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Whidden C, Cissé AB, Cole F, Doumbia S, Guindo A, Karambé Y, Treleaven E, Liu J, Tolo O, Guindo L, Togola B, Chiu C, Tembely A, Keita Y, Greenwood B, Chandramohan D, Johnson A, Kayentao K, Webster J. Community case management to accelerate access to healthcare in Mali: a realist process evaluation nested within a cluster randomized trial. Health Policy Plan 2024; 39:864-877. [PMID: 39058651 PMCID: PMC11384120 DOI: 10.1093/heapol/czae066] [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: 05/07/2023] [Revised: 05/30/2024] [Accepted: 07/25/2024] [Indexed: 07/28/2024] Open
Abstract
The Proactive Community Case Management (ProCCM) trial in Mali reinforced the health system across both arms with user fee removal, professional community health workers (CHWs) and upgraded primary health centres (PHCs)-and randomized village-clusters to receive proactive home visits by CHWs (intervention) or fixed site-based services by passive CHWs (control). Across both arms, sick children's 24-hour treatment and pregnant women's four or more antenatal visits doubled, and under-5 mortality halved, over 3 years compared with baseline. In the intervention arm, proactive CHW home visits had modest effects on children's curative and women's antenatal care utilization, but no effect on under-5 mortality, compared with the control arm. We aimed to explain these results by examining implementation, mechanisms and context in both arms We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs and upgraded clinics interacted with providers' and patients' agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms.
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Affiliation(s)
- Caroline Whidden
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | | | - Faith Cole
- Department of Anthropology, University of California, 375 Portola Plaza, Los Angeles, CA 90095, United States
- Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI 48103, United States
| | - Saibou Doumbia
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Abdoulaye Guindo
- Faculté des Sciences de l'Éducation et des Sciences Humaines, Université des Lettres et des Sciences Humaines de Bamako, Rue 627 Porte 83, Bamako BP E 2528, Mali
| | - Youssouf Karambé
- Institut National de la Jeunesse et des Sports, Bamako J35J+CJF, Mali
| | - Emily Treleaven
- Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI 48103, United States
| | - Jenny Liu
- Institute for Health & Aging, University of California, 490 Illinois Street, San Francisco, CA 94158, United States
| | - Oumar Tolo
- Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Lamine Guindo
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Bréhima Togola
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Calvin Chiu
- School of Public Health, University of California, 2121 Berkeley Way, Berkeley, CA 94704, United States
| | - Aly Tembely
- Ministère de la Santé et du Développement Social, Cité Administrative, Bamako JXGR+R48, Mali
| | - Youssouf Keita
- Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Brian Greenwood
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Ari Johnson
- Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
- Institute for Global Health Sciences, University of California, 550 16th Street, San Francisco, CA 94110, United States
| | - Kassoum Kayentao
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
- Malaria Research & Training Centre, Université des Sciences, des Techniques et des Technologies de Bamako, Bamako PO Box 1805, Mali
| | - Jayne Webster
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
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Pepito VCF, Amit AML, Tang CS, Co LMB, Aliazas NAK, De Los Reyes SJ, Baquiran RS, Tanchanco LBS. Exposure to family planning messages and teenage pregnancy: results from the 2017 Philippine National Demographic and Health Survey. Reprod Health 2022; 19:229. [PMID: 36544191 PMCID: PMC9769471 DOI: 10.1186/s12978-022-01510-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/06/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Teenage pregnancy is known to have physical, emotional, and psychosocial effects. Because of these risks, family planning and contraception messages have been disseminated in various forms of media, but their association with teenage pregnancy has not been studied previously in the Philippines. This study aims to examine the association between exposure to various family planning and contraception messages disseminated in various media channels and pregnancy among Filipino women aged 15-19. The study also intended to examine interactions between the different media channels where these family planning and contraception messages are being disseminated on their effect on teenage pregnancy. METHODS We used data from the individual recode of the 2017 Philippine National Demographic and Health Survey. We used logistic regression for survey data to study the association between exposure to family planning and contraception messages and teenage pregnancy. RESULTS Out of 5120 respondents, 44% of respondents have accessed information on contraception from the internet, 25% have heard information about contraception through the radio, 55% of respondents have heard about contraception via television, 15% have read about contraception in the newspapers and magazines, and only 6% have received information on contraception via short messaging service (SMS). There were 420 (8.56%) who have ever been pregnant. After adjusting for confounding variables, those who were exposed to family planning/contraceptive messages via the internet (aOR: 0.90; 95% CI: 0.59, 1.35) and newspapers/magazines (aOR: 0.78; 95% CI: 0.44, 1.41) have lower odds of teenage pregnancy, but no strong evidence of their effectiveness. On the other hand, exposure to family planning messages through the radio (aOR: 1.06; 95% CI: 0.71, 1.59), television (aOR: 1.09; 95% CI: 0.72, 1.65), and short messaging service (aOR: 1.29; 95% CI: 0.51, 3.22) marginally increase the risk of teenage pregnancy. We did not find any pairwise interactions between the different exposure variables. CONCLUSIONS Our results highlight the need to improve the content and key messages of contraceptive and family planning messages in the Philippines, especially those that are broadcasted online and in print media. There is also a need to increase the reach of these different family planning and contraception messages, especially by utilizing social media and other print and online media platforms commonly used by the youth.
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Affiliation(s)
- Veincent Christian F. Pepito
- grid.443223.00000 0004 1937 1370School of Medicine and Public Health, Ateneo de Manila University, Pasig, Philippines
| | - Arianna Maever L. Amit
- grid.443223.00000 0004 1937 1370School of Medicine and Public Health, Ateneo de Manila University, Pasig, Philippines ,grid.11159.3d0000 0000 9650 2179National Clinical Trials and Translation Center, National Institutes of Health, University of the Philippines Manila, Manila, Philippines
| | - Clinton S. Tang
- grid.443223.00000 0004 1937 1370School of Medicine and Public Health, Ateneo de Manila University, Pasig, Philippines
| | - Luis Miguel B. Co
- grid.443223.00000 0004 1937 1370School of Medicine and Public Health, Ateneo de Manila University, Pasig, Philippines
| | - Neil Andrew K. Aliazas
- grid.443223.00000 0004 1937 1370School of Medicine and Public Health, Ateneo de Manila University, Pasig, Philippines
| | - Sarah J. De Los Reyes
- grid.443223.00000 0004 1937 1370School of Medicine and Public Health, Ateneo de Manila University, Pasig, Philippines ,Dr. Fe del Mundo Medical Center, Quezon, Philippines
| | - Raymundo S. Baquiran
- grid.443223.00000 0004 1937 1370School of Medicine and Public Health, Ateneo de Manila University, Pasig, Philippines
| | - Lourdes Bernadette S. Tanchanco
- grid.443223.00000 0004 1937 1370School of Medicine and Public Health, Ateneo de Manila University, Pasig, Philippines ,The Medical City, Pasig, Philippines ,MedMom Institute for Human Development, Mandaluyong, Philippines
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Baynes C, Steyn P, Soi C, Dinis A, Tembe S, Mehrtash H, Narasimhan M, Kiarie J, Sherr K. Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review. Front Glob Womens Health 2022; 3:1038297. [PMID: 36561275 PMCID: PMC9763469 DOI: 10.3389/fgwh.2022.1038297] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
Objective As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC. Design and methods We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007-2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned. Results Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners. Conclusions IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.
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Affiliation(s)
- Colin Baynes
- Department of Global Health, University of Washington, Seattle, WA, United States,Correspondence: Colin Baynes
| | - Petrus Steyn
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - Caroline Soi
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Aneth Dinis
- Department of Global Health, University of Washington, Seattle, WA, United States,The National Directorate of Public Health, Ministry of Health of Mozambique, Maputo, Mozambique
| | - Stelio Tembe
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Hedieh Mehrtash
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Manjulaa Narasimhan
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - James Kiarie
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States,Department of Epidemiology, University of Washington, Seattle, WA, United States,Department of Industrial and Systems Engineering, University of Washington, Seattle, WA, United States
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Butalid RM, Vequizo RM, Resurreccion PF. Fertility tracking tool for visually impaired and non-visually impaired women: A qualitative study. BELITUNG NURSING JOURNAL 2022; 8:266-274. [PMID: 37547120 PMCID: PMC10401369 DOI: 10.33546/bnj.1949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/21/2021] [Accepted: 05/04/2022] [Indexed: 08/08/2023] Open
Abstract
Background A natural family planning device, Fertility Tracking Tool (FTT), was developed to serve as a visual and tactile guide in monitoring the fertile and infertile days of the menstrual cycle. However, there is lack of preferences about the tool among visually impaired and non-visually impaired women. Therefore, understanding their viewpoints will provide additional input for the final design of the product. Objective This study aimed to explore the opinions of potential users of FTT in terms of acceptability, price sensitivity, buying intention, product placement, branding, and packaging. Methods The study employed a qualitative research design with data gathered from focus group discussions. Eleven FGD sessions were conducted participated by one group of visually impaired and ten groups of non-visually impaired women from Iligan City, Philippines, selected through purposive sampling technique. Semi-structured FGD guide was utilized, and the sessions were audio-recorded. The data were analyzed through thematic analysis. Results The themes that emerged in the study were "adaptable" with three sub-themes (easy to use, safe to use, and aesthetic), "cost-effective", "marketable", "accessibility convenience", "remarkable brand", and "complementary packaging". The study shows that the FTT is acceptable to both visually impaired and non-visually impaired women because it is user-friendly, has no side effects, and has a unique design. The accounts implying less price sensitivity, buying intention, accessibility preferences, notable branding, and auxiliary packaging are indications of the business potential of FTT. Conclusion This study made a novel contribution to the nursing practice as the FTT is a newly invented device for natural family planning. The strong support from the government is necessary for FTT commercialization or even free distribution to the qualified users, not only in the research locale but extending the nationwide. The extensive FTT use may increase the natural contraceptive utilization in the Philippines, resulting in improved women's health and population control. The FTT utilization can also be adapted across the globe to result in a better impact.
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Affiliation(s)
- Roselyn M. Butalid
- College of Nursing, Mindanao State University-Iligan Institute of Technology, Iligan City, Philippines
| | - Reynaldo M. Vequizo
- College of Science and Mathematics, Mindanao State University-Iligan Institute of Technology, Iligan City, Philippines
| | - Pamela F. Resurreccion
- College of Economics, Business and Accountancy, Mindanao State University-Iligan Institute of Technology, Iligan City, Philippines
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Hoyt J, Hamon JK, Krishnaratne S, Houndekon E, Curry D, Mbembe M, Marcus S, Kambanje M, Pryor S, Barbra AA, Muhumuza H, Spilotros N, Webster J. "It was my own decision": the transformational shift that influences a woman's decision to use contraceptives covertly. BMC Womens Health 2022; 22:144. [PMID: 35501811 PMCID: PMC9063140 DOI: 10.1186/s12905-022-01731-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/21/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Family planning (FP) is an important element of sexual and reproductive health and rights, but socio-cultural barriers and unbalanced gender relations often limit women's decision-making about contraceptive use. Covert contraceptive use (CCU) exemplifies the limits on women's decision-making and represents a way in which some women overcome constraints to achieve their reproductive goals. This study explores the decision-making process through which women choose to use contraceptives covertly. METHODS A qualitative synthesis was conducted using data from women, health providers, community members, health administrators, and intervention implementers (n = 400) to explore the decision-making process through which women choose to use contraceptives covertly. Interviews and focus group discussions were conducted at two time points as part of an evaluation of interventions integrating FP and childhood immunisation services at sites in Benin, Kenya, Malawi and Uganda. The sexual and reproductive health empowerment framework by Karp et al. (2020) was adapted and used to guide the analysis. RESULTS Women recognised that although they suffered the negative consequences of frequent pregnancies and of raising large families, they lacked overt decision-making power over their fertility. Women were confident to engage in CCU because they believed their husbands did not understand these consequences nor acknowledged their suffering, which justified not informing them. CCU was a difficult choice however, women felt comfortable voicing their reproductive preferences in settings where health providers were supportive. CONCLUSIONS Women chose to use contraceptives covertly when they questioned the unfairness of their situation and recognised their own power to act in accordance with their reproductive preferences. This represented an important shift in a woman's perception of who is entitled to make decisions about contraceptive use. Importantly, health providers can play a key role in supporting women's autonomous decision making about contraceptive use and should be careful not to undermine women's confidence.
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Affiliation(s)
- Jenna Hoyt
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Jessie K. Hamon
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Shari Krishnaratne
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | | | | | | | | | | | - Jayne Webster
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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Krishnaratne S, Hoyt J, Hamon JK, Ariko AB, Atayo C, Morukileng J, Spilotros N, Webster J. Acceptability of family planning in a changing context in Uganda: a realist evaluation at two time points. BMJ Open 2022; 12:e054277. [PMID: 35396286 PMCID: PMC8995957 DOI: 10.1136/bmjopen-2021-054277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES This study sought to understand, during an intervention which integrated family planning (FP) and immunisation, (1) if and how prevailing contextual factors influenced acceptability and use of modern contraceptive methods (MCMs) in a pastoral community in Uganda, (2) what mechanisms were triggered by these contextual factors (3) if these contextual factors changed between two time points 2 years apart and (4) the impact of contextual changes on mechanisms triggered and acceptability and use outcomes. DESIGN Qualitative realist evaluation over two time points. SETTING Government health facilities in Moroto District, Karamoja, Uganda. PARTICIPANTS 69 participants involved in the delivery and uptake of integrated FP and childhood immunisation services. INTERVENTION Integrated delivery of FP and childhood immunisation services offered to women accessing immunisation services in health facilities between January 2016 and December 2019. RESULTS Four key themes were identified that encompassed context and mechanisms influencing acceptability of MCMs across both time points of the evaluation. These were: (1) fear of side effects of MCMs; (2) preference for natural FP methods; (3) pastoral lifestyles in the community and (4) food insecurity. The context of these themes changed over time leading to the triggering of mechanisms with an overall increase in acceptability of MCMs over time. Key mechanisms of acceptability triggered included: affective attitude, intervention coherence, self-efficacy, perceived effectiveness and opportunity cost, leading to the development of three context-acceptability theories. CONCLUSIONS In this study, social and cultural norms played a strong role in influencing acceptability of the intervention. The context combined with intervention components were found to trigger several mechanisms that mapped to constructs of diffusion of innovations and acted as catalysts for mechanisms of acceptability. The context in which the intervention was implemented changed leading to the triggering of mechanisms and an increase in the perceived value and acceptability of MCM use.
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Affiliation(s)
- Shari Krishnaratne
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenna Hoyt
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jessie K Hamon
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Carol Atayo
- International Rescue Committee Uganda, Moroto, Uganda
| | - Job Morukileng
- Uganda Public Health Fellowship Programme, Kampala, Uganda
| | | | - Jayne Webster
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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O'Malley G, Beima-Sofie KM, Roche SD, Rousseau E, Travill D, Omollo V, Delany-Moretlwe S, Bekker LG, Bukusi EA, Kinuthia J, Barnabee G, Dettinger JC, Wagner AD, Pintye J, Morton JF, Johnson RE, Baeten JM, John-Stewart G, Celum CL. Health Care Providers as Agents of Change: Integrating PrEP With Other Sexual and Reproductive Health Services for Adolescent Girls and Young Women. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:668672. [PMID: 36303982 PMCID: PMC9580786 DOI: 10.3389/frph.2021.668672] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/22/2021] [Indexed: 10/07/2023] Open
Abstract
Background: Successful integration of pre-exposure prophylaxis (PrEP) with existing reproductive health services will require iterative learning and adaptation. The interaction between the problem-solving required to implement new interventions and health worker motivation has been well-described in the public health literature. This study describes structural and motivational challenges faced by health care providers delivering PrEP to adolescent girls and young women (AGYW) alongside other SRH services, and the strategies used to overcome them. Methods: We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with HCWs from two demonstration projects delivering PrEP to AGYW alongside other SRH services. The Prevention Options for the Women Evaluation Research (POWER) is an open label PrEP study with a focus on learning about PrEP delivery in Kenyan and South African family planning, youth mobile services, and public clinics at six facilities. PrIYA focused on PrEP delivery to AGYW via maternal and child health (MCH) and family planning (FP) clinics in Kenya across 37 facilities. IDIs and FGDs were transcribed verbatim and analyzed using a combination of inductive and deductive methods. Results: We conducted IDIs with 36 participants and 8 FGDs with 50 participants. HCW described a dynamic process of operationalizing PrEP delivery to better respond to patient needs, including modifying patient flow, pill packaging, and counseling. HCWs believed the biggest challenge to sustained integration and scaling of PrEP for AGYW would be lack of health care worker motivation, primarily due to a misalignment of personal and professional values and expectations. HCWs frequently described concerns of PrEP provision being seen as condoning or promoting unprotected sex among young unmarried, sexually active women. Persuasive techniques used to overcome these reservations included emphasizing the social realities of HIV risk, health care worker professional identities, and vocational commitments to keeping young women healthy. Conclusion: Sustained scale-up of PrEP will require HCWs to value and prioritize its incorporation into daily practice. As with the provision of other SRH services, HCWs may have moral reservations about providing PrEP to AGYW. Strategies that strengthen alignment of HCW personal values with professional goals will be important for strengthening motivation to overcome delivery challenges.
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Affiliation(s)
- Gabrielle O'Malley
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | - Stephanie D. Roche
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Elzette Rousseau
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Danielle Travill
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Victor Omollo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Elizabeth A. Bukusi
- Department of Global Health, University of Washington, Seattle, WA, United States
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Departments of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Gena Barnabee
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Julie C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jennifer F. Morton
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Rachel E. Johnson
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Connie L. Celum
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
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Hoyt J, Krishnaratne S, Hamon JK, Boudarene L, Chantler T, Demissie SD, Landegger J, Moseti E, Marcus S, Kambanje M, Pryor S, Spilotros N, Gnintoungbe M, Curry D, Webster J. "As a woman who watches how my family is… I take the difficult decisions": a qualitative study on integrated family planning and childhood immunisation services in five African countries. Reprod Health 2021; 18:41. [PMID: 33588879 PMCID: PMC7885443 DOI: 10.1186/s12978-021-01091-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 01/27/2021] [Indexed: 11/10/2022] Open
Abstract
Background Family planning (FP) has the potential to improve maternal and child health outcomes and to reduce poverty in sub-Saharan Africa. However, substantial unmet need for modern contraceptive methods (MCMs) persists in this region. Current literature highlights multi-level barriers, including socio-cultural norms that discourage the use of MCMs. This paper explores women’s choices and decision-making around MCM use and examines whether integrating FP services with childhood immunisations influenced women’s perceptions of, and decision to use, an MCM. Methods 94 semi-structured interviews and 21 focus group discussions with women, health providers, and community members (N = 253) were conducted in health facilities and outreach clinics where an intervention was delivering integrated FP and childhood immunisation services in Benin, Ethiopia, Kenya, Malawi and Uganda. Data were coded using Nvivo software and an analytical framework was developed to support interpretative and thematic analyses on women’s decision-making about MCM use. Results Most women shared the reproductive desire to space or limit births because of the perceived benefits of improved health and welfare for themselves and for their children, including the economic advantages. For some, choices about MCM use were restricted because of wider societal influences. Women’s decision to use MCMs was driven by their reproductive desires, but for some that was stymied by fears of side effects, community stigma, and disapproving husbands, which led to clandestine MCM use. Health providers acknowledged that women understood the benefits of using MCMs, but highlighted that the wider socio-cultural norms of their community often contributed to a reluctance to use them. Integration of FP and childhood immunisation services provided repeat opportunities for health providers to counter misinformation and it improved access to MCMs, including for women who needed to use them covertly. Conclusions Some women chose to use MCMs without the approval of their husbands, and/or despite cultural norms, because of the perceived health and economic benefits for themselves and for their families, and because they lived with the consequences of short birth intervals and large families. Integrated FP and childhood immunisation services expanded women’s choices about MCM use and created opportunities for women to make decisions autonomously.
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Affiliation(s)
- Jenna Hoyt
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
| | - Shari Krishnaratne
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Jessie K Hamon
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Lydia Boudarene
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Tracey Chantler
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | | | | | | | | | | | - Jayne Webster
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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