Mobilizing stakeholders for implant removals in Burkina Faso using landscape assessment data.

BACKGROUND: Successful efforts to encourage uptake of subdermal contraceptive implants, with a lifespan of three to five years, necessitate planning to ensure that quality removal services are available when desired. In Burkina Faso, implant use has tripled over the past 8 years and now comprises almost half of the contraceptive method mix. Population Monitoring for Action (PMA) surveys identified barriers to obtaining quality removal when desired, particularly when the implant is not palpable, or providers lack needed skills or supplies. The Expanding Family Planning Choices (EFPC) project supported ministries of health in four countries with evaluation and strengthening of implant removal services. METHODS: An implant removal landscape assessment was conducted at 24 health facilities in three regions of Burkina Faso with high implant use that included provider observations of implant removal, interviews with providers and health facility managers, and facility readiness surveys. The project used landscape data to mobilize stakeholders through a series of participatory workshops to develop a collaborative roadmap and commit to actions supporting quality implant removals. RESULTS: Landscape findings revealed key gaps in provision of quality removal services, including high levels of provider confidence for implant insertion and removal (82% and 71%, respectively), low competence performing simple and difficult removals (19.2% and 11.1%, respectively), inadequate supplies and equipment (no facilities had all necessary materials for removal), lack of difficult removal management systems, and a lack of standard data collection tools for removal. Exposure to the data convinced stakeholders to focus on removals rather than expanding insertion services. While not all roadmap commitments were achieved, the process led to critical investments in quality implant removals. CONCLUSION: Landscape data revealed that facilities lack needed supplies and equipment, and providers lack skills needed to perform quality implant removals, limiting client reproductive choice. Disseminating this data enabled stakeholders to identify and commit to evidence-based priority actions. Stakeholders have since capitalized on program learnings and the roadmap, including following MOH guidance for implant removal supplies and health provider training. Our experience in Burkina Faso offers a replicable model of how data can direct collective action to improve quality of contraceptive implant removals.

Six Recommendations for Provider Behavior Change in Family Planning.

Health care provider behavior has the power to influence family planning and reproductive health outcomes positively and negatively, underlining the importance of provider behavior change (PBC) initiatives. However, global health practitioners lack a shared understanding of PBC interventions and what influences provider behavior. Furthermore, PBC interventions in family planning and reproductive health have tended to address individual and workplace environmental factors rather than the full breadth of factors that influence provider behavior, including the broader systems and contexts where providers operate. This commentary contributes to a common understanding of PBC, including the determinants of provider behavior, and describes actions to advance PBC efforts in family planning and reproductive health. To inform these considerations, we conducted a narrative review of more than 70 articles and project materials describing interventions that aimed to change provider behaviors pertaining to family planning and reproductive health and used the review to identify the most and least common provider cadres addressed, behavioral determinants targeted, and strategies implemented. We strongly encourage global health practitioners to design future PBC interventions for a more diverse set of cadres and contexts, consider the full set of factors that influence provider behavior, pair provider- and client-side interventions, shift the narrative around PBC from "blaming" to supporting providers, move beyond training-only interventions, and improve the rigor of measurement and evidence-building efforts for PBC. These considerations can be used to advance the field of PBC in family planning and reproductive health to improve outcomes across the service delivery continuum.

Findings and Lessons Learned From Strengthening the Provision of Voluntary Long-Acting Reversible Contraceptives With Postabortion Care in Guinea.

Integrating voluntary family planning into postabortion care (PAC) presents a critical opportunity to reduce future unintended pregnancies. Although Guinea has low contraceptive prevalence overall, acceptance of long-acting reversible contraceptives (LARCs) among PAC clients is higher than among interval LARC users and higher than the national average. In 2014, we assessed the extent of LARC provision within PAC services and the factors influencing integration. Primary and secondary data collected from 143 interviews, 75 provider assessments, and facility inventories and service statistics from all 38 public facilities providing PAC in Guinea allowed exploration of voluntary family planning uptake in the context of PAC. Study findings showed that 38 of 456 (8.3%) public health facilities or 38 of 122 (31.1%) facilities with a mandate to manage obstetric complications provided PAC services. Service statistics from 4,544 PAC clients in 2013 indicate that 95.2% received counseling and 73.0% voluntarily left the facility with contraception, with 29.6% of acceptors choosing a LARC. Family planning within PAC was emphasized in advocacy, policy and guidelines, quality improvement, and supervision, and the range of contraceptive options for postabortion clients was expanded to enable them to avoid a second unintended pregnancy. Factors that influenced provision of family planning within PAC included (1) the ability of champions both within and outside the Ministry of Public Health to advocate for PAC and leverage donor resources, (2) the incorporation of PAC with postabortion family planning into national policies, standards, and guidelines, (3) training of large numbers of providers in PAC and LARCs, and (4) integration of LARCs within PAC into quality improvement and supervision tools and performance standards. Guinea has gradually scaled up provision of PAC services nationwide and its experience may offer learning opportunities for other countries; however, continued advocacy for further expansion to more rural areas of the country and among private health facilities is necessary.

"When I sleep under the net, nothing bothers me; I sleep well and I'm happy": Senegal's culture of net use and how inconveniences to net use do not translate to net abandonment.

BACKGROUND: Despite recent advances in the fight against the disease, malaria remains a serious threat to the health and well-being of populations in endemic countries. The use of long-lasting insecticidal nets (LLIN) reduces contact between the vector and humans, thereby reducing transmission of the disease. LLINs have become an essential component of malaria control programmes worldwide. METHODS: The Culture of Net Use study used qualitative and quantitative methods in a longitudinal and iterative design over two phases, in order to capture changes in net use over a year and a half period and covering both dry and rainy seasons. Data were collected from a total of 56 households in eight regions to understand variations due to geographical, cultural, and universal coverage differences. At the time of the data collection, the universal coverage campaign had been completed in six of the eight regions (Dakar and Thies excluded). RESULTS: Perceived barriers to use were primarily related to the characteristics of the net itself, include shape, insecticide, and a variety of minority responses, such as perceived lack of mosquito density and being unaccustomed to using nets. Insecticide-related complaints found that insecticide did not present a significant barrier to use, but was cited as a nuisance. Feelings of suffocation continued to be the most commonly cited nuisance. Respondents who favoured the use of insecticide on nets appeared to be more aware of the health and malaria prevention benefits of the insecticide than those who perceived it negatively. CONCLUSION: Despite prior evidence that barriers such as heat, shape, insecticide and perceived mosquito density contribute to non-use of LLINs in other countries, this study has shown that these factors are considered more as nuisances and that they do not consistently prevent the use of nets among respondents in Senegal. Of those who cited inconveniences with their nets, few were moved to stop using a net. Respondents from this study overcame these barriers and continue to value the importance of nets.

"You need to take care of it like you take care of your soul": perceptions and behaviours related to mosquito net damage, care, and repair in Senegal.

BACKGROUND: Net care and repair behaviours are essential for prolonging the durability of long-lasting insecticidal nets. Increased net durability has implications for protection against malaria as well as cost savings from less frequent net distributions. This study investigated behaviours and motivations for net care and repair behaviours in Senegal with the aim of informing social and behaviour change communication (SBCC) programmes, using the Health Belief Model as a framework. METHODS: Data were collected from 114 participants in eight regions of Senegal. Participants were eligible for the study if they were at least 18 years old and if their household owned at least one net. These respondents included 56 in-depth interview respondents and eight focus groups with 58 participants. In addition, the qualitative data were supplemented with observational questionnaire data from a total of 556 sleeping spaces. Of these spaces, 394 had an associated net. RESULTS: Reported net care and repair behaviours and motivations varied substantially within this sample. Children and improper handling were seen as major sources of net damage and respondents often tried to prevent damage by storing nets when not in use. Washing was seen as an additional method of care, but practices for washing varied and may have been damaging to nets in some cases. Participants mentioned a sense of pride of having a net in good condition and the uncertainty around when they could expect another net distribution as motivations for net care. Net repair appeared to be a less common behaviour and was limited by the perspective that net degradation was inevitable and that repairs themselves could weaken nets. CONCLUSION: These findings can be understood using the Health Belief Model framework of perceived severity, perceived susceptibility, perceived barriers, perceived benefits, self-efficacy, and cues to action. This model can guide SBCC messages surrounding net care and repair to promote practices associated with net longevity. Such messages should promote the benefits of intact nets and provide tools for overcoming barriers to care and repair.

User-determined end of net life in Senegal: a qualitative assessment of decision-making related to the retirement of expired nets.

BACKGROUND: Procurement and distribution of long-lasting insecticidal nets (LLINs) in the African region has decreased from 145 million in 2010 to 66 million nets in 2012. As resources for LLIN distribution appear to stagnate, it is important to understand the users' perception of the life span of a net and at what point and why they stop using it. In order to get the most value out of distributed nets and to ensure that they are used for as long as possible, programmes must communicate to users about how to assess useful net life and how to extend it. METHODS: Data were collected from 114 respondents who participated in 56 in-depth interviews (IDIs) and eight focus group discussions (FGDs) in August 2012 in eight regions in Senegal. Households were eligible for the study if they owned at least one net and had an available household member over the age of 18. Data were coded by a team of four coders in ATLAS.ti using a primarily deductive approach. RESULTS: Respondents reported assessing useful net life using the following criteria: the age of net, the number and size of holes and the presence of mosquitoes in the net at night. If they had the means to do so, many respondents preferred the acquisition of a new net rather than the continued use of a very torn net. However, respondents would preferentially use newer nets, saving older, but useable nets for the future or sharing them with family or friends. Participants reported observing alternative uses of nets, primarily for nets that were considered expired. CONCLUSIONS: The results indicate that decisions regarding the end of net life vary among community members in Senegal, but are primarily related to net integrity. Additional research is needed into user-determined end of net life as well as care and repair behaviours, which could extend useful net life. The results from this study and from future research on this topic should be used to understand current behaviours and develop communication programmes to prolong the useful life of nets.