Protocol for a matched-pair cluster control trial of ARCHES (Addressing Reproductive Coercion in Health Settings) among women and girls seeking contraceptive services from community-based clinics in Nairobi, Kenya.

BACKGROUND: Reproductive coercion (RC) and intimate partner violence (IPV) are prevalent forms of gender-based violence (GBV) associated with reduced female control over contraceptive use and subsequent unintended pregnancy. Although the World Health Organization has recommended the identification and support of GBV survivors within health services, few clinic-based models have been shown to reduce IPV or RC, particularly in low or middle-income countries (LMICs). To date, clinic-based GBV interventions have not been shown to reduce RC or unintended pregnancy in LMIC settings. INTERVENTION: ARCHES (Addressing Reproductive Coercion in Health Settings) is a single-session, clinic-based model delivered within routine contraceptive counseling that has been demonstrated to reduce RC in the United States. ARCHES was adapted to the Kenyan context via a participatory process to reduce GBV and unintended pregnancy among women and girls seeking contraceptive services in this setting. Core elements of ARCHES include enhanced contraceptive counseling that addresses RC, opportunity for patient disclosure of RC and IPV (and subsequent warm referral to local services), and provision of a palm-sized educational booklet. METHODS: A matched-pair cluster control trial is being conducted to assess whether the ARCHES intervention (treatment condition), as compared to standard-of-care contraceptive counseling (control condition), reduces RC and IPV, and improves contraceptive outcomes for woman and girls of reproductive age (15 to 49 years) seeking contraceptive services from community-based clinics in Nairobi, Kenya. All six clinics were assigned to intervention-control pairs based on similarities in patient volume and demographics, physical structure and neighborhood context. Survey data will be collected from patients immediately prior to their clinic visit (baseline, T1), immediately after their clinic visit (exit), and at 3- and 6-months post-visit (T2 and T3, respectively). DISCUSSION: This study is the first to assess the efficacy of an adaptation of the ARCHES model to reduce GBV and improve reproductive health outside of the U.S., and one of only a small number of controlled trials to assess reductions in GBV associated with a clinic-based program in an LMIC context. Evidence from this trial will inform health system efforts to reduce GBV, and to enhance female contraceptive control and reproductive health in Kenya and globally. TRIAL REGISTRATION: Registered May 23, 2018 - ClinicalTrials.gov, NCT03534401. Unique Protocol ID: 170084.

Improving Voluntary, Rights-Based Family Planning: Experience From Nigeria And Uganda.

BACKGROUND: Growing focus on the need for voluntary, rights-based family planning (VRBFP) has drawn attention to the lack of programs that adhere to the range of rights principles. This paper describes two first-of-their-kind interventions in Kaduna State, Nigeria and in Uganda in 2016-2017, accompanied by implementation research based on a conceptual framework that translates internationally agreed rights into family planning programming. METHODS: This paper describes the interventions, and profiles lessons learned about VRBFP implementation from both countries, as well as measured outcomes of VRBFP programming from Nigeria. RESULTS: The intervention components in both projects were similar. Both programs built provider and supervisor capacity in VRBFP using comparable curricula; developed facility-level action plans and supported action plan implementation; aimed to increase clients' rights literacy at the facility using posters and handouts; and established or strengthened health committee structures to support VRBFP. Through the interventions, rights literacy increased, and providers were able to see the benefits of taking a VRBFP approach to serving clients. The importance of ensuring a client focus and supporting clients to make their own family planning choices was reinforced. Providers recognized the importance of treating all clients, regardless of age or marital status, for example, with dignity. Privacy and confidentiality were enhanced. Recognition of what violations of rights are and the need to report and address them through strong accountability systems grew. Many lessons were shared across the two countries, including the need for rights literacy; attention to health systems issues; strong and supportive supervision; and the importance of working at multiple levels. Additionally, some unique lessons emanated from each country experience. CONCLUSION: The assessed feasibility and benefits of using VRBFP programming and outcome measures in both countries bode well for adoption of this approach in other geographies.

Rapid Integration of Zika Virus Prevention Within Sexual and Reproductive Health Services and Beyond: Programmatic Lessons From Latin America and the Caribbean.

The emergence of the Zika virus (ZIKV) in Latin America and the Caribbean during the 2015-2016 outbreak has required local health systems to adapt, suddenly and continuously. This field action report explores the outbreak's sexual and reproductive health (SRH) complexities and the experience of the International Planned Parenthood Federation (IPPF) and 4 of its member associations as part of the United States Agency for International Development's rapid response in the region. It outlines approaches and actions that IPPF and its member associations undertook over 3 broad programmatic phases-developing ZIKV protocols and training personnel; delivering ZIKV-integrated services and information; and providing screening, care, and support for children and families affected by congenital Zika syndrome (CZS)-as the project worked to integrate ZIKV prevention, screening, and response within SRH service delivery models. It also describes the challenges and lessons learned in implementing a ZIKV response program in the region and recommendations from a service delivery perspective that can be useful in informing the responses to future rapid onset epidemics with SRH relevance. Challenges identified include adapting to a rapidly evolving evidence base during the early stages of the epidemic; traditional and restrictive regional social norms around gender, sex, and sexuality; the lack of focus on sexual transmission in national ZIKV public health messaging; and a lack of services, government support, and referral pathways for supporting children and families affected by CZS. Some of the key recommendations include finding ways to share rapidly evolving clinical updates conveniently and frequently, such as through digital technologies and platforms; partnering with multidisciplinary organizations, such as disability rights and services organizations, that can fill gaps in needed services; and leveraging the need for urgent action as a catalyst of change around more inclusive and gender-transformative social norms and services.

Sex differences in intrusive memories following trauma.

BACKGROUND: A key mechanism thought to underlie Posttraumatic Stress Disorder (PTSD) is enhanced emotional memory consolidation. Recent evidence in healthy controls revealed that women have greater negative memory consolidation following stress relative to men. This study examined emotional memory consolidation in women and men with PTSD, and in trauma-exposed and non-trauma controls to test the hypothesis that emotionally negative memory consolidation would be greater in women with PTSD. METHOD: One hundred and forty-seven men and women (47 with PTSD, 49 trauma-exposed controls, and 51 non-trauma controls) completed an emotional memory task where they looked at negative, neutral and positive images from the International Affective Picture System (IAPS). Delayed recall and an intrusive memory diary were completed two days later. RESULTS: Women displayed greater recall, and reported more negative intrusive memories than men. A gender x group interaction effect showed that both women with PTSD and trauma-exposed women reported more intrusive memories than women without trauma exposure or men. CONCLUSION: This study provided preliminary evidence of sex differences in intrusive memories in those with PTSD as well as those with a history of trauma exposure. Future research should include measures of sex hormones to further examine sex differences on memory consolidation in the context of trauma exposure and PTSD.

Introduction of Subcutaneous Depot Medroxyprogesterone Acetate (DMPA-SC) Injectable Contraception at Facility and Community Levels: Pilot Results From 4 Districts of Uganda.

Reproductive Health Uganda (RHU), a local NGO, introduced subcutaneous depot medroxyprogesterone acetate (DMPA-SC, brand name Sayana Press) in 4 districts of Uganda between April 2016 and March 2017. RHU trained public and private facility providers on all family planning methods including DMPA-SC; trained community health workers (known as village health teams, VHTs) to give family planning counseling, provide short-acting methods including DMPA-SC, and make referrals for long-acting and permanent methods; conducted mobile outreach and raised awareness of family planning; and provided family planning commodities. We used a retrospective cross-sectional evaluation design drawing on data from (1) in-depth interviews with 32 facility- and community-based providers; (2) key informant interviews with 7 policy makers and program staff; and (3) family planning program statistics from 4 RHU clinics, 26 mobile outreach sites, and 40 VHTs in 4 study districts. Data collection took place between April and June 2017. Over 12 months, 14,273 units of DMPA-SC were provided in RHU clinics, by mobile outreach teams, and by VHTs. DMPA-SC units were mostly administered in community settings either by VHTs (70%) or at mobile outreach events (26%). A substantial proportion (43%) of DMPA-SC units were administered to young people (<25 years), a significantly higher proportion compared with other methods provided to this age group through the project (P<.001), except condoms. In addition, a greater proportion of DMPA-SC units provided at the community level by VHTs were used by young people (45%) compared with units provided at outreach (36%) or in clinics (35%). Overall, injectables (DMPA-SC and intramuscular DMPA combined) came to represent 43% of all contraceptive methods provided, up from a baseline of 20%. This shift occurred despite significant increases in the volume of all other methods provided (P<.001). Qualitative data revealed various factors that facilitated introduction, including comprehensive training, commodity availability, strong referral links, and early community engagement. RHU's experience supports the viability of community-based delivery of DMPA-SC and identifies opportunities to strengthen this approach. There is further evidence that DMPA-SC may be popular with young people, especially in community settings.

The Net Promoter Score (NPS) for Insight Into Client Experiences in Sexual and Reproductive Health Clinics.

The Net Promoter Score (NPS) metric, commonly used by Fortune 500 companies to measure the customer experience, is calculated using a 0-to-10 scale to answer 1 question: "How likely is it that you would recommend [company X] to a friend or colleague?" Despite the value of this methodology as a predictor of growth and indicator of customer satisfaction in for-profit industries, uptake of the NPS has been slower in the social sector due to concerns about its applicability and acceptability in noncommercial settings, particularly among low-literacy populations. To address these concerns, we conducted a series of small-scale pilots in El Salvador, India, Kenya, and Nigeria to test different implementation approaches of the NPS in sexual and reproductive health clinics-including face-to-face interviews, a guided drop box, integration of the NPS question into an existing client exit interview, and self-administered and volunteer-assisted online surveys using tablets in clinics-and compared the traditional 0-to-10 number scale with an emoji-face scale. Findings showed that the NPS can be effectively adapted for use in low-resource health clinics among low-literacy clients using the number scale. There was no statistically significant difference in mean likeliness to recommend services when using the emoji versus numerical scales in India; however, there was a statistically significant difference when using the guided drop box approach versus face-to-face interviews. When combined with demographic and service-use questions, the NPS generated useful insights on client groups that were more or less likely to recommend the services. While providing an online survey on tablets can be an efficient methodology for implementing the NPS, self-administered approaches may be limited by a client's level of literacy or comfort with technology. For those client populations with a lower NPS, we advise using a qualitative feedback process that can elicit critical feedback to identify actions to improve their experience. Our experience with testing and implementing the NPS in SRH clinics in diverse settings suggests it is a promising approach to gaining insight into the client experience in nonprofit health care settings.

Negative appraisals and fear extinction are independently related to PTSD symptoms.

BACKGROUND: Considerable research has revealed impaired fear extinction to be a significant predictor of PTSD. Fear extinction is also considered the primary mechanism of exposure therapy, and a critical factor in PTSD recovery. The cognitive theory of PTSD proposes that symptoms persist due to excessive negative appraisals about the trauma and its sequelae. Research has not yet examined the relationship between fear extinction and negative appraisals in PTSD. METHODS: A cross-sectional sample of participants with PTSD (n =21), and trauma-exposed controls (n =33) underwent a standardized differential fear conditioning and extinction paradigm, with skin conductance response (SCR) amplitude serving as the index of conditioned responses. The Posttraumatic Cognitions Inventory (PTCI) was used to index catastrophic negative appraisals. RESULTS: Participants with PTSD demonstrated a slower decrease in overall SCR responses during extinction and greater negative appraisals compared to the group. A moderation analysis revealed that both negative trauma-relevant appraisals and fear extinction learning were independently associated with PTSD symptoms, but there was no moderation interaction. LIMITATIONS: The current study was limited by a modest sample size, leading to the inclusion of participants with subclinical PTSD symptoms. Further, the current study only assessed fear extinction learning; including a second day extinction recall task may show alternative effects. CONCLUSIONS: These findings indicate that negative appraisals and fear extinction did not interact, but had independent relationships with PTSD symptoms. Here we show for the first time in an experimental framework that negative appraisals and fear extinction play separate roles in PTSD symptoms.

IMPAIRED FEAR EXTINCTION ASSOCIATED WITH PTSD INCREASES WITH HOURS-SINCE-WAKING.

BACKGROUND: Prior research has demonstrated that time-of-day may play an important role in the extinction of conditioned fear, with extinction better learned earlier in the day rather than later. Impaired fear extinction memory is widely considered a key mechanism of posttraumatic stress disorder (PTSD). The relationship between fear extinction and PTSD symptoms may be moderated by hours-since-waking. METHOD: In the present experiment, we examined whether hours-since-waking would moderate fear extinction learning ability in a clinical PTSD sample (n = 15), compared to trauma-exposed (n = 33) and nonexposed controls (n = 22). Participants completed a standardized differential fear conditioning and extinction paradigm, providing skin conductance response measures to quantify conditioned responding. RESULTS: Mixed-model analysis of variance revealed a PTSD-specific impairment in extinction learning ability in the late extinction phase. A moderation analysis showed that hours-since-waking was a significant moderator of the relationship between impaired late extinction and PTSD symptoms. Specifically, we found that participants with higher PTSD symptoms demonstrated poorer fear extinction learning ability as they were awake for longer. CONCLUSIONS: The results of the current study add to a growing literature indicating deficits in fear extinction learning in PTSD samples, compared to trauma-exposed and nonexposed controls. These results support previous findings that fear extinction is impaired later in the day, and extends this to a clinical sample, suggesting that exposure-therapy may be optimized by scheduling sessions in the morning.

Implementing a critical care course for ward nurses.

This article describes the setting up and evaluation of a course for ward-based nurses, which is designed to improve their skills in caring for highly dependent patients. The authors suggest such courses can increase nurses' confidence and competence and, as well as enhancing care, can improve communication with senior staff about issues of concern.