Contraceptive uptake after training community health workers in couples counseling: A cluster randomized trial

Strengthening contraceptive counselling services to empower clients and meet their needs: protocol for a two-stage, multiphase complex intervention in Pakistan and Nigeria

BACKGROUND

High-quality contraceptive counselling can accelerate global efforts to reduce the unmet need for and suboptimal use of modern contraceptives. This study aims to identify a package of interventions designed to strengthen in Pakistan and Nigeria and determine their effectiveness in increasing client-level decision-making, autonomy and meeting of contraceptive needs.

METHODS

A multisite, two-stage and five-phase intervention design will start with a pre-formative, formative, design, experimental and reflective phase. The pre-formative phase will map potential study sites and establish the sampling frame. The two-part formative phase will first use participatory approaches to identify clients' perspectives, including young couples and providers, to ensure research contextualisation and address each interest group's needs and priorities followed by clinical observations of client-provider encounters to document routine care. The design workshop in the third phase will result in the development of a package of contraceptive counselling interventions. In the fourth experimental phase, a multi-intervention, three-arm, single-blinded, parallel cluster randomised-controlled trial will compare routine care (arm 1) with the contraceptive counselling package (arm 2) and the same package combined with wider methods availability (arm 3). The study aims to enrol a total of 7920 participants. The reflective phase aims to identify implementation barriers and enablers. The outcomes are clients' level of decision-making autonomy and use of modern contraceptives.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the WHO Scientific and Ethics Review Committee (Protocol ID Pakistan: ERC 006232 and Nigeria ERC: 006523). Each study site is required and has obtained the necessary ethical and regulatory approvals that are required in each specific country. Findings will be presented at local, national and international conferences and disseminated by peer-review publications.

TRIAL REGISTRATION NUMBER

NCT06081842.

Impact of sexual and reproductive health interventions among young people in sub-Saharan Africa: a scoping review

Objectives

The aim of this scoping review was to identify and provide an overview of the impact of sexual and reproductive health (SRH) interventions on reproductive health outcomes among young people in sub-Saharan Africa.

Methods

Searches were carried out in five data bases. The databases were searched using variations and combinations of the following keywords: contraception, family planning, birth control, young people and adolescents. The Cochrane risk-of-bias 2 and Risk of Bias in Non-Randomized Studies-of-Interventions tools were used to assess risk of bias for articles included.

Results

Community-based programs, mHealth, SRH education, counselling, community health workers, youth friendly health services, economic support and mass media interventions generally had a positive effect on childbirth spacing, modern contraceptive knowledge, modern contraceptive use/uptake, adolescent sexual abstinence, pregnancy and myths and misperceptions about modern contraception.

Conclusion

Sexual and reproductive health interventions have a positive impact on sexual and reproductive health outcomes. With the increasing popularity of mHealth coupled with the effectiveness of youth friendly health services, future youth SRH interventions could integrate both strategies to improve SRH services access and utilization.

Providing family planning counseling services for women with chronic medical conditions in an inpatient setting: A randomized feasibility trial

OBJECTIVES

This study aimed to evaluate the feasibility and effectiveness of providing bedside family planning services to women with chronic medical conditions in the inpatient setting.

STUDY DESIGN

We initiated a parallel randomized controlled trial of patients listed as female aged 18 to 44 years who were admitted to the hospital from February 2018 to May 2021 with at least one chronic medical condition associated with lower rates of contraception usage and no documentation of contraception. Patients who confirmed they were not using contraception were enrolled and randomized to one of the three arms. They received bedside family planning counseling and an offer of contraception prior to discharge (oral contraceptive pills, etonogestrel implant, or medroxyprogesterone injection), received a flyer recommending they talk with their outpatient physician about contraception, or received standard care. The primary outcomes were contraception use at 3 months and 12 months after discharge.

RESULTS

Altogether 76 subjects were enrolled and randomized with 22 in the counseling arm and 27 each in the other arms. In the counseling arm, five (23%; 95% CI: 8.0%-45%) elected to receive contraception prior to discharge. Inferential statistics at follow-up were not able to be calculated due to high attrition.

CONCLUSIONS

Providing counseling and offering immediate contraception initiation in the inpatient setting may be a feasible approach to improving contraception access for this population. Additional investigation into the acceptability, efficacy, and generalizability of this approach is warranted.

IMPLICATIONS

Utilizing the inpatient setting may be a feasible approach for delivering contraception counseling to women with chronic medical conditions. This approach merits further study for effectiveness and acceptability. This study highlights the need for contraceptive counseling and initiation to become a standard part of hospital care for pregnancy-capable individuals.

Involving men and boys in family planning: A systematic review of the effective components and characteristics of complex interventions in low- and middle-income countries

Background

Involving men and boys as both users and supporters of Family Planning (FP) is now considered essential for optimising maternal and child health outcomes. Evidence on how to engage men and boys to meet FP needs is therefore important.

Objectives

The main objective of this review was to assess the strength of evidence in the area and uncover the effective components and critical process- and system-level characteristics of successful interventions.

Search Methods

We searched nine electronic databases, seven grey literature databases, organisational websites, and the reference lists of systematic reviews relating to FP. To identify process evaluations and qualitative papers associated with the included experimental studies, we used Connected Papers and hand searches of reference lists.

Selection Criteria

Experimental and quasi-experimental studies of behavioural and service-level interventions involving males aged 10 years or over in low- and middle-income countries to increase uptake of FP methods were included in this review.

Data Collection and Analysis

Methodology was a causal chain analysis involving the development and testing of a logic model of intervention components based on stakeholder consultation and prior research. Qualitative and quantitative data relating to the evaluation studies and interventions were extracted based on the principles of 'effectiveness-plus' reviews. Quantitative analysis was undertaken using r with robust variance estimation (RVE), meta-analysis and meta-regression. Qualitative analysis involved 'best fit' framework synthesis.

Results

We identified 8885 potentially relevant records and included 127 in the review. Fifty-nine (46%) of these were randomised trials, the remainder were quasi-experimental studies with a comparison group. Fifty-four percent of the included studies were assessed as having a high risk of bias. A meta-analysis of 72 studies (k = 265) showed that the included group of interventions had statistically significantly higher odds of improving contraceptive use when compared to comparison groups (odds ratio = 1.38, confidence interval = 1.21 to 1.57, prediction interval = 0.36 to 5.31, p < 0.0001), but there were substantial variations in the effect sizes of the studies (Q = 40,647, df = 264, p < 0.0001; I 2 = 98%) and 73% was within cluster/study. Multi-variate meta-regression revealed several significant intervention delivery characteristics that moderate contraceptive use. These included community-based educational FP interventions, interventions delivered to women as well as men and interventions delivered by trained facilitators, professionals, or peers in community, home and community, or school settings. None of the eight identified intervention components or 33 combinations of components were significant moderators of effects on contraceptive use. Qualitative analysis highlighted some of the barriers and facilitators of effective models of FP that should be considered in future practice and research.

Authors' Conclusions

FP interventions that involve men and boys alongside women and girls are effective in improving uptake and use of contraceptives. The evidence suggests that policy should continue to promote the involvement of men and boys in FP in ways that also promote gender equality. Recommendations for research include the need for evaluations during conflict and disease outbreaks, and evaluation of gender transformative interventions which engage men and boys as contraceptive users and supporters in helping to achieve desired family size, fertility promotion, safe conception, as well as promoting equitable family planning decision-making for women and girls.

Effects of Postpartum Family Planning Counselling on Contraceptives Knowledge, Attitude and Intention Among Women Attending a General Hospital in The Gambia: A Randomized Controlled Trial

Purpose

This study aimed to evaluate the effectiveness of PPFP counselling on contraceptives knowledge, attitudes and intention among women attending a general hospital in The Gambia.

Materials and Methods

A quasi-experimental design with an intervention and comparison group was used. The intervention was PPFP counselling using the GATHER approach. A sample size of 674 participants was determined by a formula for comparison between the two groups. The questionnaire was developed based on a literature review and was pre-tested on 10% of the total study sample size (68). A reliability of 0.731 was obtained. A systematic random sampling method was employed to select study participants who met the inclusion criteria. Data were collected during face-to-face interviews in local languages with a 100% response rate at baseline and 96% at post-test. Data were analysed using the SPSS version 21.00 and the statistical analysis included both descriptive and inferential methods. An ethical approval was obtained from the Research and Ethics Committee, School of Basic Medical Sciences, College of Medicine, University of Benin (CMS/REC/2017/017) and the Gambia Government/Medical Research Council Laboratories Joint Ethics Committee (R017016Av1.1).

Results

Baseline respondents' socio-demographic characteristics revealed that the two groups had similar characteristics. A statistically significant difference existed on knowledge, attitude, and intention to use contraceptive methods between the intervention and comparison groups at post-intervention (p<0.05) while no significant difference was observed at baseline. Significant gains were achieved in the intervention group in terms of knowledge, attitude, and intention post-intervention.

Conclusion

PPFP counselling during the postpartum period and before the discharge of women from the hospital may improve knowledge, attitude and intention to use contraceptives and, therefore, increase the likelihood of contraceptive uptake and thus prevent unwanted and closely spaced pregnancies.

Use of community-based interventions to promote family planning use among pastoralist women in Ethiopia: cluster randomized controlled trial

Background

Afar region is one of the pastoralist dominated regions in Ethiopia. The region is characterized by a low contraceptive prevalence rate (CPR) of 5.4%. Lack of awareness of contraceptive use, husband objection and religious barriers are attributed to low CPR in the region. This study assessed the effect of community-based interventions for promoting family planning (FP) use among pastoralist communities in Ethiopia.

Methods

The study design was a three-arm, parallel, clustered randomized controlled trial (CRT). The three study arms were: (1) male involvement in family planning (FP) education; (2) women’s education on FP; and (3) control. A total of 33 clusters were randomized and allocated with a one-to-one ratio. Intervention components included (1) health education on FP to married women and men by faema leaders (a traditional community-based structure that serves as a social support group); (2) video-assisted message on FP; and (3) assisting the faema leader using health workers and health extension workers (HEWs). The intervention was given for a total of nine months. FP use and intentions were measured as outcome variables. In addition, a cluster-level summary considering a cluster effect analysis was performed. The result was presented with t.test, adjusted risks and its 95% confidence interval (CI).

Results

The proportion of FP use among the arms was 34% in the male involvement in FP education, 17.5% in women’s education on FP and 4.3% in the control. There was a positive change in the proportion of FP use in the male involvement in FP education and women’s education on FP arms with absolute risk (AR) of 0.29 (95% CI, 0.23,0.34) and 0.13 (95% CI,0.08,0.17), respectively, as compared to the control arm. Similarly, married women in the male involvement in FP education and women’s education on FP arms had 3.4 (2.48, 4.91) and 2.1 (1.50, 2.95) higher intention to use FP, respectively, as compared with the control arm.

Conclusion

The present study suggests that in such male-dominated pastoralist communities with more considerable religious barriers, the community-based health education mainly targeting males appears to be a promising strategy for improving FP use and intention to use FP.

Trial registration

ClinicalTrials.gov, NCT03450564, March, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01434-x.

Elevating Social and Behavior Change as an Essential Component of Family Planning Programs

The global family planning community has made significant progress towards enabling 120 million more women and girls to use contraceptives by 2020, though we enter the decade ahead with a long road yet to travel. While investment in strong health systems and supply chains is still needed, the supply‐driven approach dominant in family planning fails to address the individual, relational, and social barriers faced by women and couples in achieving their reproductive intentions and desired family size. Overcoming these barriers will require a better understanding of behavioral drivers and the social environment in which family planning decisions are made, and an increased investment in the proven, yet underutilized, approach of social and behavior change (SBC). We make the case that a more intentional focus on the science of human behavior in family planning can help advance the achievement of global, regional, and national goals while also calling for strategic and sustained investment that reflects the critical importance and proven impact of SBC approaches.

The mediating role of partner communication on contraceptive use among adolescent girls and young women participating in a small-group intervention in Malawi: A longitudinal analysis

Though effective reproductive health interventions have been developed for adolescent girls and young women (AGYW) in sub-Saharan Africa, few have explored whether specific components of the interventions are responsible for observed changes in behaviour. Data for this longitudinal mediation analysis come from a quasi-experimental, sexual and reproductive health study conducted among AGYW (age 15-24) in Malawi. We assessed the extent to which the relationship between attending communication-specific small-group sessions and contraceptive use at one-year was mediated by contraceptive communication with partners at six months, using a bootstrapping procedure to estimate indirect effects. Of 358 participants, 44% attended communication-specific small-group sessions, 37% communicated with partners about contraception at six months, and 21% used non-barrier contraception at one-year. Participants who attended communication-specific small-group sessions had increased contraceptive communication with partners at six months (aOR = 1.48, 95% CI: 1.07-2.38) and increased non-barrier contraceptive use at one-year (aOR = 3.53, 95% CI: 1.86-6.69). The relationship between attending communication-specific small-group sessions and non-barrier contraceptive use at one-year was partially mediated by contraceptive communication with partners at six months (indirect effect = 0.04, 95% CI: 0.01-0.07). Our results suggest that contraceptive communication with partners is modifiable through interventions and important for AGYW non-barrier contraceptive uptake.

Couples' decision-making on post-partum family planning and antenatal counselling in Uganda: A qualitative study

BACKGROUND

Although health workers have been trained to provide post-partum family planning (PPFP), uptake remains low in Uganda. An important reason is that women want the agreement of their partner, who is often absent at the time of delivery. In order to address this, we aimed to understand the views of couples and explore barriers and facilitators to implementation of antenatal couples' counselling on PPFP in Uganda.

METHODS

We conducted individual interviews with a purposive sample of 12 postpartum and 3 antenatal couples; and 34 focus groups with a total of 323 participants (68 adolescent women, 83 women aged 20-49, 79 men, 93 health workers) in four contrasting communities (urban and rural) in South-West and Central Uganda. These were recorded, transcribed, translated, and analysed thematically.

RESULTS

Although most participants felt that it is important for partners to discuss family planning, half of the couples were unaware of each other's views on contraception. Most had similar views on motivation to use family planning but not on preferred contraceptive methods. Most liked the idea of antenatal couples' counselling on PPFP. The main barrier was the reluctance of men to attend antenatal clinics (ANC) in health facilities. Respondents felt that Village Health Teams (VHTs) could provide initial counselling on PPFP in couples' homes (with telephone support from health workers, if needed) and encourage men to attend ANC. Suggested facilitators for men to attend ANC included health workers being more welcoming, holding ANC clinics at weekends and "outreach" clinics (in rural villages far from health facilities).

CONCLUSION

Antenatal couples' counselling has the potential to facilitate agreement PPFP, but some men are reluctant to attend antenatal clinics. Counselling at home by VHTs as well as simple changes to the organisation of antenatal clinics, could make it possible to deliver antenatal couples' counselling on PPFP.

Prevention of cervical cancer through two HPV-based screen-and-treat implementation models in Malawi: protocol for a cluster randomized feasibility trial

Background

Cervical cancer is the leading cause of cancer incidence and mortality among Malawian women, despite being a largely preventable disease. Implementing a cervical cancer screening and preventive treatment (CCSPT) program that utilizes rapid human papillomavirus (HPV) testing on self-collected cervicovaginal samples for screening and thermal ablation for treatment may achieve greater coverage than current programs that use visual inspection with acetic acid (VIA) for screening and cryotherapy for treatment. Furthermore, self-sampling creates the opportunity for community-based screening to increase uptake in populations with low screening rates. Malawi’s public health system utilizes regularly scheduled outreach and village-based clinics to provide routine health services like family planning. Cancer screening is not yet included in these community services. Incorporating self-sampled HPV testing into national policy could address cervical cancer screening barriers in Malawi, though at present the effectiveness, acceptability, appropriateness, feasibility, and cost-effectiveness still need to be demonstrated.

Methods

We designed a cluster randomized feasibility trial to determine the effectiveness, acceptability, appropriateness, feasibility, and budget impact of two models for integrating a HPV-based CCSPT program into family planning (FP) services in Malawi: model 1 involves only clinic-based self-sampled HPV testing, whereas model 2 includes both clinic-based and community-based self-sampled HPV testing. Our algorithm involves self-collection of samples for HPV GeneXpert® testing, visual inspection with acetic acid for HPV-positive women to determine ablative treatment eligibility, and same-day thermal ablation for treatment-eligible women. Interventions will be implemented at 14 selected facilities. Our primary outcome will be the uptake of cervical cancer screening and family planning services during the 18 months of implementation, which will be measured through an Endline Household Survey. We will also conduct mixed methods assessments to understand the acceptability, appropriateness, and feasibility of the interventions, and a cost analysis to assess budget impact.

Discussion

Our trial will provide in-depth information on the implementation of clinic-only and clinic-and-community models for integrating self-sampled HPV testing CCSPT with FP services in Malawi. Findings will provide valuable insight for policymakers and implementers in Malawi and other resource-limited settings with high cervical cancer burden.

Trial registration

ClinicalTrials.gov identifier: NCT04286243. Registered on February 26, 2020.

A systematic review of the effectiveness of counselling strategies for modern contraceptive methods: what works and what doesn't?

AIM

The aim of this systematic review was to synthesise the evidence on the comparative effectiveness of different counselling strategies for modern contraception on contraceptive behaviour and satisfaction, and to examine their advantages and disadvantages.

METHODS

Six electronic databases (Medline, Embase, Global Health, Popline, CINAHL Plus, and Cochrane Library) were searched to identify publications comparing two or more contraceptive counselling strategies and reporting quantitative results on contraceptive use, uptake, continuation or switching, or client satisfaction. Studies of women or couples from any country, published in English since 1990 were considered.

RESULTS

A total of 63 publications corresponding to 61 studies met the inclusion criteria. There was substantial heterogeneity in study settings, interventions and outcome measures. Interventions targeting women initiating a method (including structured counselling on side effects) tended to show positive effects on contraceptive continuation. In contrast, the majority of studies of provider training and decision-making tools for method choice did not find evidence of an effect. Additional antenatal or postpartum counselling sessions were associated with increased postpartum contraceptive use, regardless of their timing in pregnancy or postpartum. Dedicated pre-abortion contraceptive counselling was associated with increased use only when accompanied by broader contraceptive method provision. Male partner or couples counselling was effective at increasing contraceptive use in two of five studies targeting non-users, women initiating implants or seeking abortion. High-quality evidence is lacking for the majority of intervention types.

CONCLUSIONS

The evidence base and quality of studies are limited, and further research is needed to determine the effectiveness of many counselling interventions in different settings.

Community-based integrated approach to changing women's family planning behaviour in Pakistan, 2014-2016

Setting: Karachi, Pakistan. Objective: To assess the effectiveness of a community-based integrated approach in changing women's behaviour regarding contraceptive use. Design: The Sukh Initiative is a multipronged approach with door-to-door services using community health workers to provide quality family planning/reproductive health services at both public and private facilities and a 24/7 family planning helpline service that provides youth skill-based education. Methods: Retrospective pre- and post-intervention data using samples of 5140 and 3810 women, respectively. Results: The contraceptive prevalence rate increased by 10.7%, from 42.3% at baseline to 53.0% mid-intervention, with an increase in use of modern contraceptive methods of 9.2%. A significant association was found between door-to-door counselling and the use of contraceptive methods (OR 3.4, 95%CL 2.9-4.1) and access to public and private facilities for modern contraceptives (OR 2.4, 95%CL 2.0-3.0). However, support group meetings and 24/7 helpline use did not show any association with use of contraceptive method. Conclusion: The study helped to increase access to and choice of family planning services through a community-based approach that successfully reduced unmet needs and improved continuity in contraceptive use.

Effect of family planning interventions on couple years of protection in Malawi

OBJECTIVE

The primary objective was to assess the effect of family planning interventions at two health facilities in Malawi on couple years of protection (CYP).

METHODS

A prospective quasi-experimental design was used to compare CYP and uptake of long-acting reversible contraception (LARC) between two intervention facilities (Area 25 Health Center and Kasungu District Hospital) and two nonintervention facilities (Mkanda Health Center and Dowa District Hospital). The interventions included community mobilization and demand generation for family planning, and training and mentoring of providers in LARC insertion. Monthly data were collected from 1 year prior to intervention implementation until 2 years thereafter.

RESULTS

From the pre-intervention year to the second post-intervention year, CYP increased by 175.1% at Area 25, whereas it decreased by 33.8% at Mkanda. At Kasungu and Dowa, CYP increased by 90.7% and 64.4%, respectively. Uptake of LARC increased by 12.2% at Area 25 r, 6.2% at Kasungu, and 2.9% at Dowa, but decreased by 3.8% at Mkanda.

CONCLUSIONS

The interventions led to an increase in CYP and LARC uptake. Future family planning programs should sensitize communities about family planning and train providers to provide all contraceptives so that women can make informed decisions and use the contraceptive of their choice.

Evaluation of Family Planning Counselling in North Jordan

Objectives

Counselling plays a key role in enhancing reproductive services, providing contraception-related information and supporting long-term family planning for women of childbearing age. This study aimed to evaluate family planning counselling sessions in selected governmental and private clinics in northern Jordan.

Methods

This cross-sectional study was conducted between January and June 2016 in Irbid, Jordan. A total of 200 women attending two private clinics affiliated with the Jordanian Association for Family Planning and Protection (JAFPP) and six governmental clinics were invited to participate in the study. Counselling sessions were attended by an independent observer and evaluated with regards to their compliance with the standard Greet, Ask, Tell, Help, Explain, Return (GATHER) framework.

Results

A total of 198 women participated in the study (response rate: 99.0%), including 80 women (40.4%) from JAFPP clinics and 118 (59.6%) from governmental clinics. In total, 42.9% of the counselling sessions were deemed adequate, with providers applying 80% or more of the GATHER framework, while 26.8% of the sessions were deemed semi-adequate and 30.3% were considered inadequate. Counselling services provided in the governmental clinics were significantly less adequate than those provided in JAFPP clinics (P <0.001).

Conclusion

The quality of counselling services in governmental family planning centres in Jordan needs to be improved to ensure that women receive the highest possible level of care. Healthcare policymakers should therefore focus on developing and supporting effective family planning counselling services in northern Jordan.

Increasing the uptake of long-acting and permanent methods of family planning: A qualitative study with village midwives in East Java and Nusa Tenggara Barat Provinces, Indonesia

OBJECTIVE

this analysis aims to explore midwives' insights into the provision of long-acting and permanent methods of contraception (LAPMs) in the selected areas of East Java and Nusa Tenggara Barat (NTB) Provinces, Indonesia.

DESIGN

a qualitative study using in-depth interviews was conducted with 12 village midwives from 12 villages, to explore their perceptions and experiences in delivering family planning services.

SETTING

the study was carried out in May-June 2013, as part of the baseline assessment in the Improving Contraceptive Method Mix (ICMM) study. We interviewed 12 village midwives working in 12 villages in six study districts: Tuban, Kediri, and Lumajang Districts in East Java Province; and Lombok Barat, Lombok Timur, and Sumbawa Districts in NTB Province.

MEASUREMENT

an interview guideline was used in all interviews. It covered several topics, such as community perceptions of LAPMs, availability of contraception and related equipment, availability of human resources, and midwives' efforts to improve LAPM coverage. All interviews were recorded and transcribed. Content and thematic analyses were carried out by grouping and coding the information based on the identified themes and topics.

FINDINGS

according to village midwives interviewed in this study, community-level acceptance of LAPMs has increased over time; however, some still prefer using short-acting methods for a long period. The reasons include lack of awareness about the benefits and side effects of LAPMs, fear of surgical procedures, rumored consequences (for example, that LAPMs would limit women's ability to perform hard physical labor), and religious beliefs. There were several challenges reported by village midwives in delivering LAPM services, such as confusion about midwives' eligibility to provide LAPM services, lack of Contraceptive Technology Update (CTU) and counseling trainings, and shortage of supporting equipment (such as exam tables and IUD and implant insertion kits). There were several strategies implemented by village midwives to improve LAPM use, including strengthening the counseling services, accompanying clients to higher health facilities to obtain LAPM services, and providing services for groups of clients. All village midwives emphasized the importance of strengthening collaboration among stakeholders to increase the uptake of LAPM services.

KEY CONCLUSIONS

as midwives are the main family planning providers in Indonesia, efforts to address their challenges is essential. Enabling a supportive policy environment, strengthening promotional activities, increasing the number of training programs designed for village midwives-in addition to enhancing inter-sectoral collaboration-are some recommendations to improve LAPM uptake in study areas.