Advocacy as a Tool for Advancing Family Planning in the Democratic Republic of the Congo: A Case Study.

The national strategic plan for family planning (FP) in the Democratic Republic of the Congo (DRC) calls for an increase in modern contraceptive prevalence in 2025. The DRC's size and weak health infrastructure pose significant challenges to programming in all areas of primary health care, including FP. Notwithstanding, in the past decade, a group of advocates organized to undertake a series of activities to improve the policy environment for FP in the DRC. We outline the 4 major accomplishments to date: revitalizing a multisectoral FP stakeholder group at the national and provincial levels, obtaining the repeal of the Law of 1920 in the form of a new Public Health Law passed in 2018, soliciting public statements favorable to FP from political figures including 2 presidents, and securing the disbursement of government funds for the purchase of contraceptives. We reveal the work behind the scenes needed to obtain these advocacy wins. Given that the field of advocacy does not lend itself to rigorous evaluation using randomized trials or quasi-experimental design, it is important to document and analyze how such advocacy wins can be attained.

Evaluation of the effect of the Momentum project on family planning outcomes among first-time mothers aged 15-24 years in Kinshasa, DRC.

OBJECTIVES: This article presents the effect of Momentum, a nursing student-led community-based service delivery project, on postpartum family planning (FP) outcomes among first-time mothers in Kinshasa, Democratic Republic of the Congo. STUDY DESIGN: We employed a quasi-experimental design, with three intervention and three comparison health zones (HZ). Data were collected through interviewer-administered questionnaires in 2018 and 2020. The sample consisted of 1927 nulliparous women aged 15-24 years who were 6 months pregnant at baseline. Random effects and treatment effects models were used to assess the effect of Momentum on 14 postpartum FP outcomes. RESULTS: The intervention group was associated with a unit increase of 0.6 (95% confidence interval [CI]: 0.4, 0.8)) in contraceptive knowledge and personal agency (95% CI: 0.3, 0.9), a unit decrease of 0.9 (95% CI: -1.2, -0.5) in the number of FP myths/misconceptions endorsed, and percentage point increases of 23.4 (95% CI: 0.2, 0.3) in FP discussion with a health worker, 13.0 (95% CI: 0.1, 0.2) in obtaining a contraceptive method within 6 weeks of delivery, and 13.3 (95% CI: 0.1, 0.2) in modern contraceptive use within 12 months of delivery. Intervention effects included percentage point increases of 5.4 (95% CI: 0.0, 0.1) in partner discussion and 15.4 (95% CI: 0.1, 0.2) in perceived community support for postpartum FP use. The level of exposure to Momentum was significantly associated with all behavioral outcomes. CONCLUSIONS: The study demonstrated the effect of Momentum on increased postpartum FP-related knowledge, perceived norms, personal agency, partner discussion, and modern contraceptive use. IMPLICATIONS: Community-based service delivery by nursing students can potentially lead to improved postpartum FP outcomes among urban adolescent and young first-time mothers in other provinces of the Democratic Republic of the Congo and other African countries.

Social paediatrics and early child development: Part 1.

Diseases of modernism, rather than infectious diseases and chronic medical conditions, increasingly cause childhood morbidity and mortality. Thus, the goal of enhancing life outcomes for all children has become imperative. Paediatricans may begin with a renewed interest in social paediatrics - the care of the disadvantaged child in Canada, requiring a focus on all the complex factors that impact families and the community. New paediatricians need the tools to impact both social determinants of health and political policies to support health for all. Such interest is as old as the field of paediatrics (social medicine began with the great pathologist, Virchow, in the 1800s). The new neuroscience of experience-based brain and biological development has caught up with the social epidemiology literature. It is now known from both domains that a child's poor developmental and health outcomes are a product of early and ongoing socioeconomic and psychological experiences. In the era of epigenetics, it is now understood that both nature and nurture control the genome. Future paediatricians need to understand the science of experience-based brain development, and the interventions demonstrated to improve life trajectories. A challenge is to connect the traditional population health approach with traditional primary care responsibilities. New and enhanced collaborative interdisciplinary networks with, for example, public health, primary care, community resources, education and justice systems are required.

Provider and Staff Perceptions and Experiences Implementing Behavioral Health Integration in Six Low-Income Health Care Organizations.

Behavioral health integration (BHI) is a proven, effective practice for addressing the joint behavioral health and medical health needs of vulnerable populations. As part of the New Orleans Charitable Health Fund (NOCHF) program, this study addressed a gap in literature to better understand factors that impact the implementation of BHI by analyzing perceptions and practices among staff at integrating organizations. Using a mixed-method design, quantitative results from the Levels of Integration Measure (LIM), a survey tool for assessing staff perceptions of BHI in primary care settings (n=86), were analyzed alongside qualitative results from in-depth interviews with staff (n=27). Findings highlighted the roles of strong leadership, training, and process changes on staff collaboration, relationships, and commitment to BHI. This study demonstrates the usefulness of the LIM in conjunction with in-depth interviews as an assessment tool for understanding perceptions and organizational readiness for BHI implementation.

Task-shifting the provision of DMPA-SC in the DR Congo: Perspectives from two different groups of providers.

OBJECTIVES: To document the experience of three groups of Family Planning service providers participating in task-shifting for the provision of subcutaneous depot-medroxyprogesterone acetate (DMPA-SC) at the community level in the DRC. STUDY DESIGN: This article compares results from interviews with DMPA-SC providers in two separate pilot studies: 1) 53 medical and nursing school students teaching women how to self-inject (2016-2017); and 2) 34 lay community health workers providing DMPA-SC in rural areas of Lualaba (2017). All providers gave information on socio-demographic characteristics, recruitment,) training, supervision, experience and satisfaction with the provision of DMPA-SC. The paper examines variations in responses from the different provider cadres. RESULTS: Despite substantive variations in provider profiles in terms of age, educational and marital status, reported levels of satisfaction with offering DMPA-SC in the community were consistently high. Over 90% of all providers declared being comfortable or very comfortable interacting with FP clients, and more than three quarters of them were very comfortable performing an injection. Over 90% of Lualaba providers and over 80% of student providers gave correct responses to DMPA-SC protocol questions regarding referral of clients to facilities and side-effects management. The vast majority declared being (very) satisfied with their experience providing DMPA-SC. CONCLUSIONS: Providers with and without a clinical background, when properly trained and supervised, can provide DMPA-SC at the community level in both urban and rural settings of the DRC. Support strategies from the Family Planning environment (continuous contraceptive supplies and adequate referral system to fixed facilities) are key to engaging community health workers and sustainably leveraging task-shifting opportunities. IMPLICATION STATEMENT: This study provides additional evidence on the acceptability and feasibility of task-shifting in relation to DMCP-SC and supports further scale-up efforts.

Family Planning in the Democratic Republic of the Congo: Encouraging Momentum, Formidable Challenges.

Momentum for family planning in the Democratic Republic of the Congo (DRC) is evident in multiple ways: strong political will, increasing donor support, a growing number of implementing organizations, innovative family planning programming, and a cohesive family planning stakeholder group. Between 2013 and 2017, the modern contraceptive prevalence rate (mCPR) in the capital city of Kinshasa increased from 18.5% to 26.7% among married women, but as of 2013-14, it was only 7.8% at the national level. The National Multisectoral Strategic Plan for Family Planning: 2014-2020 calls for achieving an mCPR of 19.0% by 2020, an ambitious goal in light of formidable challenges to family planning in the DRC. Of the 16,465 health facilities reporting to the national health information system in 2017, only 40% offer family planning services. Key challenges include uncertainty over the political situation, difficulties of ensuring access to family planning services in a vast country with a weak transportation infrastructure, funding shortfalls for procuring adequate quantities of contraceptives, weak contraceptive logistics and supply chain management, strong cultural norms that favor large families, and low capacity of the population to pay for contraceptive services. This article describes promising initiatives designed to address these barriers, consistent with the World Health Organization's framework for health systems strengthening. For example, the national family planning coordinating mechanism is being replicated at the provincial level to oversee the expansion of family planning service delivery. Promising initiatives are being implemented to improve the supply and quality of services and generate demand for family planning, including social marketing of subsidized contraceptives at both traditional and non-traditional channels and strengthening of services in military health facilities. To expand contraceptive access, family planning is being institutionalized in nursing schools, allowing students to operate as community-based distributors. While major challenges remain, significant progress in family planning has been made in the DRC, which should be judged not in comparison with sub-Saharan African countries with high mCPR and mature programs, but rather with those starting from much further behind.

Leveraging long acting reversible contraceptives to achieve FP2020 commitments in sub-Saharan Africa: The potential of implants.

BACKGROUND: In developing regions, an estimated 214 million women have an unmet need for family planning. Reaching Family Planning 2020 (FP2020) commitments will require a shift in modern contraceptive promotion, including improved access to long-acting reversible contraceptives (LARCs). Until now, a lack of market data limited understanding of the potential of LARCs to increase contraceptive access and choice. METHODS: From 2015, the FPwatch Project conducted representative surveys in Ethiopia, Nigeria, and Democratic Republic of Congo (DRC) using a full census approach in selected administrative areas. In these areas, every public and private sector outlet with the potential to sell or distribute modern contraceptives was approached. In outlets with modern contraceptives, product audits and provider interviews assessed contraceptive market composition, market share, availability, price, and outlet readiness to perform services. RESULTS: Fifty-four percent of outlets in Ethiopia had LARC commodities or services available at the time of the survey, versus 7% and 8% of outlets in Nigeria and DRC, respectively. When present, LARCs were usually available with at least two other methods (99%, 39%, and 84% of public health facilities in Ethiopia, Nigeria and DRC, respectively). Many public facilities had both implants and IUDs in stock (76%, 47%, and 53%, respectively). Lack of readiness to provide LARCs was mostly due to a lack of equipment, private room, or the commodity itself. Market share for implants in the public sector was 60%, 53%, and 37% of Couple Years of Protection (CYP) in Ethiopia, Nigeria, and DRC. DISCUSSION: Limited availability of LARCs in Nigeria and DRC restricts contraceptive choice and makes it difficult for women to adopt and use modern contraception consistently. Brand-specific subsidies, task shifting, and promotion of methods that require less equipment and training are promising strategies for increasing uptake. Substantial government investment is required to improve availability and affordability. Investment in implants should be prioritized to make progress towards FP2020 commitments.

Acceptability of the community-level provision of Sayana® Press by medical and nursing students in Kinshasa, Democratic Republic of the Congo.

OBJECTIVES: The objectives were to assess acceptors' attitudes toward Sayana® Press as a method and toward the mechanism of community-based distribution by medical and nursing (M/N) students, known locally as "DBCs," in Kinshasa, Democratic Republic of the Congo, and to evaluate the experience of these DBCs. STUDY DESIGN: In 2015, surveys were conducted among (1) acceptors of Sayana® Press on the day of the initial injection, (2) these same acceptors 3 months later and (3) the DBCs providing community-based services. The analysis was descriptive and involved no significance testing. RESULTS: Acceptors of Sayana® Press expressed high levels of satisfaction with the method, despite some pain experienced at injection and subsequent side effects. Although most were satisfied with the counseling and services received from the DBCs, less than one third realized that the providers were M/N students. The DBCs expressed satisfaction in serving as community-based distributors; more than 95% would recommend it to others. Their primary complaints were lack of remuneration, stockouts and need for greater supervision. CONCLUSIONS: Consistent with results from previous pilot introductions of Sayana® Press in three African countries, clients were highly satisfied with Sayana® Press as a method. The reported preference for resupply at health centers may reflect a lack of client awareness that the DBCs administering methods near the health center were not in fact staff from the health center. The pilot served to gain acceptance for the use of M/N students in community-based distribution, paving the way for additional task-shifting pilots in Kinshasa. IMPLICATIONS: Sayana® Press represents a promising new method for increasing access to modern contraception in low-income countries. The Kinshasa experience is the first to test the use of medical and nursing students as providers at the community level. The study reports high levels of satisfaction on three counts: acceptors of the contraceptive method, acceptors of the mode of service delivery, and DBCs in their role as providers of contraception at the community level. However, many clients were not aware that the DBCs were students. The study represents an important contribution to the literature on task-shifting, especially in a country with chronic shortages of healthcare personnel.

Quality of voluntary medical male circumcision services during scale-up: a comparative process evaluation in Kenya, South Africa, Tanzania and Zimbabwe.

BACKGROUND: The rapid expansion of voluntary medical male circumcision (VMMC) has raised concerns whether health systems can deliver and sustain VMMC according to minimum quality criteria. METHODS AND FINDINGS: A comparative process evaluation was used to examine data from SYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-Up, among health facilities providing VMMC across two years of program scale-up. Site-level assessments examined the availability of guidelines, supplies and equipment, infection control, and continuity of care services. Direct observation of VMMC surgeries were used to assess care quality. Two sample tests of proportions and t-tests were used to examine differences in the percent of facilities meeting requisite preparedness standards and the mean number of directly-observed surgical tasks performed correctly. Results showed that safe, high quality VMMC can be implemented and sustained at-scale, although substantial variability was observed over time. In some settings, facility preparedness and VMMC service quality improved as the number of VMMC facilities increased. Yet, lapses in high performance and expansion of considerably deficient services were also observed. Surgical tasks had the highest quality scores, with lower performance levels in infection control, pre-operative examinations, and post-operative patient monitoring and counseling. The range of scale-up models used across countries additionally underscored the complexity of delivering high quality VMMC. CONCLUSIONS: Greater efforts are needed to integrate VMMC scale-up and quality improvement processes in sub-Saharan African settings. Monitoring of service quality, not just adverse events reporting, will be essential in realizing the full health impact of VMMC for HIV prevention.

Early childhood programs and the education system.

Policy makers, advocates and experts agree that the current delivery of early childhood development programs is fragmented. Many point to the education system as a better alternative for a more coherent approach that has the necessary infrastructure in place in communities, and is well placed to meet the needs of all young children and their families. In other jurisdictions, early childhood development programs have moved into education. In Canada, provincial and local school authorities are taking on more early childhood programs.

Getting results used: evidence from reproductive health programmatic research in Guatemala.

This article reviews 44 operations research projects aiming to improve reproductive health services in Guatemala, conducted by the Population Council from 1988 to 2001. It documents the experience of the research programme, traces the extent to which research results are identifiable in existing programmes, and analyses factors influencing utilization. Utilization of research results occurs as a gradual process of information sharing, where researchers influence decision-makers through a continual stream of information rather than a single set of findings. Utilization depends on leadership, collaborative planning and implementation, close monitoring, and feasible research designs, among other factors. To influence policy formulation, organizations should form enduring links among institutions and develop critical research skills among personnel who collaborate with or manage service programmes. To understand how operations research affects policy and programme change, one must consider not just individual projects, but rather the synergistic impact of multiple projects on a broad range of themes over time.

Systematic review of the effectiveness of mass communication programs to change HIV/AIDS-related behaviors in developing countries.

This review systematically examined the effectiveness of 24 mass media interventions on changing human immunodeficiency virus (HIV)-related knowledge, attitudes and behaviors. The intervention studies were published from 1990 through 2004, reported data from developing countries and compared outcomes using (i) pre- and post-intervention data, (ii) treatment versus control (comparison) groups or (iii) post-intervention data across levels of exposure. The most frequently reported outcomes were condom use (17 studies) and knowledge of modes of HIV transmission (15), followed by reduction in high-risk sexual behavior (eight), perceived risk of contracting HIV/acquired immunodeficiency syndrome (AIDS) (six), interpersonal communication about AIDS or condom use (six), self-efficacy to negotiate condom use (four) and abstaining from sexual relations (three). The results yielded mixed results, and where statistically significant, the effect size was small to moderate (in some cases as low as 1-2% point increase). On two of the seven outcomes, at least half of the studies did show a positive impact of the mass media: knowledge of HIV transmission and reduction in high-risk sexual behavior. Further rigorous evaluation on comprehensive programs is required to provide a more definitive answer to the question of media effects on HIV/AIDS-related behavior in developing countries.

Diffusion of innovations and HIV/AIDS.

As the HIV/AIDS epidemic continues its relentless spread in many parts of the world, DOI provides a useful framework for analyzing the difficulties in achieving behavior change necessary to reduce HIV rates. The DOI concepts most relevant to this question include communication channels, the innovation-decision process, homophily, the attributes of the innovation, adopter categories, and opinion leaders. The preventive measures needed to halt the transmission of HIV constitute a "preventive innovation." This article describes the attributes of this preventive innovation in terms of relative advantage, compatibility, complexity, trialability, and observability. It reviews studies that incorporated DOI into HIV/AIDS behavior change interventions, both in Western countries and in the developing world. Finally, it discusses possible reasons that the use of DOI has been fairly limited to date in HIV/AIDS prevention interventions in developing countries.