of Washington, Seattle, WA, United States
- *Correspondence: Alison L. Drake
| | - Caitlin Quinn
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Nancy Kidula
- WHO Regional Office for Africa, Intercounty Support Team for Eastern and Southern Africa, Harare, Zimbabwe
| | - Euphemia Sibanda
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
| | - Petrus Steyn
- The United Nations Development Programme/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP Research), Geneva, Switzerland
| | - Magdalena Barr-DiChiara
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Muhammad S. Jamil
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Michelle Rodolph
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Mary E. Gaffield
- The United Nations Development Programme/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP Research), Geneva, Switzerland
| | - James Kiarie
- The United Nations Development Programme/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP Research), Geneva, Switzerland
| | - Rachel Baggaley
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Cheryl Johnson
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
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Mukamuyango J, Ingabire R, Parker R, Nyombayire J, Abaasa A, Asiki G, Easter SR, Wall KM, Nyirazinyoye L, Tichacek A, Kaslow N, Price MA, Allen S, Karita E. Uptake of long acting reversible contraception following integrated couples HIV and fertility goal-based family planning counselling in Catholic and non-Catholic, urban and rural government health centers in Kigali, Rwanda. Reprod Health 2020; 17:126. [PMID: 32807177 PMCID: PMC7433361 DOI: 10.1186/s12978-020-00981-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When integrated with couples' voluntary HIV counselling and testing (CVCT), family planning including long acting reversible contraceptives (LARC) addresses prongs one and two of prevention of mother-to-child transmission (PMTCT). METHODS In this observational study, we enrolled equal numbers of HIV concordant and discordant couples in four rural and four urban clinics, with two Catholic and two non-Catholic clinics in each area. Eligible couples were fertile, not already using a LARC method, and wished to limit or delay fertility for at least 2 years. We provided CVCT and fertility goal-based family planning counselling with the offer of LARC and conducted multivariate analysis of clinic, couple, and individual predictors of LARC uptake. RESULTS Of 1290 couples enrolled, 960 (74%) selected LARC: Jadelle 5-year implant (37%), Implanon 3-year implant (26%), or copper intrauterine device (IUD) (11%). Uptake was higher in non-Catholic clinics (85% vs. 63% in Catholic clinics, p < 0.0001), in urban clinics (82% vs. 67% in rural clinics, p < 0.0001), and in HIV concordant couples (79% vs. 70% of discordant couples, p = .0005). Religion of the couple was unrelated to clinic religious affiliation, and uptake was highest among Catholics (80%) and lowest among Protestants (70%) who were predominantly Pentecostal. In multivariable analysis, urban location and non-Catholic clinic affiliation, Catholic religion of woman or couple, younger age of men, lower educational level of both partners, non-use of condoms or injectable contraception at enrollment, prior discussion of LARC by the couple, and women not having concerns about negative side effects of implant were associated with LARC uptake. CONCLUSIONS Fertility goal-based LARC recommendations combined with couples' HIV counselling and testing resulted in a high uptake of LARC methods, even among discordant couples using condoms for HIV prevention, in Catholic clinics, and in rural populations. This model successfully integrates prevention of HIV and unplanned pregnancy.
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Affiliation(s)
| | - Rosine Ingabire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Julien Nyombayire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Andrew Abaasa
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, London, WC1E 7HT, UK
- Medical Research Council, Uganda Vaccine Research Institute & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Gershim Asiki
- Medical Research Council, Uganda Vaccine Research Institute & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Sarah Rae Easter
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin M Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Nadine Kaslow
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA, USA
| | - Matt A Price
- International AIDS Vaccine Initiative, New York, NY, USA
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA, USA
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA.
| | - Etienne Karita
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
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12
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Malama K, Kilembe W, Inambao M, Hoagland A, Sharkey T, Parker R, Wall KM, Tichacek A, Sarkar S, Vwalika B, Haddad L, Chomba E, Allen S. A couple-focused, integrated unplanned pregnancy and HIV prevention program in urban and rural Zambia. Am J Obstet Gynecol 2020; 222:S915.e1-S915.e10. [PMID: 31945337 PMCID: PMC8377731 DOI: 10.1016/j.ajog.2020.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Zambia's total fertility rate (5 births per woman) and adult HIV prevalence (11.5%) are among the highest in the world, with heterosexual couples being the most affected group. Jointly counseling and testing couples for HIV has reduced up to 58% of new HIV infections in Zambian clinics. Married women using contraceptives in Zambia have a high (20%) unmet need for family planning and low (8.6%) uptake of cost-effective long-acting reversible contraceptives. We present an integrated counseling, testing, and family-planning program to prevent HIV and unplanned pregnancy in Zambia. OBJECTIVE The objective of this study was to integrate effective HIV prevention and family-planning services for Zambian couples. STUDY DESIGN A 3 year program (2013-2016) progressively integrated the promotion and provision of couples' voluntary HIV counseling and testing and long-acting reversible contraceptives. The program was based in 55 urban and 215 rural government clinics across 33 districts. In the first year, a couples' family-planning counseling training program was developed and combined with existing couples HIV counseling training materials. To avoid congestion during routine clinic hours, joint counseling services were initially provided on weekends, while nurses were trained in intrauterine device and hormonal implant insertion and removal during weekday family-planning services. Demand was created through mutual referral between weekend and weekday programs and by clinic staff, community health workers, and satisfied family-planning clients. When the bulk of integrated service training was completed, the program transitioned services to routine weekday clinic hours, ensuring access to same-day services. Performance indicators included number of staff trained, clients served, integrated service referrals, HIV infections averted, and unplanned pregnancies averted. RESULTS A stepwise approach trained high-performing service providers to be trainers and used high-volume clinics for practicum training of the next generation. In total, 1201 (391 urban, 810 rural) counselors were trained and served 120,535 urban and 87,676 rural couples. In urban clinics, 236 nurses inserted 65,619 long-acting reversible contraceptives, while in rural clinics, 243 nurses inserted 35,703 implants and intrauterine devices. The program prevented an estimated 12,869 urban and 8279 rural adult HIV infections, and 98,626 unintended urban pregnancies. In the final year, the proportion of clients receiving joint counseling services on weekdays rose from 11% to 89%, with many referred from within clinics including HIV testing and treatment services (32%), outpatient department (31%), family planning (16%), and infant vaccination (15%). The largest group of clients requesting long-acting reversible contraceptives (45%) did so after joint fertility goal-based counseling, confirming the high impact of this couple-focused demand creation approach. Remaining family-planning clients responded to referrals from clinic nurses (34%), satisfied implant/intrauterine device users (13%), or community health workers (8%). CONCLUSION Integrated HIV and unplanned pregnancy prevention can be implemented in low-resource public sector facilities. Combination services offered to couples mutually leverage HIV prevention and unplanned pregnancy prevention. The addition of long-acting reversible contraceptives is an important complement to the method mix available in government clinics. Demand creation in the clinic and in the community must be coordinated with a growing supply of well-trained providers.
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Affiliation(s)
- Kalonde Malama
- Aix Marseille University, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de la Santé and Traitement de l'Information Médicale, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azurr, Marseille, France.
| | - William Kilembe
- Zambia Emory HIV Research Project, Rwanda Zambia HIV Research Group, Emory University, Lusaka, Zambia
| | - Mubiana Inambao
- Zambia Emory HIV Research Project, Rwanda Zambia HIV Research Group, Emory University, Lusaka, Zambia; Department of Obstetrics and Gynaecology, Ndola Central Hospital, Ndola, Zambia
| | - Alexandra Hoagland
- Zambia Emory HIV Research Project, Rwanda Zambia HIV Research Group, Emory University
| | - Tyronza Sharkey
- Zambia Emory HIV Research Project, Rwanda Zambia HIV Research Group, Emory University, Lusaka, Zambia
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, the Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA
| | - Kristin M Wall
- Rwanda Zambia HIV Research Group, the Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, the Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA
| | - Supriya Sarkar
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia, School of Medicine, Lusaka, Zambia
| | - Lisa Haddad
- Department of Obstetrics and Gynaecology, School of Medicine, Emory University, Atlanta, GA
| | | | - Susan Allen
- Rwanda Zambia HIV Research Group, the Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA
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13
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Eastment MC, Wanje G, Richardson BA, Nassir F, Mwaringa E, Barnabas RV, Sherr K, Mandaliya K, Jaoko W, McClelland RS. Performance of family planning clinics in conducting recommended HIV counseling and testing in Mombasa County, Kenya: a cross-sectional study. BMC Health Serv Res 2019; 19:665. [PMID: 31521157 PMCID: PMC6744633 DOI: 10.1186/s12913-019-4519-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/09/2019] [Indexed: 11/28/2022] Open
Abstract
Background A high proportion of African women utilize family planning (FP) services. Accordingly, incorporating HIV testing into FP services may strategically target the first WHO 90–90-90 goal of 90% of people living with HIV knowing their status. Methods The objective of this analysis was to determine the proportion of new FP clients counseled and tested for HIV, as well as correlates of HIV testing, in a random sample of 58 FP clinics in Mombasa County, Kenya. Structured interviews of FP clinic managers collected data on characteristics of FP clinics and staff. Study staff performed a 3-month review of FP registers, summarizing new client HIV testing and counseling (HTC). Because overall rates of HTC were quite low, a binary variable was created comparing clinics performing any HIV counseling and/or testing to clinics performing none. Generalized linear models were used to calculate prevalence ratios (PR) and identify correlates of HTC. Factors associated with any HTC with a p-value < 0.10 in univariate analysis were included in a multivariate analysis. Results Of the 58 FP clinics, 26 (45%) performed any counseling for HIV testing, and 23 (40%) performed any HIV testing. Counseling for HIV testing was conducted for 815/4389 (19%) new clients, and HIV testing was performed for 420/4389 (10%). Clinics without trained HIV testing providers uniformly did not conduct HIV counseling and/or testing (0/12 [0%]), while 27/46 (59%) of clinics with ≥1 provider performed some HTC (p < 0.001). In the subset of 46 clinics with ≥1 trained HIV testing provider, correlates of performing HTC included being a public versus non-public clinic (PR 1.70 95%CI 1.01–2.88), and having an HIV comprehensive care center (CCC) onsite (PR 2.05, 95%CI 1.04–4.06). Conclusion Trained HIV testing providers are crucial for FP clinics to perform any HTC. Approaches are needed to increase routine HTC in FP clinics including staffing changes and/or linkages with other testing services (in standalone VCT services or lab facilities) in order to improve the implementation of existing national guidelines. A future cluster randomized trial is planned to test an implementation strategy, the Systems Analysis and Improvement Approach (SAIA) to increase HTC in FP clinics.
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Affiliation(s)
| | - George Wanje
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA.,Fred Hutchinson Cancer Research Center, Vaccine and Infectious Disease Division, Seattle, WA, USA
| | - Faiza Nassir
- Department of Obstetrics and Gynecology, Coast General Hospital, Mombasa, Kenya
| | | | - Ruanne V Barnabas
- Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, Seattle, WA, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Walter Jaoko
- University of Nairobi, Medical Microbiology, Nairobi, Kenya
| | - R Scott McClelland
- Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, Seattle, WA, USA
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14
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Optimal HIV testing strategies for South Africa: a model-based evaluation of population-level impact and cost-effectiveness. Sci Rep 2019; 9:12621. [PMID: 31477764 PMCID: PMC6718403 DOI: 10.1038/s41598-019-49109-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 08/19/2019] [Indexed: 11/26/2022] Open
Abstract
Although many African countries have achieved high levels of HIV diagnosis, funding constraints have necessitated greater focus on more efficient testing approaches. We compared the impact and cost-effectiveness of several potential new testing strategies in South Africa, and assessed the prospects of achieving the UNAIDS target of 95% of HIV-positive adults diagnosed by 2030. We developed a mathematical model to evaluate the potential impact of home-based testing, mobile testing, assisted partner notification, testing in schools and workplaces, and testing of female sex workers (FSWs), men who have sex with men (MSM), family planning clinic attenders and partners of pregnant women. In the absence of new testing strategies, the diagnosed fraction is expected to increase from 90.6% in 2020 to 93.8% by 2030. Home-based testing combined with self-testing would have the greatest impact, increasing the fraction diagnosed to 96.5% by 2030, and would be highly cost-effective compared to currently funded HIV interventions, with a cost per life year saved (LYS) of $394. Testing in FSWs and assisted partner notification would be cost-saving; the cost per LYS would also be low in the case of testing MSM ($20/LYS) and self-testing by partners of pregnant women ($130/LYS).
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15
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Mutisya R, Wambua J, Nyachae P, Kamau M, Karnad SR, Kabue M. Strengthening integration of family planning with HIV/AIDS and other services: experience from three Kenyan cities. Reprod Health 2019; 16:62. [PMID: 31138271 PMCID: PMC6538540 DOI: 10.1186/s12978-019-0715-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Kenya has made remarkable progress in integrating a range of reproductive health services with HIV/AIDS services over the past decade. This study describes a sub-set of outcomes from the Bill & Melinda Gates Foundation (BMGF)-funded Jhpiego-led Kenya Urban Reproductive Health Initiative (Tupange) Project (2010–2015), specifically addressing strengthening family planning (FP) integration with a range of primary care services including HIV testing and counselling, HIV care services, and maternal, newborn and child care. Methods A cross-sectional study was conducted between August and October 2013 in the cities of Mombasa, Nairobi and Kisumu in Kenya to assess the level of FP integration across six other service delivery areas (antenatal care clinic, maternity wards, postnatal care clinic, child welfare clinic, HIV testing and counseling (HTC) clinics, HIV/AIDS services in comprehensive care clinics). The variables of interest were level of integration, provider knowledge, and provider skills. Routine program monitoring data on workload was utilized for sampling, with additional data collected and analyzed from twenty health facilities selected for this study, along with client exit interviews. Descriptive analysis and Chi-square/ Fishers Exact tests were done to explore relationships between variables of interest. Results Integration of FP occurred in all the five service areas to varying degrees. Service provider FP knowledge in four service delivery areas (HTC clinic, antenatal clinic, postnatal clinic, and child welfare clinic) increased with increasing levels of integration. Forty-seven percent of the clients reported that time spent accessing FP services in the HTC clinic was reasonable. However, no FP knowledge was reported from service providers in HIV/AIDS comprehensive care clinics in all levels of integration despite observed provision of counseling and referral for FP services. Conclusions Integration of FP services in other primary care service areas including HTC clinic can be enhanced through targeted interventions at the facility. A holistic approach to address service providers’ capacity and attitudes, ensuring FP commodity security, and creating a supportive environment to accommodate service integration is necessary and recommended. Additional studies are necessary to identify ways of enhancing FP integration, particularly with HIV/AIDS care services. Electronic supplementary material The online version of this article (10.1186/s12978-019-0715-8) contains supplementary material, which is available to authorized users.
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16
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Narasimhan M, Yeh PT, Haberlen S, Warren CE, Kennedy CE. Integration of HIV testing services into family planning services: a systematic review. Reprod Health 2019; 16:61. [PMID: 31138307 PMCID: PMC6538541 DOI: 10.1186/s12978-019-0714-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Despite significant interest in integrating sexual and reproductive health (SRH) services into HIV services, less attention has been paid to linkages in the other direction. Where women and girls are at risk of HIV, offering HIV testing services (HTS) during their visits to family planning (FP) services offers important opportunities to address both HIV and unwanted pregnancy needs simultaneously. METHODS We conducted a systematic review of studies comparing FP services with integrated HTS to those without integrated HTS or with a lower level of integration (e.g., referral versus on-site services), on the following outcomes: uptake/counseling/offer of HTS, new cases of HIV identified, linkage to HIV care and treatment, dual method use, client satisfaction and service quality, and provider knowledge and attitudes about integrating HTS. We searched three online databases and included studies published in a peer-reviewed journal prior to the search date of June 20, 2017. RESULTS Of 530 citations identified, six studies ultimately met the inclusion criteria. Three studies were conducted in Kenya, and one each in Uganda, Swaziland, and the USA. Most were in FP clinics. Three were from the Integra Initiative. Overall rigor was moderate, with one cluster-randomized trial. HTS uptake was generally higher with integrated sites versus comparison or pre-integration sites, including in adjusted analyses, though outcomes varied slightly across studies. One study found that women at integrated sites were more likely to have high satisfaction with services, but experienced longer waiting times. One study found a small increase in HIV seropositivity among female patients testing after full integration, compared to a dedicated HIV tester. No studies comparatively measured linkage to HIV care and treatment, dual method use, or provider knowledge/attitudes. CONCLUSIONS Global progress and success for reaching SRH and HIV targets depends on progress in sub-Saharan Africa, where women bear a high burden of both unintended pregnancy and sexually transmitted infections, including HIV. While the evidence base is limited, it suggests that integration of HTS into FP services is feasible and has potential for positive joint outcomes. The success and scale-up of this approach will depend on population needs and health system factors.
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Affiliation(s)
- Manjulaa Narasimhan
- Department of Reproductive Health and Research and UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme, World Health Organization, Geneva, Switzerland
| | - Ping Teresa Yeh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Sabina Haberlen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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17
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Milford C, Greener LR, Beksinska M, Greener R, Mabude Z, Smit J. Provider understandings of and attitudes towards integration: Implementing an HIV and sexual and reproductive health service integration model, South Africa. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2019; 17:183-192. [PMID: 30003849 DOI: 10.2989/16085906.2018.1478314] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In South Africa, a lack of integration between sexual and reproductive health (SRH) and HIV services has led to lost opportunities in the treatment cascade. In a context of high HIV, tuberculosis (TB) and unplanned pregnancies, a model for integrating SRH and HIV services was implemented in a hospital and six feeder clinics in KwaZulu-Natal, South Africa. Changes in healthcare provider knowledge, attitudes and understandings were explored following model implementation. Baseline data were collected via focus group discussions (FGDs) and a cross-sectional survey, and were used to inform the development of a model for integrating SRH and HIV services. Following the implementation of the model, an endline survey was conducted to explore any changes. Four FGDs were conducted with healthcare providers at study facilities. A total of 46 providers participated in the baseline survey, and 44 in the endline survey. Qualitative data were thematically analysed using NVivo 11, and quantitative data were descriptively analysed using SPSS 24. The understanding of integration improved by endline. Integration of services was considered important for reducing stigma and increasing access to and improving quality of care. Concerns raised were that integration would increase workload and time per client. Physical structure of facilities was not always conducive to referral or integration. Perceived benefits of integration and actual integration of services improved between baseline and endline. Enhanced understanding of integration and increased levels of reported integration over time imply that providers are more aware, suggesting that the model was effective. Provider perspectives and understandings are important for the successful integration of services. This integration model is relevant and useful to inform training and mentoring of providers, as well as to provide recommendations for policy implementation.
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Affiliation(s)
- Cecilia Milford
- a MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences , University of the Witwatersrand , Durban , South Africa
| | - Letitia Rambally Greener
- a MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences , University of the Witwatersrand , Durban , South Africa
| | - Mags Beksinska
- a MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences , University of the Witwatersrand , Durban , South Africa
| | - Ross Greener
- a MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences , University of the Witwatersrand , Durban , South Africa
| | - Zonke Mabude
- a MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences , University of the Witwatersrand , Durban , South Africa
| | - Jenni Smit
- a MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences , University of the Witwatersrand , Durban , South Africa
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18
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Milford C, Beksinska M, Greener LR, Mabude Z, Smit J. Implementation of a sexual and reproductive health service integration model: South African providers’ reports. COGENT MEDICINE 2019. [DOI: 10.1080/2331205x.2019.1592740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Cecilia Milford
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Mags Beksinska
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Letitia Rambally Greener
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Zonke Mabude
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Jennifer Smit
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
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19
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Hauck K, Morton A, Chalkidou K, Chi YL, Culyer A, Levin C, Meacock R, Over M, Thomas R, Vassall A, Verguet S, Smith PC. How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations. Soc Sci Med 2019; 220:141-149. [PMID: 30428401 PMCID: PMC6323413 DOI: 10.1016/j.socscimed.2018.10.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/22/2018] [Accepted: 10/31/2018] [Indexed: 11/23/2022]
Abstract
Health interventions often depend on a complex system of human and capital infrastructure that is shared with other interventions, in the form of service delivery platforms, such as healthcare facilities, hospitals, or community services. Most forms of health system strengthening seek to improve the efficiency or effectiveness of such delivery platforms. This paper presents a typology of ways in which health system strengthening can improve the economic efficiency of health services. Three types of health system strengthening are identified and modelled: (1) investment in the efficiency of an existing shared platform that generates positive benefits across a range of existing interventions; (2) relaxing a capacity constraint of an existing shared platform that inhibits the optimization of existing interventions; (3) providing an entirely new shared platform that supports a number of existing or new interventions. Theoretical models are illustrated with examples, and illustrate the importance of considering the portfolio of interventions using a platform, and not just piecemeal individual analysis of those interventions. They show how it is possible to extend principles of conventional cost-effectiveness analysis to identify an optimal balance between investing in health system strengthening and expenditure on specific interventions. The models developed in this paper provide a conceptual framework for evaluating the cost-effectiveness of investments in strengthening healthcare systems and, more broadly, shed light on the role that platforms play in promoting the cost-effectiveness of different interventions.
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Affiliation(s)
- K Hauck
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, Medical School Building, St Mary's Campus, London, W2 1PG, United Kingdom.
| | - A Morton
- Department of Management Science, Strathclyde Business School, University of Strathclyde, 199 Cathedral Street, Glasgow, G4 0QU, United Kingdom.
| | - K Chalkidou
- Center for Global Development, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, Medical School Building, St Mary's Campus, London, W2 1PG, United Kingdom.
| | - Y-Ling Chi
- Global Health and Development Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, Medical School Building, St Mary's Campus, London, W2 1PG, United Kingdom.
| | - A Culyer
- Department of Economics and Related Studies, University of York, Heslington, York, YO10 5DD, United Kingdom.
| | - C Levin
- Department of Global Health, University of Washington, NJB Box #359931, 325 Ninths Avenue, Seattle, WA, 98104, USA.
| | - R Meacock
- Centre for Primary Care, The University of Manchester, 4.311 Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, United Kingdom.
| | - M Over
- Center for Global Development, 2055 L Street NW, Fifth Floor, Washington, DC, 20036, USA.
| | - R Thomas
- Department of Health Policy, London School of Economics and Political Science, Cowdray House, Houghton Street, London, WC2A 2AE, United Kingdom.
| | - A Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
| | - S Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.
| | - P C Smith
- Imperial College Business School, Imperial College London, South Kensington Campus, London, SW7 2AZ, United Kingdom.
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Milford C, Scorgie F, Rambally Greener L, Mabude Z, Beksinska M, Harrison A, Smit J. Developing a model for integrating sexual and reproductive health services with HIV prevention and care in KwaZulu-Natal, South Africa. Reprod Health 2018; 15:189. [PMID: 30442150 PMCID: PMC6238282 DOI: 10.1186/s12978-018-0633-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are few rigorous studies evaluating the benefits of vertical versus integrated delivery of healthcare services, and limited published studies describing conceptual models of integration at service-delivery level in public healthcare facilities. This article seeks to fill this gap, by describing the development of a district-based model for integrating sexual and reproductive health (SRH) and HIV services in KwaZulu-Natal, South Africa. METHODS Baseline data were collected from seven urban public healthcare facilities through client and provider interviews, and a facility inventory was completed to assess current service integration practices. Feedback sessions were held with health providers from participating facilities to share data collected and explore appropriate integration scenarios. A conceptual model of potential service integration was then designed, and subsequently implemented and evaluated in the research sites. RESULTS Key principles of the model included a focus on health system strengthening and strong community input and involvement. The model was designed primarily to support the integration of family planning into HIV services, and included measures to improve client and commodity monitoring; capacity building through training and mentorship; and a 'health navigation' strategy to strengthen referrals within and between public healthcare facilities. Endline evaluation data were collected in the same facilities following implementation of the model. CONCLUSIONS This manuscript demonstrates the utility of the conceptual model. It shows that service integration can be accomplished in a phased manner with support of community and healthcare providers. In addition, local context must be taken into account and the components of the model should be flexible to suit the needs of the health system.
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Affiliation(s)
- Cecilia Milford
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa.
| | - Fiona Scorgie
- Wits RHI (Reproductive Health and HIV Institute), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Letitia Rambally Greener
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa.,Wits RHI (Reproductive Health and HIV Institute), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Zonke Mabude
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Mags Beksinska
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Abigail Harrison
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Jennifer Smit
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
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Birdthistle IJ, Fenty J, Collumbien M, Warren C, Kimani J, Ndwiga C, Mayhew S. Integration of HIV and reproductive health services in public sector facilities: analysis of client flow data over time in Kenya. BMJ Glob Health 2018; 3:e000867. [PMID: 30245866 PMCID: PMC6144905 DOI: 10.1136/bmjgh-2018-000867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/24/2018] [Accepted: 05/28/2018] [Indexed: 11/07/2022] Open
Abstract
Introduction Integration of HIV/AIDS with reproductive health (RH) services can increase the uptake and efficiency of services, but gaps in knowledge remain about the practice of integration, particularly how provision can be expanded and performance enhanced. We assessed the extent and nature of service integration in public sector facilities in four districts in Kenya. Methods Between 2009 and 2012, client flow assessments were conducted at six time points in 24 government facilities, purposively selected as intervention or comparison sites. A total of 25 539 visits were tracked: 15 270 in districts where 6 of 12 facilities received an intervention to strengthen HIV service integration with family planning (FP); and 10 266 visits in districts where half the facilities received an HIV-postnatal care intervention in 2009–2010. We tracked the proportion of all visits in which: (1) an HIV service (testing, counselling or treatment) was received together with an RH service (FP counselling or provision, antenatal care, or postnatal care); (2) the client received HIV counselling. Results Levels of integrated HIV-RH services and HIV counselling were generally low across facilities and time points. An initial boost in integration was observed in most intervention sites, driven by integration of HIV services with FP counselling and provision, and declined after the first follow-up. Integration at most sites was driven by temporary rises in HIV counselling. The most consistent combination of HIV services was with antenatal care; the least common was with postnatal care. Conclusions These client flow data demonstrated a short-term boost in integration, after an initial intervention with FP services providing an opportunity to expand integration. Integration was not sustained over time highlighting the need for ongoing support. There are multiple opportunities for integrating service delivery, particularly within antenatal, FP and HIV counselling services, but a need for sustained systems and health worker support over time. Trial registration number NCT01694862
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Affiliation(s)
- Isolde J Birdthistle
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Justin Fenty
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Martine Collumbien
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Susannah Mayhew
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Mackenzie D, Pfitzer A, Maly C, Waka C, Singh G, Sanyal A. Postpartum family planning integration with maternal, newborn and child health services: a cross-sectional analysis of client flow patterns in India and Kenya. BMJ Open 2018; 8:e018580. [PMID: 29615443 PMCID: PMC5892750 DOI: 10.1136/bmjopen-2017-018580] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Maternal, newborn and child health (MNCH) services represent opportunities to integrate postpartum family planning (PPFP). Objectives were to determine levels of MNCH-family planning (FP) integration and associations between integration, client characteristics and service delivery factors in facilities that received programmatic PPFP support. DESIGN AND SETTING Cross-sectional client flow assessment conducted during May-July 2014, over 5 days at 10 purposively selected public sector facilities in India (4 hospitals) and Kenya (2 hospitals and 4 health centres). PARTICIPANTS 2158 client visits tracked (1294 India; 864 Kenya). Women aged 18 or older accessing services while pregnant and/or with a child under 2 years. INTERVENTIONS PPFP/postpartum intrauterine device-Bihar, India (2012-2013); Jharkhand, India (2009-2014); Embu, Kenya (2006-2010). Maternal, infant and young child nutrition/FP integration-Bondo, Kenya (2011-2014). PRIMARY OUTCOME MEASURES Proportion of visits where clients received integrated MNCH-FP services, client characteristics as predictors of MNCH-FP integration and MNCH-FP integration as predictor of length of time spent at facility. RESULTS Levels of MNCH-FP integration varied widely across facilities (5.3% to 63.0%), as did proportion of clients receiving MNCH-FP integrated services by service area. Clients travelling 30-59 min were half as likely to receive integrated services versus those travelling under 30 min (OR 0.5, 95% CI 0.4 to 0.7, P<0.001). Clients receiving MNCH-FP services (vs MNCH services only) spent an average of 10.5 min longer at the facility (95% CI -0.1 to 21.9, not statistically significant). CONCLUSIONS Findings suggest importance of focused programmatic support for integration by MNCH service area. FP integration was highest in areas receiving specific support. Integration does not seem to impose an undue burden on clients in terms of time spent at the facility. Clients living furthest from facilities are least likely to receive integrated services.
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Affiliation(s)
- Devon Mackenzie
- Jhpiego/Maternal and Child Survival Program, Washington, DC, USA
| | - Anne Pfitzer
- Jhpiego/Maternal and Child Survival Program, Washington, DC, USA
| | | | | | | | - Abanti Sanyal
- Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Mutemwa R, Mayhew SH, Warren CE, Abuya T, Ndwiga C, Kivunaga J. Does service integration improve technical quality of care in low-resource settings? An evaluation of a model integrating HIV care into family planning services in Kenya. Health Policy Plan 2017; 32:iv91-iv101. [PMID: 29194543 PMCID: PMC5886058 DOI: 10.1093/heapol/czx090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 12/29/2022] Open
Abstract
The aim of this study was to investigate association between HIV and family planning integration and technical quality of care. The study focused on technical quality of client-provider consultation sessions. The cross-sectional study observed 366 client-provider consultation sessions and interviewed 37 health care providers in 12 public health facilities in Kenya. Multilevel random intercept and linear regression models were fitted to the matched data to investigate relationships between service integration and technical quality of care as well as associations between facility-level structural and provider factors and technical quality of care. A sensitivity analysis was performed to test for hidden bias. After adjusting for facility-level structural factors, HIV/family planning integration was found to have significant positive effect on technical quality of the consultation session, with average treatment effect 0.44 (95% CI: 0.63-0.82). Three of the 12 structural factors were significantly positively associated with technical quality of consultation session including: availability of family planning commodities (9.64; 95% CI: 5.07-14.21), adequate infrastructure (5.29; 95% CI: 2.89-7.69) and reagents (1.48; 95% CI: 1.02-1.93). Three of the nine provider factors were significantly positively associated with technical quality of consultation session: appropriate provider clinical knowledge (3.14; 95% CI: 1.92-4.36), job satisfaction (2.02; 95% CI: 1.21-2.83) and supervision (1.01; 95% CI: 0.35-1.68), while workload (-0.88; 95% CI: -1.75 to - 0.01) was negatively associated. Technical quality of the client-provider consultation session was also determined by duration of the consultation and type of clinic visit and appeared to depend on whether the clinic visit occurred early or later in the week. Integration of HIV care into family planning services can improve the technical quality of client-provider consultation sessions as measured by both health facility structural and provider factors.
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Affiliation(s)
- Richard Mutemwa
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Susannah H Mayhew
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Charlotte E Warren
- Population Council, 4301 Connecticut Avenue NW, Suite 280 Washington, DC 20008 United States
| | - Timothy Abuya
- Population Council, Ralph Bunche Rd, Upper Hill, Nairobi, Kenya
| | - Charity Ndwiga
- Population Council, Ralph Bunche Rd, Upper Hill, Nairobi, Kenya
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Mayhew SH, Sweeney S, Warren CE, Collumbien M, Ndwiga C, Mutemwa R, Lut I, Colombini M, Vassall A. Numbers, systems, people: how interactions influence integration. Insights from case studies of HIV and reproductive health services delivery in Kenya. Health Policy Plan 2017; 32:iv67-iv81. [PMID: 29194544 PMCID: PMC5886080 DOI: 10.1093/heapol/czx097] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 11/12/2022] Open
Abstract
Drawing on rich data from the Integra evaluation of integrated HIV and reproductive-health services, we explored the interaction of systems hardware and software factors to explain why some facilities were able to implement and sustain integrated service delivery while others were not. This article draws on detailed mixed-methods data for four case-study facilities offering reproductive-health and HIV services between 2009 and 2013 in Kenya: (i) time-series client flow, tracking service uptake for 8841 clients; (ii) structured questionnaires with 24 providers; (iii) in-depth interviews with 17 providers; (iv) workload and facility data using a periodic activity review and cost-instruments; and (v) contextual data on external activities related to integration in study sites. Overall, our findings suggested that although structural factors like stock-outs, distribution of staffing and workload, rotation of staff can affect how integrated care is provided, all these factors can be influenced by staff themselves: both frontline and management. Facilities where staff displayed agency of decision making, worked as a team to share workload and had management that supported this, showed better integration delivery and staff were able to overcome some structural deficiencies to enable integrated care. Poor-performing facilities had good structural integration, but staff were unable to utilize this because they were poorly organized, unsupported or teams were dysfunctional. Conscientious objection and moralistic attitudes were also barriers.Integra has demonstrated that structural integration is not sufficient for integrated service delivery. Rather, our case studies show that in some cases excellent leadership and peer-teamwork enabled facilities to perform well despite resource shortages. The ability to provide support for staff to work flexibly to deliver integrated services and build resilient health systems to meet changing needs is particularly relevant as health systems face challenges of changing burdens of disease, climate change, epidemic outbreaks and more.
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Affiliation(s)
- Susannah H Mayhew
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Sedona Sweeney
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Martine Collumbien
- Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Richard Mutemwa
- Centre for Infectious Disease Control – Zambia (CIDRZ), Zambia
| | | | - Integra Initiative
- Full list of Integra Initiative team members is provided in the Acknowledgements
| | - Manuela Colombini
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Warren CE, Mayhew SH, Hopkins J. The Current Status of Research on the Integration of Sexual and Reproductive Health and HIV Services. Stud Fam Plann 2017; 48:91-105. [PMID: 28493283 PMCID: PMC5518217 DOI: 10.1111/sifp.12024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Integration of services for sexual and reproductive health (SRH) and HIV has been widely promoted globally in the belief that both clients and health providers benefit through improvements in quality, efficient use of resources, and lower costs, helping to maximize limited health resources and provide comprehensive client-centered care. This article builds on the growing body of research on integrated sexual SRH and HIV services. It brings together critical reviews on issues within the wider SRH and rights agenda and synthesizes recent research on integrated services, drawing on the Integra Initiative and other major research. Unintended pregnancy and HIV are intrinsically interrelated SRH issues, however broadening the constellation of services, scaling up, and mainstreaming integration continue to be challenging. Overcoming stigma, reducing gender-based violence, and meeting key populations' SRH needs are critical. Health systems research using SRH as the entry point for integrated services and interaction with communities and clients is needed to realize universal health coverage.
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