Geospatial Distribution of Family Planning Services in Kira Municipality, Wakiso District, Uganda

Boosting Contraceptive Uptake in Urban Uganda: Older Women Benefit When Layering Adolescent and Youth Interventions Onto Existing Family Planning Programming

INTRODUCTION

Uganda has a large young population with a high unmet need for family planning (FP). Although there have been many efforts to improve access to and uptake of contraception, improvements have been slow. The Ministry of Health Uganda partnered with The Challenge Initiative (TCI) to implement a novel multipronged approach layering adolescent and youth sexual reproductive health (AYSRH) onto a functioning general FP program for women of reproductive age in 3 local governments of Buikwe, Mukono, and Iganga. We describe the approach and aim to determine whether layering AYSRH interventions onto an existing program resulted in increased contraceptive uptake among adolescents and youth aged 10-24 years and among women aged 25-49 years.

METHODS

We analyzed service statistics from the Uganda Health Management Information System to assess contraceptive uptake for adolescents and youth (aged 10-24 years) and older women (aged 25-49 years) before and after the implementation of the AYSRH approach in 3 areas (Buikwe, Iganga, and Mukono) compared to 11 areas where only the general FP program was implemented and the Uganda country total.

RESULTS

This analysis showed that before the start of TCI's support, levels of contraceptive uptake were similar in all local governments. However, after implementation, there was an increase in uptake for general FP program only areas (1.7-point advantage over country total) and an even greater increase in general FP+AYSRH areas (2.4-point advantage over FP only programming). This was observed in both adolescents and youth aged 10-24 years and among women aged 25-49 years.

CONCLUSION

The layering of TCI's AYSRH interventions onto a well-functioning FP platform not only increased contraceptive uptake among adolescents and youth aged 10-24 years but also boosted uptake among women older than age 25 years.

Improving Contraceptive Service Quality and Accessibility for Adolescents and Youth Through Proprietary Patent Medicine Vendors in Four Nigerian States

INTRODUCTION

In Nigeria, health care services and commodities have increasingly been accessed through private sector entities, including retail pharmacies and drug shops (also called proprietary patent medicine vendors [PPMVs]). However, PPMVs cannot provide long-acting or permanent methods, and concerns have been raised about their quality of services and their need to better comply with government regulations. This article describes how The Challenge Initiative's (TCI) family planning program supported 4 state governments in Nigeria to develop a model to strengthen public-private partnerships between PPMVs and primary health centers (PHCs) to leverage PPMVs to provide adolescents and youth with high-quality contraceptive information, services, and referrals to PHCs.

PROGRAM DESCRIPTION

The intervention implemented a hub-spoke model by strengthening the linkages between neighboring PPMVs and large PHCs for delivering contraceptive services to adolescents and youth. The steps in the implementation process included: (1) introducing the intervention to state governments, (2) selecting PPMVs as spokes and high-volume PHCs as hubs, (3) conducting whole-site orientations jointly with PPMV and PHC staff, (4) strengthening referral links between PPMVs and PHCs, (5) implementing supportive supervision and coaching, and (6) strengthening client data management. TCI worked with the state and local ministry of health to improve PPMV operators' knowledge, attitudes, and skills to deliver adolescent- and youth-friendly services.

LESSONS LEARNED AND RECOMMENDATIONS

Implementing the PPMV intervention with state governments and PHCs strengthened the public-private partnership. A functional referral system in Plateau State demonstrated significant success, enabling increased contraceptive choice and adherence to regulations for adolescents and youth. We recommend that the government strengthen the working relationship between PPMVs and PHCs, incorporate PPMVs into the routine supportive supervision of the state health system, and incorporate a referral linkage with PHCs into the design and implementation of PPMV programs.

The role of partners, parents and friends in shaping young women's reproductive choices in Peri-urban Nairobi: a qualitative study

BACKGROUND

Contraceptive use among young women in Nairobi remains low despite high general knowledge of family planning (FP) methods. This paper draws on social norms theory to explore the role of key influencers (partners, parents and friends) in women's FP use and how women anticipate normative reactions or sanctions.

METHODS

A qualitative study with 16 women, 10 men and 14 key influencers across 7 peri-urban wards in Nairobi, Kenya. Interviews were conducted during the COVID-19 pandemic in 2020 by phone. A thematic analysis was conducted.

RESULTS

Women identified parents, specifically mothers, aunts, partners, friends and healthcare workers as key influencers on FP. Their interactions with these key influencers varied based on trust, the information they needed about FP, and whether they perceived a key influencer to perpetuate or challenge existing social norms on FP. Mothers were perceived to understand the social risks of using FP and thus could advise on discreet FP use, and aunts were trusted and approachable sources to impartially describe the benefits and drawbacks of FP. Although women identified partners as key FP decision makers, they were cognisant of possible power imbalances affecting a final FP choice.

CONCLUSIONS

FP interventions should consider the normative influence key actors have on women's FP choices. Opportunities to design and deliver network-level interventions which seek to engage with social norms surrounding FP in order to challenge misconceptions and misinformation among key influencers should be explored. Intervention design should consider dynamics of secrecy, trust and emotional closeness that mediate discussions of FP to address changing norms. Further training to change norms held by healthcare providers about why women, in particular unmarried young women, access FP should be provided to reduce barriers for FP access.

Scaling Access to Contraception for Youth in Urban Slums: The Challenge Initiative's Systems-Based Multi-Pronged Strategy for Youth-Friendly Cities

INTRODUCTION

More than half of all adolescents globally live in Asia, with India having the largest adolescent population in the world at 253 million. In sub-Saharan Africa, adolescents make up the greatest proportion of the population, with 23% of the population aged 10-19. And these numbers are predicted to grow rapidly-particularly in urban areas as rural youth migrate to cities for economic opportunities. While adolescents and youth are subject to high sexual and reproductive health risks, few efforts have been documented for addressing these in urban settings, especially in poor settlements.

METHODS

The Challenge Initiative (TCI) is a demand-driven, family planning platform for sustainable scale and impact that lets city governments-in particular urban slums-lead implementation. It is currently active in 11 countries in Africa and Asia. In June 2018, TCI heightened its focus on adolescent and youth sexual and reproductive health (AYSRH) for youth living in urban slums. It now supports 39 city governments. TCI dedicates technical and program support to married (including first-time parents) and unmarried youth ages 15-24 years. Using an innovative coaching model and an online learning platform (TCI University), TCI supports city governments as they implement AYSRH interventions to accelerate the impact of TCI's model for rapid scale.

RESULTS

TCI has been assessing the performance of cities implementing its AYSRH approaches using its RAISE tool and has found considerable improvement over two rounds of assessments through TCI coaching and support for adaptation of its high-impact interventions between the first and second round.

CONCLUSIONS

TCI's AYSRH approach scaled rapidly to 39 cities and multiple urban slums since 2018, using its evidence-based interventions and coaching model. In the context of universal health coverage, TCI has supported segmented demand generation and improved access to quality and affordable contraceptive as well as youth-friendly health services. It provides a menu of interventions for cities to implement for youth-including such approaches as public-private partnerships with pharmacies and quality assurance using quick checklists-along with an innovative coaching model. This approach has facilitated greater access to contraceptive methods of choice for youth.

Total Demand, Use and Unmet Need for Modern Contraceptives Among Women Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda. Implications for Urban Health

Background: Update and utilization of modern contraceptives has public health benefits including reduction of unintended pregnancies, unsafe abortions, and related maternal mortality. However, paucity of evidence on key indicators of family planning in the informal settlements abounds. Data are usually collapsed within the larger urban communities that tend to mask peculiarities of informal settlements. This study determined the proportion of women using modern contraceptives, the unmet need for modern contraceptives and the total demand in informal settlements of an urban municipality. Methods: A cross-sectional study conducted among 626 women in the reproductive age (15-49 years) in the informal settlements of Kira municipality (part of metropolitan Kampala). Multi-stage sampling was applied in the selection of the respondents. Descriptive and log-binomial regression analysis were conducted to determine percentage of women using modern contraceptives, unmet need, and total demand with their associated factors. All analyses were conducted using STATA version 15.0. Results: The total demand for modern contraceptives was 84.9%, modern contraceptive prevalence was 47.4% nearly meeting the national target of 50%, however the unmet need was 37.3%, which much higher than the national target of 10%. Lower total demand for contraceptives was associated with higher women's education status and preference to have another child, while higher total demand was associated with having at least one living child. Higher modern contraceptives use was associated with older age, having at least one living child and high decision-making power, while lower modern contraceptives use was associated with higher education and undetermined fertility preference. Lower unmet need for modern contraceptives was associated with older age (PR 0.68, 95% CI: 0.48-0.97) and high decision-making power (PR 0.64, 95% CI: 0.50-0.81), while higher unmet need was found among those who having at least one living child (PR 1.40, 95% CI: 1.01-1.93) and undetermined fertility preference (PR 1.70, 95% CI: 1.24-2.34). Conclusions: Total demand and contraceptive use were found to be higher in the informal settlements of Kira municipality, however, the unmet need was much higher among this population as compared to the national urban estimates. This indicates a much higher demand for contraceptives and the need to consider the diverse socio-demographic characteristics of urban spaces. Development of Interventions need to critically consider the diverse urban space, associated explanatory variables and a collaborative systems lens to achieve sustained improvements.

Quality of Care in Family Planning Services: Differences Between Formal and Informal Settlements of Kira Municipality, Uganda

Background: Quality of care (QoC) of family planning (FP) affects contraceptive use, and it varies across types of urban settlement. This study assesses the difference in service delivery point (SDP) structural and process factors between formal and informal urban settlements, and the opinion of the client on the QoC in informal settlements. This is useful in creating an evidence base to advocate for better quality services for the most vulnerable in society. Methods: This was a cross-sectional survey that included SDPs of Kira municipality in Wakiso district, Uganda. Data were collected from all the service points in Kira municipality with the caretakers consented. In addition, using multi-stage sampling, 626 women of reproductive age (15-49 years) who lived in the informal settlements of Kira municipality were interviewed. Data were collected using structured questionnaires, descriptive analysis was carried out in Stata version 14.0, and Chi-square and t-tests were used to compare the informal with the formal settlements. Results: Formal settlements generally had more higher-level SDPs compared to informal settlements (value of p < 0.001). SDPs in the formal settlements provided more FP methods and had more community health workers (CHW) to support their work. Also, SDPs in the formal settlements were more likely to have long-term FP methods available and more likely to have trained personnel to insert and remove implants and IUDs compared to those in informal settlements. Additionally, more SDPs in the formal settlements provided counseling for permanent, long-term, and short-term FP methods. Of the 626 interviewed women, most of the women (68.6%) reported that they would not return to the previous FP provider or refer a friend to the same provider (72.7%). Conclusions: There is a lower quality FP services in the informal settlements with a commensurable effect on the client satisfaction with the services. Therefore, improving the quality of FP services in informal settlements should be a top priority. Improved quality of services could act as a motivation to increase the uptake of modern contraceptives in such settings.

Framing Contraceptive Use Motivations Among Adolescents and Young Adults Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda

Introduction: The use of contraceptives among adolescents and young adults is one of the most cost-effective strategies to address many sexual and reproductive health (SRH) challenges, including unintended pregnancies, early marriages, and sexually transmitted infections. Despite a high burden of SRH challenges, uptake and unmet needs of modern contraceptives remain low in Uganda, especially among adolescents and young adults in informal settlement settings. This study aimed to explore the motivations of adolescents and young people to use modern contraceptives (or not). Methods: We analysed qualitative data from eight focus group discussions with 88 adolescents and young people aged 18-24 years residing in informal settlements of urban communities in Kira Municipality of Wakiso district, Uganda. Results: Motivations for use (or not) of modern contraceptives were framed by two interrelated constructs, sources of information on contraception and the unacceptable use of contraceptives among adolescents widespread in the community. These two, in turn, formed the scope of knowledge upon which adolescents and young people based their decision on whether or not to access and use modern contraceptives. Conclusion: To be more effective, sexual and reproductive health programs and interventions that aim to motivate the use of modern contraceptives among adolescents and young people in informal settings should be more comprehensive and focused on alleviating individual, health systems, social, religious factors that reinforce negative health-seeking behaviours towards contraceptive use. In addition, there is a need to support adolescents and young people with socio-economic empowering strategies that equip them with sufficient resources to choose contraceptives of their choice.

Women Deprivation Index and Family Planning Utilisation in Urban Geography of West African Countries

Inequalities in health care utilisation and outcomes vary significantly across geographies. Though available evidence suggests disparity in contraceptive uptake in favour of urban compared with rural geographies, there are unassessed nuances among women in urban communities. This study examines some of these disparities within the context of socioeconomic deprivations and family planning utilisation among urban women in West Africa. A secondary analysis of the most recent Demographic and Health Survey dataset of five selected West African countries was conducted, using pooled data of 21,641 women aged 15-49 years. Associations between family planning utilisation and women's deprivation status were investigated using a binary logistic regression model. The findings show that more than one-quarter of the women were severely deprived across the countries except Senegal (17.4%), and the severely deprived consistently have relatively low contraceptive prevalence rates (CPR) (16.0-24.3%) compared with women with no/low deprivation across the countries except Senegal (39.8%). The results for long-acting reversible contraceptives (LARC) were not consistent across the five countries: whereas, LARC utilisation was lower among severely deprived women in Nigeria (9.1%), Guinea (9.6%), and Mali (19.3%), utilisation was similar across the deprivation groups in Benin and Senegal. In the multivariable analyses, the log-odds of modern contraceptive utilisation decreases by 0.27 among the moderately deprived (ß = -0.27, SE = 0.05, p < 0.01) and by 0.75 among the severely deprived women (ß = -0.75, SE = 0.05, p < 0.01) compared with those with no/low deprivation, with variations across the countries. Similarly, the log-odds of LARC utilisation decreases by 0.44-0.72 among the severely deprived women compared with those with no/low deprivation across the countries except Senegal. This study concluded that family planning intervention programmes and policies need to underscore the deprivation context of urban geographies, particularly among women living in informal settlements.