Implementation and Scale-Up of the Standard Days Method of Family Planning: A Landscape Analysis

Implementation strategies to scale up self-administered depot medroxyprogesterone acetate subcutaneous injectable contraception: a scoping review

BACKGROUND

Self-administered depot medroxyprogesterone acetate subcutaneous injectable contraception (DMPA-SC) is registered in many countries. It shows great potential for improving contraceptive access, continuation, and autonomy. However, there are challenges in rolling out this new efficacious intervention, and major implementation problems have been encountered during scale-up.

OBJECTIVE

To describe the implementation strategies to scale up self-administered DMPA-SC and the barriers, facilitators, and outcomes of these programs.

METHOD

Recent guidelines, including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews, were used to design and report this review. An article or report was eligible for inclusion if it reported interventions that could scale up self-administered DMPA-SC implementation or its facilitators, barriers, or outcomes. We searched six electronic databases and the grey literature for eligible articles and reports. Two reviewers independently screened the document titles, abstracts, and full texts to identify eligible documents. Data were extracted using structured forms. Using the Effective Practice and Organization of Care (EPOC) taxonomy of health systems framework for thematic analysis, data were presented in a narrative approach.

RESULTS

Of the 755 retrieved documents, 34 were included in this review. Most of the documents included were multi-country reports (n = 14), and all documents were published within the last 5 years (2018-2021). This review identified documents that reported interventions in all EPOC domains. The most-reported interventions were: task-sharing amongst health workforce cadres, engaged leadership, encouraging policies, training and education, DMPA-SC demand generation, integration into existing programs, improved funding mechanisms, collaboration with development partners, and supply chain strengthening. The main barriers were suboptimal funding, inadequate human resources, and poor logistics supply of DMPA-SC. There was minimal evidence of scale-up outcomes.

CONCLUSION

This scoping review reported a wide range of interventions employed by countries and programs to scale up DMPA-SC self-administration but minimal evidence of the scale-up outcomes. Evidence from this review can help design better programs that improves access to quality family planning services to achieve the Sustainable Development Goals (SDG) targets 3.7. However, efforts should focus on rigorous implementation research that assess scaled up self-administered DMPA-SC interventions and report their outcomes.

REGISTRATION

The protocol for this review was registered in the protocols.io repository ( https://www.protocols.io/view/a-protocol-for-a-scoping-review-of-implementation-x54v9yemmg3e/v1 ).

Down But Not Out: Vasectomy Is Faring Poorly Almost Everywhere-We Can Do Better To Make It A True Method Option

INTRODUCTION

Demand for vasectomy-1 of 2 contraceptive methods for men-has been low, with deep-seated myths, misconceptions, and provider bias against it widespread. Programmatic attention and donor funding have been limited and sporadic.

METHODS

We analyzed vasectomy use in 84 low- and middle-income countries (LMICs) plus the 11 high-income countries with vasectomy prevalence above 1%. These 95 countries comprise 90% of the world's population. Data come from United Nations survey compilations, population estimates, and gender inequality rankings. We also reviewed recent articles on vasectomy and analyses of chronic challenges to vasectomy service provision.

RESULTS

Vasectomy use is 61% lower now than 2 decades ago. Of 922 million women using contraception worldwide, 17 million rely on vasectomy-27 million fewer than in 2001. In contrast, 219 million women use tubectomy-8 million more than in 2001. Of 84 LMICs, 7 report vasectomy prevalence above 2%. In 56 LMICs, no more than 1 in 1,000 women relies on vasectomy. Female-to-male disparities in permanent method use widened globally, from 5:1 to 13:1, and are much higher in some regions and countries (e.g., 76:1 in India). Countries with the highest vasectomy prevalence are among those with the highest gender equality and vice versa.

CONCLUSION

Vasectomy use is surprisingly low globally and declining. Use remains negligible in almost all LMICs, reflecting low demand and program priority. For vasectomy to become an accessible, rights-based option, program efforts need to be holistic, ensuring an enabling environment while coordinating demand- and service-focused efforts. Vasectomy champions at all levels should be supported on a sustained basis. On the demand side, harnessing mass and social media to increase accurate knowledge and normalize vasectomy as a method and service will be particularly valuable. Evidence from Bolivia suggests relatively few trained providers and procedures could result in a country's attaining 1% vasectomy prevalence.

Perspectives of Muslim Religious Leaders to Shape an Educational Intervention About Family Planning in Rural Tanzania: A Qualitative Study

INTRODUCTION

Uptake of effective contraceptive methods can be hindered by poor understanding and uncertainty about its compatibility with religious beliefs. We sought to understand the perspectives of Muslim religious leaders in rural Tanzania on family planning (FP) and acceptable strategies for providing FP education to leaders and their communities.

METHODS

We conducted in-depth interviews with Muslim leaders from 4 communities in northwest Tanzania. Open-ended questions explored leaders' views on FP in relation to their communities, Muslim texts and teaching, and their experience as leaders. We also investigated how FP education could be provided in their communities and asked practical questions regarding seminar implementation. Interviews were conducted in Kiswahili and transcribed and translated into English. Data were coded independently by 2 investigators using NVivo 1.5.1 and analyzed thematically.

RESULTS

We interviewed 17 male and 15 female Muslim leaders. All leaders supported FP as a concept in which births are spaced, interpreting this as espoused by the Qur'an and a basic right of children raised in Islam. Leaders uniformly endorsed the use of breastfeeding and the calendar method to space births but had divergent and sometimes opposing views on other methods, including condom use, oral contraceptives, and intrauterine devices. All leaders acknowledged the need for FP education among their congregants and were in favor of helping to teach an FP seminar in their communities.

CONCLUSION

Our data reveal insights into how education for Muslim leaders may equip them to promote birth spacing and enhance understanding of FP in their communities in ways that are concordant with Islamic teaching. Our findings will guide the design and pilot-testing of an educational intervention for Muslim religious leaders to promote knowledge and uptake of FP in rural Tanzania.

A pharmacist-led medication review service with a deprescribing focus guided by implementation science

Background: Little research addressed deprescribing-focused medication optimization interventions while utilizing implementation science. This study aimed to develop a pharmacist-led medication review service with a deprescribing focus in a care facility serving patients of low income receiving medications for free in Lebanon followed by an assessment of the recommendations' acceptance by prescribing physicians. As a secondary aim, the study evaluates the impact of this intervention on satisfaction compared to satisfaction associated with receiving routine care. Methods: The Consolidated Framework for Implementation Research (CFIR) was used to address implementation barriers and facilitators by mapping its constructs to the intervention implementation determinants at the study site. After filling medications and receiving routine pharmacy service at the facility, patients 65 years or older and taking 5 or more medications, were assigned into two groups. Both groups of patients received the intervention. Patient satisfaction was assessed right after receiving the intervention (intervention group) or just before the intervention (control group). The intervention consisted of an assessment of patient medication profiles before addressing recommendations with attending physicians at the facility. Patient satisfaction with the service was assessed using a validated translated version of the Medication Management Patient Satisfaction Survey (MMPSS). Descriptive statistics provided data on drug-related problems, the nature and the number of recommendations as well as physicians' responses to recommendations. Independent sample t-tests were used to assess the intervention's impact on patient satisfaction. Results: Of 157 patients meeting the inclusion criteria, 143 patients were enrolled: 72 in the control group and 71 in the experimental group. Of 143 patients, 83% presented drug-related problems (DRPs). Further, 66% of the screened DRPs met the STOPP/START criteria (77%, and 23% respectively). The intervention pharmacist provided 221 recommendations to physicians, of which 52% were to discontinue one or more medications. Patients in the intervention group showed significantly higher satisfaction compared to the ones in the control group (p < 0.001, effect size = 1.75). Of those recommendations, 30% were accepted by the physicians. Conclusion: Patients showed significantly higher satisfaction with the intervention they received compared to routine care. Future work should assess how specific CFIR constructs contribute to the outcomes of deprescribing-focused interventions.

Fertility tracking tool for visually impaired and non-visually impaired women: A qualitative study

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.

Scaling Up Public Health Interventions: Engaging Partners Across Multiple Levels

Advancing the science of intervention scale-up is essential to increasing the impact of effective interventions at the regional and national levels. In contrast with work in high-income countries (HICs), where scale-up research has been limited, researchers in low- and middle-income countries (LMICs) have conducted numerous studies on the regional and national scale-up of interventions. In this article, we review the state of the science on intervention scale-up in both HICs and LMICs. We provide an introduction to the elements of scale-up followed by a description of the scale-up process, with an illustrative case study from our own research. We then present findings from a scoping review comparing scale-up studies in LMIC and HIC settings. We conclude with lessons learned and recommendations for improving scale-up research. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Use of Fertility Awareness-Based Methods for Pregnancy Prevention Among Ghanaian Women: A Nationally Representative Cross-Sectional Survey

Few studies in low- and middle-income countries have examined the use of fertility awareness-based methods (FABMs) for pregnancy prevention. Understanding the prevalence of FABM use among Ghanaian contraceptors and the characteristics and practices of users is essential. Our 2018 nationally representative survey of Ghanaian women included detailed questions on the use of rhythm and Standard Days Method/Cycle Beads (SDM). After considering multimethod use patterns, we estimated likely FABM prevalence among contraceptors, identified characteristics associated with current use of an FABM (vs. current use of a hormonal method/intrauterine device [IUD]), and described how women report using FABMs. At least 18% of contracepting Ghanaian women likely use an FABM, though this may be underreported. Among FABM users, 57% reported current use of an FABM alone; the remainder reported concurrent use of other methods. Women who were older, richer, more educated, and had fewer children had higher odds of current FABM use versus IUD/hormonal method. Although FABM users were more likely than other contraceptors to correctly identify the approximate fertile time, only 50% of FABM users did so correctly. Most (92%) rhythm users were interested in making their method use more effective. While 72% had heard of SDM, less than 25% had heard of various other ways to make the rhythm method more effective. Only 17% of rhythm users had ever discussed the method with a health professional. Rhythm users indicated substantial willingness to track additional biomarkers (e.g., daily temperature or cervical mucus) or to use a phone to enhance the effectiveness of their method, and most indicated no substantial difficulty getting partners to abstain or withdraw on fertile days. A nontrivial proportion of reproductive age Ghanaian women are using an FABM, nearly all of whom are interested in learning how to improve its effectiveness. The family planning field should better address these women's contraceptive needs in commitment to reproductive autonomy and choice.

What About Methods for Men? A Qualitative Analysis of Attitudes Toward Male Contraception in Burkina Faso and Uganda

CONTEXT

Male contraceptive options are limited; however, product development efforts tend to focus on female methods. Research on attitudes toward methods for men-particularly in regions of low contraceptive prevalence, such as Sub-Saharan Africa-could inform the development of new male methods.

METHODS

Qualitative data were taken from focus group discussions with 80 men aged 23-67 and 398 women aged 15-50 conducted in Burkina Faso and Uganda in 2016. Transcripts were analyzed thematically to explore support among men and women for male contraceptive methods, and to extract suggestions about ideal method characteristics.

RESULTS

Male and female participants in both countries expressed support for new male contraceptive options; more positive attitudes were expressed in Uganda than in Burkina Faso. Participants of both sexes recognized that male methods could reduce the family planning burden on women and offer men greater control over their fertility; however, some had concerns about side effects and thought that men would not use contraceptives. Relationship characteristics, such as polygamous unions, were cited as possible challenges. In both countries, various delivery methods (e.g., creams or jellies, injections and implants) and durations (from short-acting to permanent) were proposed.

CONCLUSIONS

The acceptability of new male methods among most participants in the two countries indicates a potential demand for male contraceptives. Options should include a variety of method characteristics to maximize choice, engage men, and support men and women's contraceptive needs.