Characterizing provider bias in contraceptive care in Tanzania and Burkina Faso: A mixed-methods study

Provider bias based on age, marital status, and parity may be a barrier to quality contraceptive care. However, the extent to which bias leads to disparities in care quality is not well understood. In this mixed-methods study, we used four different data sources from the same facilities to assess the extent of bias and how much it affects contraceptive care. First, we surveyed providers in Tanzania and Burkina Faso (N = 295) to assess provider attitudes about young, unmarried, and nulliparous clients. Second, mystery clients anonymously visited providers for contraceptive care and we randomly assigned the reported age, marital status, and parity of each visit (N = 306). We used data from these visits to investigate contraceptive care disparities across 3 domains: information provision and counseling quality, contraceptive method provision, and perceived treatment. Third, we complemented mystery client data with client exit surveys (N = 31,023) and client in-depth interviews (N = 36). In surveys, providers reported biased attitudes against young, unmarried, and nulliparous clients seeking contraceptives. Similarly, we found disparities according to these characteristics in the reporting of contraceptive care quality; however, we found that each characteristic affected a different quality of care domain. Among mystery clients we found age-related disparities in the provision of methods; 16/17-year-old clients were 18 and 11 percentage points less likely to perceive they could take a contraceptive method relative to 24-year-old clients in Tanzania and Burkina Faso, respectively. Unmarried mystery clients perceived worse treatment from providers compared to married clients. Nulliparous mystery clients reported lower quality contraceptive counseling than their parous counterparts. These results suggest that clients of different characteristics likely experience bias across different elements of care. Improving care quality and reducing disparities will require attention to which elements of care are deficient for different types of clients.

Safe abortion in Latin America: a look at abortion accompaniment collectives from the perspective of their activists

Over the last decade, activists in Latin America have expanded access to safe abortion through processes of accompaniment. Abortion accompaniment is characterised by activism and community-based strategies to facilitate access to, and safe use of, medication abortion, mainly outside clinical contexts. Drawing on findings from a survey of 515 activists who were part of Accompaniment Collectives in Latin America, this study describes the organisation of these collectives, barriers and facilitators to their activism, and how accompaniers perceive the impact and future of abortion accompaniment. Accompaniment Collectives are organised and flexible and operate in diverse social and legal contexts. The main goals of accompaniment are the normalisation and social decriminalisation of abortion culturally (84%); the social construction of autonomy (79%); and the protection of people's freedom (73%), life (71%) and health (67%). Activists in legally restrictive settings identified limited access to abortion medication (73%) and restrictive laws (71%) as the main barriers to accompaniment, while health care personnel objecting to abortion provision on grounds of conscience was most common in legally permissive settings (64%). Collectives have developed strategies to overcome such barriers to and expanding access to abortion care. Activists expect accompaniment to continue regardless of the legal status of abortion.

Removal of long-acting reversible contraceptive methods and quality of care in Dar es Salaam, Tanzania: Client and provider perspectives from a secondary analysis of cross-sectional survey data from a randomized controlled trial

Access to removal of long-acting reversible contraception (LARCs) (e.g., implants and intrauterine devices (IUDs)) is an essential part of contraceptive care. We conducted a secondary analysis of cross-sectional survey data from a randomized controlled trial. We analyzed 5,930 client surveys and 259 provider surveys from 73 public sector facilities in Tanzania to examine the receipt of desired LARC removal services among clients and the association between receipt of desired LARC removal and person-centered care. We used provider survey data to contextualize these findings, describing provider attitudes and training related to LARC removals. All facilities took part in a larger randomized controlled trial to assess the Beyond Bias intervention, a provider-focused intervention to reduce provider bias on the basis of age, marital status, and parity. Thirteen percent of clients did not receive a desired LARC removal during their visit. Clients who were young, had lower perceived socioeconomic status, and visited facilities that did not take part in the Beyond Bias intervention were less likely to receive a desired removal. Clients who received a desired LARC removal reported higher levels of person-centered care (β = .07, CI: .02 - .11, p = < .01). Half of providers reported not being comfortable removing a LARC before its expiration (51%) or if they disagreed with the client's decision (49%). Attention is needed to ensure clients can get their LARCs removed when they want to ensure patient-centered care and protect client autonomy and rights. Interventions like the Beyond Bias intervention, may work to address provider-imposed barriers to LARC removals.

Barriers and delays in access to abortion care: a cross-sectional study of people traveling to obtain care in England and the Netherlands from European countries where abortion is legal on broad grounds

INTRODUCTION

This study characterized the extent to which (1) financial barriers and (2) abortion care-seeking within a person's country of residence were associated with delays in abortion access among those travelling to England and the Netherlands for abortion care from European countries where abortion is legal on broad grounds in the first trimester but where access past the first trimester is limited to specific circumstances.

METHODOLOGY

We drew on cross-sectional survey data collected at five abortion clinics in England and the Netherlands from 2017 to 2019 (n = 164). We assessed the relationship between difficulty paying for the abortion/travel, acute financial insecurity, and in-country care seeking on delays to abortion using multivariable discrete-time hazards models.

RESULTS

Participants who reported facing both difficulty paying for the abortion procedure and/or travel and difficulty covering basic living costs in the last month reported longer delays in accessing care than those who had no financial difficulty (adjusted hazard odds ratio: 0.39 95% CI 0.21-0.74). This group delayed paying other expenses (39%) or sold something of value (13%) to fund their abortion, resulting in ~ 60% of those with financial difficulty reporting it took them over a week to raise the funds needed for their abortion. Having contacted or visited an abortion provider in the country of residence was associated with delays in presenting abroad for an abortion.

DISCUSSION

These findings point to inequities in access to timely abortion care based on socioeconomic status. Legal time limits on abortion may intersect with individuals' interactions with the health care system to delay care.

Recruiting pregnant people considering abortion: An analysis of differences in participant characteristics by recruitment site across online, abortion fund, and clinic-based sources

OBJECTIVES

This study aimed to evaluate differences by recruitment method in the characteristics of participants who are considering abortion.

STUDY DESIGN

Between June 2021 and April 2022, we recruited pregnant people considering abortion in Indiana from (1) online posts, (2) abortion funds, and (3) abortion clinics. We compared participant characteristics reported in an online survey by recruitment source.

RESULTS

Compared to those recruited from clinics (n = 94), participants recruited online (n = 84) and through abortion funds (n = 239) were later in their pregnancy, were already parenting, received less formal education, struggled financially, and were more likely to be Black or African American, queer, transgender, or nonbinary.

CONCLUSIONS

Recruitment from online sources and abortion funds reaches more people who face greater barriers to abortion care than recruitment from clinics.

IMPLICATIONS

Augmenting clinic-based recruitment with online and abortion fund recruitment could capture a more complete sample of people considering abortion.

Assessing the relationship between reproductive autonomy and contraceptive use in rural Malawi

Reproductive autonomy, or the extent to which people control matters related to their own sexual and reproductive decisions, may help explain why some people who do not intend to become pregnant nevertheless do not use contraception. Using cross-sectional survey data from 695 women aged 16 to 47 enrolled in the Umoyo Wa Thanzi (UTHA) study in Malawi in 2019, we conducted confirmatory factor analysis, descriptive analyses, and multivariable logistic regression to assess the freedom from coercion and communication subscales of the Reproductive Autonomy Scale and to examine relationships between these components of reproductive autonomy and current contraceptive use. The freedom from coercion and communication subscales were valid within this population of partnered women; results from a correlated two-factor confirmatory factor analysis model resulted in good model fit. Women with higher scores on the freedom from coercion subscale had greater odds of current contraceptive use (aOR 1.13, 95% CI: 1.03-1.23) after adjustment for pregnancy intentions, relationship type, parity, education, employment for wages, and household wealth. Scores on the communication subscale were predictive of contraceptive use in some, but not all, models. These findings demonstrate the utility of the Reproductive Autonomy Scale in more holistically understanding contractive use and non-use in a lower-income setting, yet also highlight the need to further explore the multidimensionality of women's reproductive autonomy and its effects on achieving desired fertility.

Characterizing two models for abortion care in Argentina pre-Law 27.610: 2016-2019

OBJECTIVE

Explore the use of two abortion care models in Argentina over the period 2016-2019: pro-rights private medical service providers and abortion accompaniment (via self-management and via health institutions); and compare the profile of who accesses these models and when.

METHODS

We used data from accompaniment collectives in the Socorristas en Red and private service providers. We estimated annual abortion rates via these service models and compared the profile of the populations by type of service and gestational age (2019) using descriptive statistics and chi-square tests.

RESULTS

In 2016, 37 people per 100,000 women of reproductive age obtained accompanied self-managed abortions, and the number increased to 111 per 100,000 in 2019, a threefold increase. The rate of abortions via care providers was 18 per 100,000 in 2016 and 33 in 2019. Higher proportions of those who obtained abortion via care providers were 30 years or older. A higher proportion of those accompanied were 19 years or younger; 11% of those who obtained accompanied self-managed abortions were more than 12 weeks gestation compared with 7% among those who had accompanied abortions via health institutions and 0.2% among those who had abortions with private providers. A higher proportion of those who accessed accompanied abortions after 12 weeks gestation had lower educational levels, did not work or have social security coverage, had more past pregnancies, and attempted to terminate their pregnancies prior to contacting the Socorristas compared to those who had accompanied abortions at 12 weeks or earlier.

CONCLUSIONS

In Argentina, prior to Law 27.610 models of care guaranteed access to safe abortion. It is important to continue making visible and legitimizing these models of care so that all those who decide to have an abortion, whether inside or outside health institutions, have safe and positive experiences.

Challenges accessing contraceptive care and interest in over-the-counter oral contraceptive pill use among Black, Indigenous, and people of color: An online cross-sectional survey

OBJECTIVE

To examine challenges accessing contraception in the past year and their association with interest in using an over the counter (OTC) oral contraceptive pill (OCP) among Black, Indigenous, and people of color (BIPOC) in the United States.

STUDY DESIGN

From May 2021 to March 2022, a collaborative research team conducted a cross-sectional online survey using convenience sampling to recruit people who identify as Asian American, Native Hawaiian, or Pacific Islander, Black or African American, Indigenous, or Latina/Latinx and used or wanted to use a contraceptive method in the past year. Respondents were recruited through reproductive justice and community-based organizations.

RESULTS

Among 727 respondents, 45% reported experiencing at least one challenge accessing contraception in the past year of which 37% reported a logistical challenge, and 20% reported an interpersonal challenge. Sixty-seven percent of respondents said they were likely to use an OTC OCP. Respondents who reported experiencing at least one challenge accessing contraception in the past year were more likely to say they would use an OTC OCP. Fifty-seven percent of respondents who were not using a contraceptive method in the past year reported they were likely to use an OTC OCP.

CONCLUSION

Among people in this study, interest in an OTC OCP is high, particularly among those who have faced challenges accessing contraception, and among those who are not currently using a contraceptive method.

IMPLICATIONS

Availability of an OCP OTC has the potential to address challenges accessing contraceptive care among BIPOC in the United States, who are often impacted by structural inequities and racism. Findings from this study can inform future OTC implementation strategies to ensure OTC access addresses logistical and interpersonal challenges.

Effectiveness and efficacy rates of progestin-only pills: A comprehensive literature review

OBJECTIVES

To synthesize published literature on POP effectiveness and efficacy.

STUDY DESIGN

We searched PubMed Central, PubMed, and the Cochrane library through March 07, 2022. We included articles written in English reporting a Pearl Index or life table rate for pregnancy. We excluded articles only assessing formulations that: were never marketed globally, are only sold in combination with estrogen, are currently sold only for noncontraceptive purposes, or were not given to participants continuously. Four researchers independently extracted data and two analyzed data using Excel and R.

RESULTS

We included 54 studies. Among studies at low or moderate risk of bias, the median Pearl Index rate (the failure rate during typical use) was 1.63 (range 0.00-14.20, IQR 4.03) and the median method failure Pearl Index rate (the failure rate during perfect use) was 0.97 (range 0.40-6.50, IQR 0.68). Excluding the newer formulations, Desogestrel and Drospirenone, which are closer to combined oral contraceptives in that they prevent pregnancy by inhibiting ovulation, the median Pearl Index rate is 2.00 (range 0.00-14.12, IQR 2.5) and the median method failure Pearl Index rate is 1.05 (range 0.00-10.90, IQR 1.38).

CONCLUSIONS

Among studies at low or moderate risk of bias, the median Pearl Index rate during typical POP use was much lower than currently estimated (7.00), while the median perfect use rate was similar to current estimates.

IMPLICATIONS

Future research should investigate the possibility that POPs may be much more effective during typical use than currently believed.

A commentary on progestin-only pills and the "three-hour window" guidelines: Timing of ingestion and mechanisms of action

Clinical guidelines for progestin-only pills (POPs) state that each pill should be taken at the same time each day, with only a "three-hour window" of tolerance before back-up contraception should be used. In this commentary, we summarize studies examining the timing of ingestion and mechanisms of action for various POP formulations and dosages. We found that different progestins have different properties that determine the effect of delayed or missed pills on effectiveness at preventing pregnancy. Our findings highlight that there is more margin for error for some POPs than guidelines suggest. The three-hour window recommendation should be re-evaluated in light of these findings. Since clinicians, potential POP users, and regulatory bodies rely on current guidelines to make decisions about POP use, a critical evaluation and update of these guidelines are urgently needed.

Who Accesses Birth Control Online? An Analysis of Requests for Contraception Submitted to an Online Prescribing Platform in the United States

INTRODUCTION

Telehealth has the potential to increase contraceptive access. Little is known about the characteristics of people using online prescribing platforms or whether these services help fill access gaps.

METHODS

We analyzed requests for contraception submitted between July 2015 and September 2017 to an online prescribing platform that offers sexual and reproductive care in the United States. We analyzed the characteristics of people seeking contraceptives, prevalence of contraindications to hormonal contraception among contraceptive seekers, and extent to which online prescribing may close contraceptive access gaps.

RESULTS

A total of 38,439 requests for prescription hormonal birth control were received during the study period, with requests increasing dramatically over this timeframe as the platform expanded operations to an increasing number of states. Methods were dispensed in response to 63% of requests. In this population seeking contraception, an estimated 1.2% had a contraindication to progestin-only pills, and an estimated 12.0% of patients who reported their blood pressure had a contraindication to combined hormonal methods. Few requests came from patients younger than 18 (1.2%). In multivariable negative binomial models, urban counties had a larger concentration of requests, whereas counties with higher rates of uninsurance and poverty had lower rates of requests.

CONCLUSIONS

Results suggest that the population seeking contraception from one online prescribing platform has similar levels of contraindications to hormonal contraceptives as found in prior research. Future research should seek to understand why utilization of this online prescribing platform was lower among young people, how to expand outreach to rural populations, and what underlies individuals' decisions about using these services.

Experiences using a progestin-only pill in an over-the-counter environment in the United States: a cross-sectional survey

BACKGROUND

Efforts are underway to make a progestin-only pill (POP) over the counter (OTC) in the United States (US); however, little is known about POP user experiences, which could impact uptake and continuation.

METHODS

From January 2020-September 2021, we conducted a cross-sectional online survey with individuals who used OTC POPs in a US trial. We calculated descriptive statistics and Pearson chi-square and Fisher's exact tests to assess menstrual bleeding acceptability, how OTC POP experiences compared with prior contraceptive methods, and preferred ways to get answers to questions during OTC POP use.

RESULTS

Among 550 adult and 115 adolescent participants, 80% (n=531) felt their menstrual bleeding was acceptable. Participants reported a range of menstrual bleeding experiences compared with prior long-acting or hormonal methods used; 58% (n=84) said the POP bleeding was similar or better and 36% (n=53) said it was worse. Among participants who used contraception in the month prior to the trial, 77% (n=201) said their overall OTC POP experience was similar or better. Top benefits compared with prior methods included less worry about pregnancy, ease of access, fewer side effects, and greater decision-making power. Adults preferred to get answers about OTC POPs via webpage or app, whereas teens preferred asking pharmacists or other healthcare providers.

CONCLUSIONS

Overall, OTC POP users in a trial setting found the menstrual bleeding acceptable and the method similar to or better than previous methods. POP labelling should provide clear messaging about bleeding changes users may experience.

Interest in Continued Use After Participation in a Study of Over-the-Counter Progestin-Only Pills in the United States

OBJECTIVE

To assess interest in continued use of over-the-counter progestin-only pills among individuals who used them in a trial.

METHODS

From January 2020 to September 2021, we conducted a cross-sectional online survey with individuals who completed participation in a trial evaluating over-the-counter use of norgestrel 0.075 mg tablets in the United States. We calculated descriptive statistics, Pearson's chi-square and Fisher's exact tests, and logistic regression models to assess likelihood of future over-the-counter progestin-only pill use, reasons for interest/noninterest, situations for over-the-counter progestin-only pill use, willingness to pay for an over-the-counter progestin-only pill, likelihood of future preventive health screenings, prior difficulties getting prescription contraception, and background characteristics.

RESULTS

Among 550 adult and 115 adolescent participants (75% response rate), 83% reported likelihood of future over-the-counter progestin-only pill use. Hispanic/Latinx and Black participants and adults with public insurance, prior pregnancies, and some college reported higher likelihood of future use compared with their counterparts. Among likely users, 90% were interested in long-term use and 79 % ≥ 25 years of age reported they would get future preventive screenings; participants would pay up to $20/month on average. Primary reasons for interest included convenience (81%), ease of access (80%), and saving time (77%) and money (64%). The primary reason for noninterest was bleeding associated with progestin-only pill use (52%).

CONCLUSION

There was high interest in continuing to use over-the-counter progestin-only pills among individuals who had used them in a study. These findings highlight the real-world acceptability of taking a progestin-only pill without a prescription, and contribute to evidence supporting over-the-counter access.

"It just seemed like a perfect storm": A multi-methods feasibility study on the use of Facebook, Google Ads, and Reddit to collect data on abortion-seeking experiences from people who considered but did not obtain abortion care in the United States

Most studies of abortion access have recruited participants from abortion clinics, thereby missing people for whom barriers to care were insurmountable. Consequently, research may underestimate the nature and scope of barriers that exist. We aimed to recruit participants who had considered, but failed to obtain, an abortion using three online platforms, and to evaluate the feasibility of collecting data on their abortion-seeking experiences in a multi-modal online study. In 2018, we recruited participants for this feasibility study from Facebook, Google Ads, and Reddit for an online survey about experiences seeking abortion care in the United States; we additionally conducted in-depth interviews among a subset of survey participants. We completed descriptive analyses of survey data, and thematic analyses of interview data. Recruitment results have been previously published. For the primary outcomes of this analysis, over one month, we succeeded in capturing data on abortion-seeking experiences from 66 individuals who were not currently pregnant and reported not having obtained an abortion, nor visited an abortion facility, despite feeling that abortion could have been the best option for a recent pregnancy. A subset of survey respondents (n = 14) completed in-depth interviews. Results highlighted multiple, reinforcing barriers to abortion care, including legal restrictions such as gestational limits and waiting periods that exacerbated financial and other burdens, logistical and informational barriers, as well as barriers to abortion care less frequently reported in the literature, such as a preference for medication abortion. These findings support the use of online recruitment to identify and survey an understudied population about their abortion-seeking experiences. Further, findings contribute to a more complete understanding of the full range of barriers to abortion care that people experience in the United States, and how these barriers intersect to not just delay, but to prevent people from obtaining abortion.

Patient experiences with pharmacist prescribed hormonal contraception in California independent and chain pharmacies

BACKGROUND

Pharmacist contraception care is an innovative practice that is rapidly expanding with policy changes. There is limited literature describing patient experiences with this pharmacist service.

OBJECTIVE

The objective of this study is to describe patient experiences using pharmacist-prescribed hormonal contraception in California pharmacies.

METHODS

An online survey was conducted among a cross-sectional convenience sample of people of all ages who completed a contraception visit with a pharmacist from December 2017 to January 2019 at a participating independent or chain pharmacy in California. Descriptive statistics were used to analyze data on patient characteristics, experiences and satisfaction with the service, and preventive health screenings.

RESULTS

A total of 160 individuals completed the survey and nearly all were adults (97%) and had started or completed postsecondary education (85%). Most (72%) visited the pharmacy to get a prescription for a contraceptive method they were already using. The most common method prescribed was the pill (90%). The most common reason for seeking a prescription at a pharmacy was because it would be faster than waiting for a doctor's appointment (74%), followed by the location and hours being more convenient (46% and 41%), saving money (28%), and not having a regular doctor (26%). Respondents reported satisfaction with the services overall (97%), level of comfort they felt with the pharmacist (94%), counseling provided (86%), and level of privacy (74%). Nearly all were likely to return to a pharmacist for contraception (96%) and recommend the service to a friend (95%).

CONCLUSION

Pharmacist prescribing of contraception in community pharmacies provided a convenient access point that was highly acceptable to patients who used it. One area for attention is in the level of privacy during contraception visits. These findings support the effectiveness of direct pharmacy access to contraception and encourage pharmacist contraception prescribing policies and widespread implementation.

Exploring Experiences Responding to the Individual Level Abortion Stigma Scale: Methodological Considerations From In-depth Interviews

Background: The Individual-Level Abortion Stigma (ILAS) scale is a tool to measure multiple dimensions of stigma among people who have abortions. Despite use of the scale globally, little is known about participant experiences completing the scale. We assessed reactions to and experiences with the scale among women who obtained abortions in Mexico, exploring how the items made them feel about themselves and their abortion.

Methods: We conducted 10 in-depth interviews with women approximately 6 months after their abortion. We explored experiences answering the ILAS overall as well as each sub-scale (self-judgement; worries about judgement; isolation; community condemnation). We used thematic analysis to examine overall experiences with the ILAS and framework analysis to summarize responses by sub-scale.

Results: Many respondents reported positive experiences responding to the scale or said it served a therapeutic purpose. Other participants said the scale caused strong or mixed emotions or generated doubts. Women generally described mixed and negative reactions to the “worries about judgement” and “community condemnation” sub-scales, and more neutral or positive reactions to the “isolation” and “self judgement” sub-scales. Nearly all respondents hypothesized that completing the ILAS at the time of their abortion would be more difficult than responding months after their abortion.

Conclusions: People can experience both positive and negative effects when responding to abortion stigma scales. Use of the scales may cause discomfort and introduce concepts that further perpetuate stigma. This study highlights the importance of carefully considering when it is appropriate to implement the scale and exploring safeguards for participants.

Over-the-counter oral contraceptive use among women in Mexico: results from a national survey

AIM

In Mexico, many pharmacies sell oral contraceptives (OCs) over the counter (OTC); however, little is known about the background characteristics of OTC pill users. The primary objective of this study was to understand the characteristics of OTC OC users in Mexico, including whether there were differences by age, urbanicity, and insurance status. This information is instructive as other countries explore allowing OTC access to OCs.

METHODS

We analysed the nationally representative 2014 Mexican National Survey of Demographic Dynamics (ENADID) among a sample of OC users aged 15-54 years (n=1970). We performed multivariable logistic models to understand the characteristics associated with OTC access, with age, urbanicity, and insurance status as our primary predictors of interest. Additionally, we descriptively explored knowledge of how frequently to take OCs by pill source and age.

RESULTS

Some 54% of pill users, including 66% of those aged 15-17 years, obtained their OCs OTC. In multivariable regression we found no differences in OTC access by age. However, being uninsured (adjusted odds ratio (AOR) 1.86, 95% CI 1.23 to 2.82) (compared with employer-based public insurance) and living in an urban area (AOR 4.73, 95% CI 3.37 to 6.66) (compared with rural area) were associated with a higher odds of OTC access among pill users. Women's knowledge of how frequently to take OCs was similar between OTC and prescription users within age groups.

CONCLUSIONS

These findings point to the importance of OTC availability of OCs for pill users of all ages and uninsured and urban women in Mexico in particular.

Cross-country abortion travel to England and Wales: results from a cross-sectional survey exploring people's experiences crossing borders to obtain care

Background

The laws governing abortion access vary across Europe. Even in countries with relatively liberal laws, numerous barriers to abortion access exist. In response to these barriers, evidence suggests that people living in countries with both restrictive and liberal laws travel outside of their home country for abortion care. England and Wales are common destinations for those who travel to seek abortions, but little is known about the motivations and experiences of those who undertake cross-country travel to England or Wales to obtain care. This paper aims to describe the abortion seeking and travel experiences of women and pregnant people who traveled to England and Wales for an abortion between 2017 and 2019.

Methods

We recruited 97 participants who had traveled cross-country from both liberal and restrictive contexts to seek abortion care at three participating BPAS clinics in England and Wales. Participants completed an electronic survey about their reproductive histories, abortion decision-making, experiences seeking abortion care, and traveling. We conducted a descriptive analysis, and include comparisons between participants who traveled from liberal and restrictive contexts.

Results

Over a third of participants considered abortion four weeks or more before presenting for care at BPAS, and around two-thirds sought abortion services in their home country before traveling. The majority of participants indicated that they would have preferred to have obtained an abortion earlier and cited reasons including scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. About seventy percent of participants reported travel costs between €101–1000 and 75% of participants reported that the cost of the abortion procedure exceeded €500. About half of participants indicated that, overall, their travel was very or somewhat difficult.

Conclusions

This analysis documents the burdens associated with cross-country travel for abortion and provides insight into the factors that compel people to travel. Our findings highlight the need for expanded access to abortion care throughout Europe via the removal of legal impediments and other social or procedural barriers. Removing barriers would eliminate the need for cumbersome abortion travel, and ensure that all people can obtain necessary, high-quality healthcare in their own communities.

In Europe, people who live in countries where abortion is severely restricted or illegal altogether lack access to abortion care entirely, but even people who live in countries with more liberal laws face barriers due to gestational age limits, waiting periods, and a lack of trained and willing providers. Existing evidence suggests that restrictions and barriers compel people from both countries with restrictive laws as well as those from countries with more liberal laws to travel outside of their home country for abortion services. England and Wales are common destinations for people traveling within Europe to obtain abortion services, but little is known about the experiences of these travelers. We surveyed individuals who had traveled from another country to seek abortion services in England or Wales. Our analysis documents that many participants contemplated getting an abortion and sought care in their home countries before traveling. Likewise, many participants indicated that they would have preferred to have obtained an abortion earlier in their pregnancy, and referenced scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. A majority of participants indicated that covering the costs of their abortion, and the costs of travel was difficult, and that the travel experience in its entirety was difficult. Our findings document the reasons for, and burdens associated with abortion travel and highlight the need to expand access to abortion across Europe via the elimination of all legal restrictions and impediments.

Comparison of Facebook, Google Ads, and Reddit for the Recruitment of People Who Considered but Did Not Obtain Abortion Care in the United States: Cross-sectional Survey

Background

In the United States, abortion access is restricted by numerous logistical, financial, social, and policy barriers. Most studies on abortion-seeking experiences in the United States have recruited participants from abortion clinics. However, clinic-based recruitment strategies fail to capture the experiences of people who consider an abortion but do not make it to an abortion clinic. Research indicates that many people search for abortion information on the web; however, web-based recruitment remains underutilized in abortion research.

Objective

This study aims to establish the feasibility of using Facebook, Google Ads, and Reddit as recruitment platforms for a study on abortion-seeking experiences in the United States.

Methods

From August to September 2018, we posted recruitment advertisements for a survey about abortion-seeking experiences through Facebook, Google Ads, and Reddit. Eligible participants were US residents aged 15-49 years who had been pregnant in the past 5 years and had considered abortion for a pregnancy in this period but did not abort. For each platform, we recorded staff time to develop advertisements and manage recruitment, as well as costs related to advertisement buys and social marketing firm support. We summarized the number of views and clicks for each advertisement where possible, and we calculated metrics related to cost per recruited participant and recruitment rate by week for each platform. We assessed differences across platforms using the chi-square and Kruskal-Wallis tests.

Results

Overall, study advertisements received 77,464 views in the 1-month period (from Facebook and Google; information not available for Reddit) and 2808 study page views. After clicking on the advertisements, there were 1254 initiations of the eligibility screening survey, which resulted in 98 eligible survey participants (75 recruited from Facebook, 14 from Google Ads, and 9 from Reddit). The cost for each eligible participant in each platform was US $49.48 for Facebook, US $265.93 for Google Ads, and US $182.78 for Reddit. A total of 84% (66/79) of those who screened eligible from Facebook completed the short survey compared with 73% (8/11) of those who screened eligible from Reddit and 13% (7/53) of those who screened eligible from Google Ads.

Conclusions

These results suggest that Facebook advertisements may be the most time- and cost-effective strategy to recruit people who considered but did not obtain an abortion in the United States. Adapting and implementing Facebook-based recruitment strategies for research on abortion access could facilitate a more complete understanding of the barriers to abortion care in the United States.

Factors influencing abortion decisions, delays, and experiences with abortion accompaniment in Mexico among women living outside Mexico City: results from a cross-sectional study

Access to abortion throughout much of Mexico has been restricted. Fondo Maria is an abortion accompaniment fund that provides informational, logistical, financial, and emotional support to people seeking abortion care in Mexico. This cross-sectional study examines the factors that influenced decision-making and contributed to delays in accessing care and explores experiences with Fondo Maria’s support among women living outside Mexico City (CDMX). We describe and compare the experiences of women across the sample (n = 103) who were either supported by Fondo Maria to travel to CDMX to obtain an abortion (n = 60), or self-managed a medical abortion in their home state (n = 43). Data were collected between January 2017 and July 2018. Seventy-seven percent of participants reported that it was difficult to access abortion care in their home state and 34% of participants indicated they were delayed in accessing care, primarily due to a lack of financial support. The majority of participants (58%) who travelled to CDMX for their abortion did so because it seemed safer. The money/cost of the trip was the most commonly cited reason (33%) why participants who self-managed stayed in their home state. Eighty-seven percent of participants said Fondo Maria’s services met or exceeded their expectations. Our data suggest that people seeking abortion and living outside CDMX face multiple and overlapping barriers that can delay care-seeking and influence decision-making. Abortion accompaniment networks, such as Fondo Maria, offer a well-received model of support for people seeking abortion in restrictive states across Mexico.

A Randomized Study Evaluating the Effect of Evidence-Based Information on Clinician Attitudes About Moving Oral Contraceptives Over the Counter

Objective: To assess whether evidence-based information on progestin-only pills (POPs) and over-the-counter (OTC) oral contraceptives (OCs) increases support among clinicians for bringing a POP or combined oral contraceptive (COC) OTC and to identify concerns clinicians may have about OTC access to OCs. Materials and Methods: In 2018 a survey of 778 clinicians assessed support for bringing a POP and COC OTC before and after receiving evidence-based information, which was pretested through in-depth interviews. Clinicians were randomized into two groups, stratified by clinician type. One group received information about OTC access to OCs generally, and the second group received OTC information plus information about POPs. Levels of support between arms were compared using robust Poisson models. Results: Before receiving information, 31% of clinicians supported moving a POP OTC. After receiving information, 39% of clinicians who only received OTC information supported moving a POP OTC compared to 61% who received OTC and POP information (relative risk = 1.53, 95% confidence interval: 1.34 to 1.75). Support for bringing a COC OTC increased marginally for those who received OTC and POP information, while support among those who received only OTC information increased by 12 percentage points (to 50%). Among clinicians opposed to moving a POP OTC after receiving information, top concerns included safety (26%), effectiveness (19%), potential for incorrect use (19%), and loss of preventive screenings (15%). Conclusion: Evidence-based information, particularly around POPs, has the potential to change clinician attitudes and address misconceptions about POPs and OTC access.

The impacts of contraceptive stock-outs on users, providers, and facilities: A systematic literature review

Contraceptive stock-outs are a world-wide problem, yet published research on the impacts of contraceptive stock-outs have not been comprehensively reviewed and synthesised. This systematic review highlights findings about the impacts of contraceptive stock-outs on users, providers, and facilities and identifies topics that should be explored to ensure everyone can access their preferred method of contraception. We systematically searched PubMed, Embase, Web of Science, Popline, and JSTOR for studies addressing the impacts of contraceptive stock-outs. Of 435 studies, 25 publications addressed the impacts of contraceptive stock-outs. Only two articles focused solely on contraceptive stock-outs; the remaining studies examined stock-outs alongside other factors that may influence contraceptive service provision. Studies discussed how stock-outs limited individuals' ability to use their preferred contraceptive method, influenced where contraceptive methods were obtained and how much they cost, and limited providers' and facilities' abilities to provide contraceptive care. Comparing the impacts of contraceptive stock-outs across studies was challenging, as reliability of stock was sometimes not distinguished from overall method availability, and studies used variable methods to measure stock-outs. Evidence presented in this review can inform efforts to ensure that preferred contraceptive methods are consistently available and accessible to all.

Requests for medication abortion support in Brazil during and after the Zika epidemic

Brazil declared a public health emergency during the Zika virus epidemic, recommending avoiding pregnancy. This study analyses requests received by Women Help Women for information about and support for self-managed medication abortion (MA) in Brazil during and after the Zika epidemic to understand how Zika may have impacted requests to the service. This analysis considered 20,609 requests for MA support received between January 2016 and June 2017. Reasons for seeking an abortion were analysed alongside geographic trends in the percent and rate of requests citing Zika as a reason for seeking abortion. The average number of daily requests for MA support increased from 31 in January 2016 to 48 in June 2017. The average percent of daily requests citing Zika as a reason for seeking an abortion decreased from 15% in March 2016 to 1.5% by June 2017. The most common reason for abortion seeking during and after the Zika epidemic was not being prepared for a child or not wanting any or additional children (between 52%-59% of requests). As the Zika epidemic slowed, MA requests citing Zika as a reason decreased, while requests increased overall. Few people cited Zika alone as a reason for abortion seeking, necessitating a broad contextualisation of abortion access in people's daily lived experiences and realities.

Community-based interventions for detection and management of diabetes and hypertension in underserved communities: a mixed-methods evaluation in Brazil, India, South Africa and the USA

INTRODUCTION

As non-communicable disease (NCD) burden rises worldwide, community-based programmes are a promising strategy to bridge gaps in NCD care. The HealthRise programme sought to improve hypertension and diabetes management for underserved communities in nine sites across Brazil, India, South Africa and the USA between 2016 and 2018. This study presents findings from the programme's endline evaluation.

METHODS

The evaluation utilises a mixed-methods quasi-experimental design. Process indicators assess programme implementation; quantitative data examine patients' biometric measures and qualitative data characterise programme successes and challenges. Programme impact was assessed using the percentage of patients meeting blood pressure and A1c treatment targets and tracking changes in these measures over time.

RESULTS

Almost 60 000 screenings, most of them in India, resulted in 1464 new hypertension and 295 new diabetes cases across sites. In Brazil, patients exhibited statistically significant reductions in blood pressure and A1c. In Shimla, India, and in South Africa, country with the shortest implementation period, there were no differences between patients served by facilities in HealthRise areas relative to comparison areas. Among participating patients with diabetes in Hennepin and Ramsey counties and hypertension patients in Hennepin County, the percentage of HealthRise patients meeting treatment targets at endline was significantly higher relative to comparison group patients. Qualitative analysis identified linking different providers, services, communities and information systems as positive HealthRise attributes. Gaps in health system capacities and sociodemographic factors, including poverty, low levels of health education and limited access to nutritious food, are remaining challenges.

CONCLUSIONS

Findings from Brazil and the USA indicate that the HealthRise model has the potential to improve patient outcomes. Short implementation periods and strong emphasis on screening may have contributed to the lack of detectable differences in other sites. Community-based care cannot deliver its full potential if sociodemographic and health system barriers are not addressed in tandem.

Modeling the Impacts of Price of an Over-the-Counter Progestin-Only Pill on Use and Unintended Pregnancy among U.S. Women

OBJECTIVE

To model the impacts of out-of-pocket cost of an over-the-counter (OTC) progestin-only pill on use and associated unintended pregnancy among U.S. women.

STUDY DESIGN

Using data from a 2015 nationally representative survey of 2,539 U.S. women aged 15 to 44 assessing interest in using an OTC progestin-only pill, we used discrete survival analysis and a Markov model to analyze women's likelihood of using of an OTC pill at different price points and by sociodemographic characteristics. We modeled the impact of product price on the potential total number of U.S. users and on unintended pregnancies in 1 year among adult women at risk of unintended pregnancy.

RESULTS

In a model assuming no out-of-pocket costs, more than 12.5 million adults and 1.75 million teens reported likely use of an OTC progestin-only pill if available. Among adults, this resulted in an estimated 8% decrease in unintended pregnancy in 1 year. Adult and teen women on average were willing to pay $15 and $10, respectively, resulting in 7.1 million adult and 1.3 million teen users and an estimated 5% decrease in unintended pregnancy among adults.

CONCLUSIONS

At low and no out-of-pocket cost, a large population of women in the United States might likely use an OTC progestin-only pill. A low retail price and insurance coverage are necessary to provide equitable access to this method for low-income populations across the United States, fill current gaps in contraceptive access, and potentially decrease unintended pregnancy.

Pharmacists' perspectives on prescribing hormonal contraception in Washington, DC, with a focus on young people

OBJECTIVE

To assess pharmacists' interest, comfort level, training needs, and barriers to prescribing hormonal contraceptives, particularly in the context of serving young people in Washington, DC.

DESIGN

In this mixed-methods study, we conducted a focus group discussion with pharmacists in February 2017, which was analyzed thematically using inductive and deductive coding. In January 2018 to June 2018, we conducted a survey with pharmacists, which was analyzed using descriptive statistics.

SETTING AND PARTICIPANTS

Community and outpatient pharmacists in Washington, DC.

OUTCOMES MEASURES

Pharmacists' interest and comfort level to begin prescribing hormonal contraception, particularly in the context of serving young people.

RESULTS

A total of 6 pharmacists participated in the focus group discussion, and 82 pharmacists participated in the online survey. In the survey, 59% of pharmacists were interested in prescribing hormonal contraception as independent practitioners and 63% through collaborative practice agreements; focus group participants believed that other pharmacists might be less likely to participate. In addition, focus group and survey respondents reported high levels of comfort with activities related to prescribing hormonal contraception, including 96% of survey participants reporting comfort taking blood pressure and 93% reporting comfort counseling young women on hormonal contraceptive methods. Only 25% of pharmacists reported having a private consultation space that provided both visual and auditory privacy. To ensure that pharmacies were ready to implement this service, pharmacists identified multiple concerns that needed to be addressed, including workload, liability issues, compensation, and a need for additional training on hormonal contraceptive methods, and how to counsel young people on them.

CONCLUSION

Pharmacists in Washington, DC, are interested in and comfortable with activities related to prescribing hormonal contraception, including to young people. However, to become ready to offer these services, pharmacists desire additional training, and pharmacies need to ensure confidentiality for young people and address pharmacists' concerns about workload, liability, and compensation.

Youth Perspectives on Pharmacists' Provision of Birth Control: Findings From a Focus Group Study

PURPOSE

Young women face numerous obstacles to accessing contraception, including lack of money, time, or transportation to visit a doctor. In addition, concerns about confidentiality deter many adolescents from seeking contraceptive care. Pharmacists in Washington, D.C. will soon be able to prescribe hormonal birth control, which can potentially increase contraceptive access for adolescents. This study explores the needs and concerns of teens and young women residing in Washington, D.C. to inform implementation of this service.

METHODS

In this community-based participatory research study, four focus group discussions were conducted in February 2017, two with teen females aged 14-17 years and two with young women aged 18-24 years. A youth advisory council, comprising 13 women aged 16-22 years living in Washington, D.C., helped develop the discussion guide and interpret findings. Data were analyzed thematically by age group using inductive and deductive codes.

RESULTS

Young people viewed pharmacies as convenient locations to access contraceptives but expressed concerns about privacy, affordability, and pharmacist approachability. Younger participants viewed these concerns as significant barriers for their peers. Participants suggested pharmacies protect privacy and confidentiality by offering private consultation spaces and clear information about what insurance plans can disclose to parents. Participants also recommended pharmacies create a youth-friendly, nonjudgmental environment and offer pharmacists training on contraceptive counseling for young women.

CONCLUSIONS

Addressing concerns about privacy, costs, and pharmacist approachability can help ensure that youth seeking contraceptives can easily access their preferred method. Pharmacies should continuously incorporate young people's feedback to ensure this service remains accessible and acceptable to adolescents.

Identifying gaps in the continuum of care for cardiovascular disease and diabetes in two communities in South Africa: Baseline findings from the HealthRise project

BACKGROUND

The HealthRise initiative seeks to implement and evaluate innovative community-based strategies for diabetes, hypertension and hypercholesterolemia along the entire continuum of care (CoC)-from awareness and diagnosis, through treatment and control. In this study, we present baseline findings from HealthRise South Africa, identifying gaps in the CoC, as well as key barriers to care for non-communicable diseases (NCDs).

METHODS

This mixed-methods needs assessment utilized national household data, health facility surveys, focus group discussions, and key informant interviews in Umgungundlovu and Pixley ka Seme districts. Risk factor and disease prevalence were estimated from the South Africa National Health and Nutrition Examination Survey. Health facility surveys were conducted at 86 facilities, focusing on essential intervention, medications and standard treatment guidelines. Quantitative results are presented descriptively, and qualitative data was analyzed using a framework approach.

RESULTS

46.8% of the population in Umgungundlovu and 51.0% in Pixley ka Seme were hypertensive. Diabetes was present in 11.0% and 9.7% of the population in Umgungundlovu and Pixley ka Seme. Hypercholesterolemia was more common in Pixley ka Seme (17.3% vs. 11.1%). Women and those of Indian descent were more likely to have diabetes. More than half of the population was found to be overweight, and binge drinking, inactivity and smoking were all common. More than half of patients with hypertension were unaware of their disease status (51.6% in Pixley ka Seme and 51.3% in Umgungundlovu), while the largest gap in the diabetes CoC occurred between initiation of treatment and achieving disease control. Demand-side barriers included lack of transportation, concerns about confidentiality, perceived discrimination and long wait times. Supply-side barriers included limited availability of testing equipment, inadequate staffing, and pharmaceutical stock outs.

CONCLUSION

In this baseline assessment of two South African health districts we found high rates of undiagnosed hypercholesterolemia and hypertension, and poor control of hypercholesterolemia, hypertension, and diabetes. The HealthRise Initiative will need to address key supply- and demand-side barriers in an effort to improve important NCD outcomes.

Identifying gaps in the continuum of care for hypertension and diabetes in two Indian communities

BACKGROUND

Non-communicable diseases (NCDs) represent the largest, and fastest growing, burden of disease in India. This study aimed to quantify levels of diagnosis, treatment, and control among hypertensive and diabetic patients, and to describe demand- and supply-side barriers to hypertension and diabetes diagnosis and care in two Indian districts, Shimla and Udaipur.

METHODS

We conducted household and health facility surveys, as well as qualitative focus group discussions and interviews. The household survey randomly sampled individuals aged 15 and above in rural and urban areas in both districts. The survey included questions on NCD knowledge, history, and risk factors. Blood pressure, weight, height, and blood glucose measurements were obtained. The health facility survey was administered in 48 health care facilities, focusing on NCD diagnosis and treatment capacity, including staffing, equipment, and pharmaceuticals. Qualitative data was collected through semi-structured key informant interviews with health professionals and public health officials, as well as focus groups with patients and community members.

RESULTS

Among 7181 individuals, 32% either reported a history of hypertension or were found to have a systolic blood pressure ≥ 140 mmHg and/or diastolic ≥90 mmHg. Only 26% of those found to have elevated blood pressure reported a prior diagnosis, and just 42% of individuals with a prior diagnosis of hypertension were found to be normotensive. A history of diabetes or an elevated blood sugar (Random blood glucose (RBG) ≥200 mg/dl or fasting blood glucose (FBG) ≥126 mg/dl) was noted in 7% of the population. Among those with an elevated RBG/FBG, 59% had previously received a diagnosis of diabetes. Only 60% of diabetics on treatment were measured with a RBG <200 mg/dl. Lower-level health facilities were noted to have limited capacity to measure blood glucose as well as significant gaps in the availability of first-line pharmaceuticals for both hypertension and diabetes.

CONCLUSIONS

We found high rates of uncontrolled diabetes and undiagnosed and uncontrolled hypertension. Lower level health facilities were constrained by capacity to test, monitor and treat diabetes and hypertension. Interventions aimed at improving patient outcomes will need to focus on the expanding access to quality care in order to accommodate the growing demand for NCD services.

The effect of facility-based antiretroviral therapy programs on outpatient services in Kenya and Uganda

Background

Considerable debate exists concerning the effects of antiretroviral therapy (ART) service scale-up on non-HIV services and overall health system performance in sub-Saharan Africa. In this study, we examined whether ART services affected trends in non-ART outpatient department (OPD) visits in Kenya and Uganda.

Methods

Using a nationally representative sample of health facilities in Kenya and Uganda, we estimated the effect of ART programs on OPD visits from 2007 to 2012. We modeled the annual percent change in non-ART OPD visits using hierarchical mixed-effects linear regressions, controlling for a range of facility characteristics. We used four different constructs of ART services to capture the different ways in which the presence, growth, overall, and relative size of ART programs may affect non-ART OPD services.

Results

Our final sample included 321 health facilities (140 in Kenya and 181 in Uganda). On average, OPD and ART visits increased steadily in Kenya and Uganda between 2007 and 2012. For facilities where ART services were not offered, the average annual increase in OPD visits was 4·2% in Kenya and 13·5% in Uganda. Among facilities that provided ART services, we found average annual OPD volume increases of 7·2% in Kenya and 5·6% in Uganda, with simultaneous annual increases of 13·7% and 12·5% in ART volumes. We did not find a statistically significant relationship between annual changes in OPD services and the presence, growth, overall, or relative size of ART services. However, in a subgroup analysis, we found that Ugandan hospitals that offered ART services had statistically significantly less growth in OPD visits than Ugandan hospitals that did not provide ART services.

Conclusions

Our findings suggest that ART services in Kenya and Uganda did not have a statistically significant deleterious effects on OPD services between 2007 and 2012, although subgroup analyses indicate variation by facility type. Our findings are encouraging, particularly given recent recommendations for universal access to ART, demonstrating that expanding ART services is not inherently linked to declines in other health services in sub-Saharan Africa.

Public knowledge of cardiovascular disease and response to acute cardiac events in three cities in China and India

Objective

To inform interventions targeted towards reducing mortality from acute myocardial infarction (AMI) and sudden cardiac arrest in three megacities in China and India, a baseline assessment of public knowledge, attitudes and practices was performed.

Methods

A household survey, supplemented by focus group and individual interviews, was used to assess public understanding of cardiovascular disease (CVD) risk factors, AMI symptoms, cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs). Additionally, information was collected on emergency service utilisation and associated barriers to care.

Results

5456 household surveys were completed. Hypertension was most commonly recognised among CVD risk factors in Beijing and Shanghai (68% and 67%, respectively), while behavioural risk factors were most commonly identified in Bangalore (smoking 91%; excessive alcohol consumption 64%). Chest pain/discomfort was reported by at least 60% of respondents in all cities as a symptom of AMI, but 21% of individuals in Bangalore could not name a single symptom. In Beijing, Shanghai and Bangalore, 26%, 15% and 3% of respondents were trained in CPR, respectively. Less than one-quarter of participants in all cities recognised an AED. Finally, emergency service utilisation rates were low, and many individuals expressed concern about the quality of prehospital care.

Conclusions

Overall, we found low to modest knowledge of CVD risk factors and AMI symptoms, infrequent CPR training and little understanding of AEDs. Interventions will need to focus on basic principles of CVD and its complications in order for patients to receive timely and appropriate care for acute cardiac events.

Capacity for diagnosis and treatment of heart failure in sub-Saharan Africa

OBJECTIVE

Heart failure is a major cause of disease burden in sub-Saharan Africa (SSA). There is an urgent need for better strategies for heart failure management in this region. However, there is little information on the capacity to diagnose and treat heart failure in SSA. We aim to provide a better understanding of the capacity to diagnose and treat heart failure in Kenya and Uganda to inform policy planning and interventions.

METHODS

We analysed data from a nationally representative survey of health facilities in Kenya and Uganda (197 health facilities in Uganda and 143 in Kenya). We report on the availability of cardiac diagnostic technologies and select medications for heart failure (β-blockers, ACE inhibitors and furosemide). Facility-level data were analysed by country and platform type (hospital vs ambulatory facilities).

RESULTS

Functional and staffed radiography, ultrasound and ECG were available in less than half of hospitals in Kenya and Uganda combined. Of the hospitals surveyed, 49% of Kenyan and 77% of Ugandan hospitals reported availability of the heart failure medication package. ACE inhibitors were only available in 51% of Kenyan and 79% of Ugandan hospitals. Almost one-third of the hospitals in each country had a stock-out of at least one of the medication classes in the prior quarter.

CONCLUSIONS

Few facilities in Kenya and Uganda were prepared to diagnose and manage heart failure. Medication shortages and stock-outs were common. Our findings call for increased investment in cardiac care to reduce the growing burden of heart failure.

The potential to expand antiretroviral therapy by improving health facility efficiency: evidence from Kenya, Uganda, and Zambia

BACKGROUND

Since 2000, international funding for HIV has supported scaling up antiretroviral therapy (ART) in sub-Saharan Africa. However, such funding has stagnated for years, threatening the sustainability and reach of ART programs amid efforts to achieve universal treatment. Improving health system efficiencies, particularly at the facility level, is an increasingly critical avenue for extending limited resources for ART; nevertheless, the potential impact of increased facility efficiency on ART capacity remains largely unknown. Through the present study, we sought to quantify facility-level technical efficiency across countries, assess potential determinants of efficiency, and predict the potential for additional ART expansion.

METHODS

Using nationally-representative facility datasets from Kenya, Uganda and Zambia, and measures adjusting for structural quality, we estimated facility-level technical efficiency using an ensemble approach that combined restricted versions of Data Envelopment Analysis and Stochastic Distance Function. We then conducted a series of bivariate and multivariate regression analyses to evaluate possible determinants of higher or lower technical efficiency. Finally, we predicted the potential for ART expansion across efficiency improvement scenarios, estimating how many additional ART visits could be accommodated if facilities with low efficiency thresholds reached those levels of efficiency.

RESULTS

In each country, national averages of efficiency fell below 50 % and facility-level efficiency markedly varied. Among facilities providing ART, average efficiency scores spanned from 50 % (95 % uncertainty interval (UI), 48-62 %) in Uganda to 59 % (95 % UI, 53-67 %) in Zambia. Of the facility determinants analyzed, few were consistently associated with higher or lower technical efficiency scores, suggesting that other factors may be more strongly related to facility-level efficiency. Based on observed facility resources and an efficiency improvement scenario where all facilities providing ART reached 80 % efficiency, we predicted a 33 % potential increase in ART visits in Kenya, 62 % in Uganda, and 33 % in Zambia. Given observed resources in facilities offering ART, we estimated that 459,000 new ART patients could be seen if facilities in these countries reached 80 % efficiency, equating to a 40 % increase in new patients.

CONCLUSIONS

Health facilities in Kenya, Uganda, and Zambia could notably expand ART services if the efficiency with which they operate increased. Improving how facility resources are used, and not simply increasing their quantity, has the potential to substantially elevate the impact of global health investments and reduce treatment gaps for people living with HIV.

Efficiency of Health Care Production in Low-Resource Settings: A Monte-Carlo Simulation to Compare the Performance of Data Envelopment Analysis, Stochastic Distance Functions, and an Ensemble Model

Low-resource countries can greatly benefit from even small increases in efficiency of health service provision, supporting a strong case to measure and pursue efficiency improvement in low- and middle-income countries (LMICs). However, the knowledge base concerning efficiency measurement remains scarce for these contexts. This study shows that current estimation approaches may not be well suited to measure technical efficiency in LMICs and offers an alternative approach for efficiency measurement in these settings. We developed a simulation environment which reproduces the characteristics of health service production in LMICs, and evaluated the performance of Data Envelopment Analysis (DEA) and Stochastic Distance Function (SDF) for assessing efficiency. We found that an ensemble approach (ENS) combining efficiency estimates from a restricted version of DEA (rDEA) and restricted SDF (rSDF) is the preferable method across a range of scenarios. This is the first study to analyze efficiency measurement in a simulation setting for LMICs. Our findings aim to heighten the validity and reliability of efficiency analyses in LMICs, and thus inform policy dialogues about improving the efficiency of health service production in these settings.

Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000-2013

BACKGROUND

Nigeria has made notable gains in improving childhood survival but the country still accounts for a large portion of the world's overall disease burden, particularly among women and children. To date, no systematic analyses have comprehensively assessed trends for health outcomes and interventions across states in Nigeria.

METHODS

We extracted data from 19 surveys to generate estimates for 20 key maternal and child health (MCH) interventions and outcomes for 36 states and the Federal Capital Territory from 2000 to 2013. Source-specific estimates were generated for each indicator, after which a two-step statistical model was applied using a mixed-effects model followed by Gaussian process regression to produce state-level trends. National estimates were calculated by population-weighting state values.

RESULTS

Under-5 mortality decreased in all states from 2000 to 2013, but a large gap remained across them. Malaria intervention coverage stayed low despite increases between 2009 and 2013, largely driven by rising rates of insecticide-treated net ownership. Overall, vaccination coverage improved, with notable increases in the coverage of three-dose oral polio vaccine. Nevertheless, immunization coverage remained low for most vaccines, including measles. Coverage of other MCH interventions, such as antenatal care and skilled birth attendance, generally stagnated and even declined in many states, and the range between the lowest- and highest-performing states remained wide in 2013. Countrywide, a measure of overall intervention coverage increased from 33% in 2000 to 47% in 2013 with considerable variation across states, ranging from 21% in Sokoto to 66% in Ekiti.

CONCLUSIONS

We found that Nigeria made notable gains for a subset of MCH indicators between 2000 and 2013, but also experienced stalled progress and even declines for others. Despite progress for a subset of indicators, Nigeria's absolute levels of intervention coverage remained quite low. As Nigeria rolls out its National Health Bill and seeks to strengthen its delivery of health services, continued monitoring of local health trends will help policymakers track successes and promptly address challenges as they arise. Subnational benchmarking ought to occur regularly in Nigeria and throughout sub-Saharan Africa to inform local decision-making and bolster health system performance.

Smoking prevalence and cigarette consumption in 187 countries, 1980-2012

IMPORTANCE

Tobacco is a leading global disease risk factor. Understanding national trends in prevalence and consumption is critical for prioritizing action and evaluating tobacco control progress.

OBJECTIVE

To estimate the prevalence of daily smoking by age and sex and the number of cigarettes per smoker per day for 187 countries from 1980 to 2012.

DESIGN

Nationally representative sources that measured tobacco use (n = 2102 country-years of data) were systematically identified. Survey data that did not report daily tobacco smoking were adjusted using the average relationship between different definitions. Age-sex-country-year observations (n = 38,315) were synthesized using spatial-temporal gaussian process regression to model prevalence estimates by age, sex, country, and year. Data on consumption of cigarettes were used to generate estimates of cigarettes per smoker per day.

MAIN OUTCOMES AND MEASURES

Modeled age-standardized prevalence of daily tobacco smoking by age, sex, country, and year; cigarettes per smoker per day by country and year.

RESULTS

Global modeled age-standardized prevalence of daily tobacco smoking in the population older than 15 years decreased from 41.2% (95% uncertainty interval [UI], 40.0%-42.6%) in 1980 to 31.1% (95% UI, 30.2%-32.0%; P < .001) in 2012 for men and from 10.6% (95% UI, 10.2%-11.1%) to 6.2% (95% UI, 6.0%-6.4%; P < .001) for women. Global modeled prevalence declined at a faster rate from 1996 to 2006 (mean annualized rate of decline, 1.7%; 95% UI, 1.5%-1.9%) compared with the subsequent period (mean annualized rate of decline, 0.9%; 95% UI, 0.5%-1.3%; P = .003). Despite the decline in modeled prevalence, the number of daily smokers increased from 721 million (95% UI, 700 million-742 million) in 1980 to 967 million (95% UI, 944 million-989 million; P < .001) in 2012. Modeled prevalence rates exhibited substantial variation across age, sex, and countries, with rates below 5% for women in some African countries to more than 55% for men in Timor-Leste and Indonesia. The number of cigarettes per smoker per day also varied widely across countries and was not correlated with modeled prevalence.

CONCLUSIONS AND RELEVANCE

Since 1980, large reductions in the estimated prevalence of daily smoking were observed at the global level for both men and women, but because of population growth, the number of smokers increased significantly. As tobacco remains a threat to the health of the world's population, intensified efforts to control its use are needed.