Task shifting and community engagement as the keys to increasing access to modern contraception: Findings from mixed methods operational research in coastal Kenya

RATIONALE

Kilifi County, Kenya, has a modern contraceptive prevalence of 44%, compared to the national prevalence of 61%. In 2018, the Government of Kenya and Population Services Kenya implemented a pilot project in Kilifi to improve contraceptive awareness and access.

AIMS AND OBJECTIVES

The Riziki Demonstration Project task shifted contraceptive injectable and implant provision to community health extension workers (CHEWs) and supported community engagement led by community health volunteers (CHVs). This mixed methods evaluation examined the effect of Riziki on contraceptive service provision and identified drivers of the intervention's success in increasing public sector contraceptive uptake.

METHOD

We obtained monthly contraceptive service provision data from DHIS2 for intervention and comparison facilities from June 2018 to July 2020. Controlled interrupted time series analyses were used to assess difference-in-differences effects on the levels and trends in service provision. Qualitative data included key informant interviews with health workers, community-based focus group discussions and contraceptive journey mapping. Topics included contraception-related shifts in the health system and social environment and changes to contraceptive accessibility and demand.

RESULTS

We found positive difference-in-differences effects for levels of provision for implant (adj. β  =  7.4 per month, per facility, 95% confidence interval [CI]: 2.8-12.0) and all methods combined (adj. β  =  12.2, 95% CI: 3.0-21.3). The health system provided a legal framework and management support for the pilot. Community engagement by CHVs and CHEWs, including with men and religious leaders, bolstered supportive social norms by emphasizing birth spacing and family wellbeing. Awareness and supportive social norms were strengthened among women and their husbands through counselling that leveraged CHEW and CHV community embeddedness.

CONCLUSION

Findings demonstrate the potential for task sharing combined with community engagement efforts to improve contraceptive awareness, knowledge and supply. Community engagement should include men, traditional leaders and other influencers to strengthen norms that position family planning in alignment with community values.

Assessing acceptability and effectiveness of a pleasure-oriented sexual and reproductive health chatbot in Kenya: an exploratory mixed-methods study

Integrating pleasure may be a successful strategy for reaching young people with sexual and reproductive health and rights (SRHR) interventions. However, sexual pleasure-related programming and research remains sparse. We aimed to assess chatbot acceptability and describe changes in SRHR attitudes and behaviours among Kenyan young adults engaging with a pleasure-oriented SRHR chatbot. We used an exploratory mixed-methods study design. Between November 2021 and January 2022, participants completed a self-administered online questionnaire before and after chatbot engagement. In-depth phone interviews were conducted among a select group of participants after their initial chatbot engagement. Quantitative data were analysed using paired analyses and interviews were analysed using thematic content analysis. Of 301 baseline participants, 38% (115/301) completed the endline survey, with no measured baseline differences between participants who did and did not complete the endline survey. In-depth interviews were conducted among 41 participants. We observed higher satisfaction at endline vs. baseline on reported ability to exercise sexual rights (P ≤ 0.01), confidence discussing contraception (P ≤ 0.02) and sexual feelings/needs (P ≤ 0.001) with their sexual partner(s). Qualitative interviews indicated that most participants valued the chatbot as a confidential and free-of-judgment source of trustworthy "on-demand" SRHR information. Participants reported improvements in sex-positive communication with partners and safer sex practices due to new learnings from the chatbot. We observed increases in SRHR empowerment among young Kenyans after engagement with the chatbot. Integrating sexual pleasure into traditional SRHR content delivered through digital tools is a promising strategy to advance positive SRHR attitudes and practices among youth.

Evaluating Counseling for Choice in Malawi: A Client-Centered Approach to Contraceptive Counseling

INTRODUCTION

High-quality contraceptive counseling is critical for supporting full, free, and informed contraceptive decision-making. However, the quality of family planning counseling remains poor globally and is too often not tailored to the individual client. The Counseling for Choice (C4C) approach comprises provider tools and training to structure counseling to center clients' self-identified priorities and to provide relevant information and anticipatory side effects counseling.

METHODS

Providers at 25 public and 20 private facilities in Malawi were trained in the C4C approach. Between October and December 2018, we enrolled women seeking contraceptive services in intervention facilities and in matched comparison clinics in a quasi-experimental study. We collected data immediately before and after contraceptive services were received. We used multilevel logistic regression to compare dimensions of women's counseling experience.

RESULTS

Of 1,179 participants, women counseled by C4C-trained providers rated their providers higher on several quality dimensions, including enabling informed decision-making (11.1% of the comparison group rated their provider as excellent versus 34.4% in intervention), respectful care (35.0% comparison versus 51.3% intervention), and information given about side effects (38.1% comparison versus 72.5% intervention).

CONCLUSION

In Malawi, C4C improved the quality of care that clients received and their client experience relative to standard counseling. Counseling approaches that center clients' priorities and provide enhanced anticipatory side effects counseling show promise in improving contraceptive counseling experiences and the quality of care that clients receive.

Demand Forecasting Approaches for New Contraceptive Technologies: A Landscape Review and Recommendations for Alignment

INTRODUCTION

Market size estimations and demand forecasts use a variety of methodological approaches to inform decision-making around new (and lesser-used) contraceptive methods. For contraceptive products already available at scale in a market, historical procurement and consumption data can help to inform these forecasts. However, little published guidance is available on appropriate approaches to estimating contraceptive demand in the absence of historical data.

METHODS

This landscape review aimed to describe the variety of approaches for modeling demand for new contraceptive methods, highlight opportunities for alignment around forecasting practices, and make recommendations to support more accurate forecasting and sound decision-making based on forecasts. We used the published scientific and gray literature to inform the development of a semistructured guide for key informant interviews. We conducted interviews with 29 experts representing a spectrum of interests in market size estimation and demand forecasting for new contraceptive methods (e.g., ministries of health, donors, manufacturers, technical assistance providers, and demand forecasting specialists). We coded notes from the interviews using thematic content analysis.

RESULTS

The purposes of market size estimation and demand forecasting for new contraceptive methods vary widely, as do associated model inputs and outputs. Key informants revealed a need for more standardized language around market size estimation and demand forecasting and highlighted key recommendations: select models that are fit-for-purpose, clearly articulate assumptions and uncertainty in model outputs, consider a broad range of contraceptive options in a forecast to capture the complete contraceptive supply environment, and perform a reality check of results and refresh assumptions.

CONCLUSION

We recommend following a simple decision pathway to ensure that forecasts are fit-for-purpose, with appropriate inputs, outputs, and assumptions clearly articulated. Common pitfalls around overestimating demand should be avoided. Incorporating best practices into forecasting exercises will ensure that models are useful for the stakeholders.

Trajectories of method dissatisfaction among Kenyan women using modern, reversible contraception: A prospective cohort study

OBJECTIVES

Evidence on method dissatisfaction among current contraceptive users is sparse. Group-based trajectory modeling presents a novel approach to describing method dissatisfaction.

STUDY DESIGN

In a cohort of Kenyan women using modern contraception, we identified group-based trajectories of method dissatisfaction over 24 weeks since clinic visit.

RESULTS

Among 947 women, four trajectories were identified: consistent satisfaction (71%), increasing dissatisfaction (18%), decreasing dissatisfaction (8%), and consistent dissatisfaction (3%).

DISCUSSION

Method dissatisfaction was common in a cohort of Kenyan women. Group-based trajectory models describe distinct and changing experiences of contraceptive use. Deeper understanding of trajectories of contraceptive experience may be useful for advancing person-centered family planning care that addresses users' changing preferences and challenges.

Contributions of side effects to contraceptive discontinuation and method switch among Kenyan women: a prospective cohort study

OBJECTIVE

To determine the contribution of specific contraceptive side effects to method switch and modern-method discontinuation among Kenyan women.

DESIGN

A prospective cohort study.

SETTING

Five counties in Western Kenya.

PARTICIPANTS

Women aged ≥18 years old and emancipated female minors ≥14 years old using modern, reversible contraception were recruited while attending 10 public health facilities.

METHODS

Patient-reported side effect symptoms, method switch, and discontinuation were reported through weekly text message-based surveys for 24 weeks.

MAIN OUTCOME MEASUREMENTS

Prevalence, hazards ratio (HR).

RESULTS

Among 825 women, 44% were using implants, 43% injectables, 7% intrauterine device, and 6% oral contraceptive pills at enrollment. Most (61%) women were continuing a method used in the previous month. During the 24-week follow-up, incidence of contraceptive switch was 61.3 per 100 person-years (95% confidence interval [CI] 52.4-71.8) and incidence of discontinuation was 38.5 per 100 person-years (95%CI 31.6-47.0). On average, one-quarter (prevalence [Pr] 0.24, 95%CI 0.22-0.26) of participants reported side effects or method problems weekly, with sexual side effects the most prevalent symptom (Pr 0.15, 95%CI 0.13-0.16). Lack of expected bleeding was associated with higher risk of method switch (adjusted hazard ratio [aHR] 2.36, 95%CI 1.22-4.57). Risk of all-modern method discontinuation was higher among women experiencing irregular bleeding (adjusted hazard ratio [aHR] 2.39, 95%CI 1.20-4.77), weight changes (aHR 2.72, 95%CI 1.47-4.68), and sexual side effects (aHR 2.42, 95%CI 1.40-4.20).

CONCLUSIONS

Addressing irregular bleeding, weight changes, and sexual side effects through development of new products that minimize these specific side effects and anticipatory counseling may reduce method-related discontinuation.

Bypassing high-quality maternity facilities: evidence from pregnant women in peri-urban Nairobi

Utilization of high-quality maternal care is an important link along the pathway from increased facility-based delivery to improved maternal health outcomes, however women in Nairobi do not all deliver in the highest quality facilities available to them. We explored whether women living in peri-urban Nairobi who live nearby to high-quality facilities bypassed, or travelled farther than, their nearest high technical quality facility using survey data collected before and after delivery from women (n = 358) and from facility assessments (n = 59). We defined the nearest high technical quality facility as the nearest Comprehensive Emergency Obstetric and Newborn Care (CEmONC) capable facility to each woman's neighbourhood. We compared women who delivered in their nearest CEmONC (n = 44) to women who bypassed their nearest CEmONC to deliver in a facility that was farther away (n = 200). Among bypassers, 131 (65.5%) women delivered in farther non-CEmONC facilities with lower technical quality and 69 (34.5%) delivered in farther CEmONCs with higher technical quality capacity compared to their nearby CEmONCs. Bypassers rated their delivery experience higher than non-bypassers. Women who bypassed to deliver in non-CEmONCs were less likely to have completed four antenatal care visits and to consider delivering in any CEmONC prior to delivery while women who bypassed to deliver in farther CEmONCs paid more for delivery and were more likely to report being able to access emergency funds compared to non-bypassers. Our findings suggest that women in peri-urban Nairobi bypassed their nearest CEmONC facilities in favour of delivering in facilities that provided better non-technical quality care. Bypassers with access to financial resources were also able to deliver in facilities with higher technical quality care. Policies that improve women's delivery experience and ensure that information about facility technical quality is widely distributed may be critical to increase the utilization of high-quality maternity facilities.

Use of a mobile app to capture supplemental health information during pregnancy: Implications for clinical research

PURPOSE

Mobile applications ("apps") may be efficient tools for improving the quality of clinical research among pregnant women, but evidence is sparse. We assess the feasibility and generalizability of a mobile app for capturing supplemental data during pregnancy.

METHODS

In 2017, we conducted a pilot study of the FDA MyStudies mobile app within a pregnant population identified through Kaiser Permanente Washington (KPWA), an integrated healthcare delivery system. We ascertained health conditions, medications, and substance use through app-based questionnaires. In a post-hoc analysis, we utilized electronic health records (EHR) to summarize sociodemographic and health characteristics of pilot participants and, for comparison, a pregnant population identified using similar methods.

RESULTS

Six percent (64/1070) of contacted women enrolled in the pilot study. Nearly half (23/53) reported taking medication for headaches and one-fourth for constipation (13/53) and nausea (12/53) each. Few instances (2/92) of over-the-counter medication use were identified in electronic dispensing records. One-quarter to one-third of participants with depression and anxiety/panic, respectively, reported recently discontinuing medications for these conditions. Eighty-eight percent of pilot participants reported White race (95%CI: 81-95%), versus 67% of the comparison population (N = 2065). More pilot participants filled ≥1 prescription for antianxiety medication (22% [95%CI: 13-35%]) and antidepressants (19% [95%CI 10-31%]) pre-pregnancy than the comparison population (10 and 9%, respectively).

CONCLUSIONS

Mobile apps may be a feasible tool for capturing health data not routinely available in EHR. Pregnant women willing to use a mobile app for research may differ from the general pregnant population, but confirmation is needed.

Incorporating Method Dissatisfaction into Unmet Need for Contraception: Implications for Measurement and Impact

While unmet need for contraception is commonly used to assess programmatic needs, it inadequately captures the complexity of fertility and contraceptive preferences, including women's satisfaction with their contraceptive method. In their 2019 commentary, Sarah Rominski and Rob Stephenson propose reclassifying dissatisfied current users as having an unmet need for contraception. As revising the current definition based on their proposal would require significant investment to update survey and monitoring systems, understanding the potential impact on current estimates of unmet need is critical. We estimated the impact of this approach in a Kenyan cohort of modern contraceptive users. We found the prevalence of method dissatisfaction ranges from 6.6% (95% confidence interval [CI] 5.6–7.8%) to 18.9% (95% CI 17.1–20.9%); if applied nationally, this results in a large (approximately 25–70%) increase in Kenya's current estimate of unmet need for any contraception. Our findings suggest a large impact on unmet need estimates for equivalent populations. Overall, we advocate for better measurements of method satisfaction and acceptability, with metrics developed that are robust to socioeconomic gradients and validated in low‐ and middle‐income settings to ensure women's contraceptive needs are captured equitably.

A risk scoring tool for predicting Kenyan women at high risk of contraceptive discontinuation

Objective

We developed and validated a pragmatic risk assessment tool for identifying contraceptive discontinuation among Kenyan women who do not desire pregnancy.

Study design

Within a prospective cohort of contraceptive users, participants were randomly allocated to derivation (n = 558) and validation (n = 186) cohorts. Risk scores were developed by selecting the Cox proportional hazards model with the minimum Akaike information criterion. Predictive performance was evaluated using time-dependent receiver operating characteristic curves and area under the curve (AUC).

Results

The overall contraceptive discontinuation rate was 36.9 per 100 woman-years (95% confidence interval [CI] 30.3–44.9). The predictors of discontinuation selected for the risk score included use of a short-term method or copper intrauterine device (vs. injectable or implant), method continuation or switch (vs. initiation), < 9 years of completed education, not having a child aged < 6 months, and having no spouse or a spouse supportive of family planning (vs. having a spouse who has unsupportive or uncertain attitudes towards family planning). AUC at 24 weeks was 0.76 (95% CI 0.64–0.87) with 70.0% sensitivity and 78.6% specificity at the optimal cut point in the derivation cohort. Discontinuation was 3.8-fold higher among high- vs. low-risk women (95% CI 2.33–6.30). AUC was 0.68 (95% CI 0.47–0.90) in the validation cohort. A simplified score comprising routinely collected variables demonstrated similar performance (derivation-AUC: 0.73 [95% CI 0.60–0.85]; validation-AUC: 0.73 [95% CI 0.51–0.94]). Positive predictive value in the derivation cohort was 31.4% for the full and 28.1% for the simplified score.

Conclusions

The risk scores demonstrated moderate predictive ability but identified large proportions of women as high risk. Future research is needed to improve sensitivity and specificity of a clinical tool to identify women at high risk for experiencing method-related challenges.

Implications

Contraceptive discontinuation is a major driver of unmet contraceptive need globally. Few tools exist for identifying women who may benefit most from additional support in order to meet their contraceptive needs and preferences. This study developed and assessed the validity of a provider-focused risk prediction tool for contraceptive discontinuation among Kenyan women using modern contraception. High rates of early discontinuation observed in this study emphasize the necessity of investing in efforts to develop new contraceptive technologies and stronger delivery systems to better align with women's needs and preferences for voluntary family planning.

The Utility of SMS to Report Male Partner HIV Self-testing Outcomes Among Women Seeking Reproductive Health Services in Kenya: Cohort Study

Background

Use of SMS for data collection is expanding, but coverage, bias, and logistical constraints are poorly described.

Objective

The aim of this study is to assess the use of SMS to capture clinical outcomes that occur at home and identify potential biases in reporting compared to in-person ascertainment.

Methods

In the PrEP Implementation in Young Women and Adolescents program, which integrated pre-exposure prophylaxis (PrEP) into antenatal care, postnatal care, and family planning facilities in Kisumu County, Kenya, HIV-negative women 14 years of age or older were offered oral HIV self-tests (HIVSTs) to take home to male partners. Women that brought a phone with a Safaricom SIM to the clinic were offered registration in an automated SMS system (mSurvey) to collect information on HIVST outcomes. Women were asked if they offered the test to their male partners, and asked about the test process and results. HIVST outcomes were collected via SMS (sent 2.5 weeks later), in-person (if women returned for a follow-up scheduled 1 month later), or using both methods (if women initiated PrEP, they also had scheduled follow-up visits). The SMS prompted women to reply at no charge. HIVST outcomes were compared between women with scheduled follow-up visits and those without (follow-up visits were only scheduled for women who initiated PrEP). HIVST outcomes were also compared between women reporting via SMS and in-person.

Results

Among 2123 women offered HIVSTs and mSurvey registration, 486 (23.89%) accepted HIVSTs, of whom 359 (73.87%) were eligible for mSurvey. Additionally, 76/170 (44.7%) women with scheduled follow-up visits and 146/189 (77.3%) without scheduled follow-up visits registered in mSurvey. Among the 76 women with scheduled follow-ups, 62 (82%) had HIVST outcomes collected: 19 (31%) in-person, 20 (32%) by SMS, and 23 (37%) using both methods. Among the 146 women without scheduled visits, 87 (59.6%) had HIVST outcomes collected: 3 (3%) in-person, 82 (94%) by SMS, and 2 (2%) using both methods. SMS increased the collection of HIVST outcomes substantially for women with scheduled follow-up visits (1.48-fold), and captured 82 additional reports from women without scheduled follow-up visits. Among 222 women with reported HIVST outcomes, frequencies of offering partners the HIVST (85/95, 89% in-person vs 96/102, 94% SMS; P=.31), partners using the HIVST (83/85, 98% vs 92/96, 96%; P=.50), women using HIVST with partners (82/83, 99% vs 91/92, 99%; P=.94), and seeing partner’s HIVST results (82/83, 99% vs 89/92, 97%; P=.56) were similar between women reporting in-person only versus by SMS only. However, frequency of reports of experiencing harm or negative reactions from partners was more commonly reported in the SMS group (17/102, 16.7% vs 2/85, 2%; P=.003). Barriers to the SMS system registration included not having a Safaricom SIM or a functioning phone.

Conclusions

Our results suggest that the use of SMS substantially improves completeness of outcome data, does not bias reporting of nonsensitive information, and may increase reporting of sensitive information.