New Client-Centered Discontinuation Measures Using the Demographic and Health Survey Calendar Data.

The main source of method discontinuation data comes from the calendar data of the Demographic and Health Surveys (DHS). DHS considers each episode of use contributed by a woman in the calendar to calculate method discontinuation. This means that episodes from women who contribute only one episode of contraceptive use are combined with episodes from women who contribute multiple episodes of use. This paper explores the DHS calculation of episode-based discontinuation and proposes new indicators that focus specifically on the client and puts her as the unit of analysis. First, we attempt to replicate the DHS calculation by applying weighted averages to episodes from women who contributed only one episode and from women who contributed multiple episodes of use. We then calculate three client-centered discontinuation indicators, using the five-year calendar data of the DHS. The methodology is illustrated by using data collected in Bangladesh, Kenya, and Indonesia. Starting with the very first method used and reported in the calendar and following use over 12 months, we develop a client-centered discontinuation indicator. We build on the calculation of the client-centered discontinuation indicator by: (1) excluding switching to result in all contraceptive discontinuation (complete discontinuation); and (2) limiting discontinuation to women still in need of contraception applying the DHS definitions of in need.

The role of job aids in supporting task sharing family planning services to community pharmacists and patent proprietary medicine vendors in Kaduna and Lagos, Nigeria.

BACKGROUND: CPs and PPMVs are an important source of modern contraceptives in Nigeria, yet many lack the requisite knowledge and skills to capably provide these services. This skills gap might be addressed through targeted family planning (FP) training. This study measures family planning knowledge retention of CPs and PPMVs after receiving training in FP counseling and services in Kaduna and Lagos States, in Nigeria. METHODS: In a quasi-experimental longitudinal design without a comparison group, 559 CPs and PPMVs who were enrolled in the IntegratE project between January and December 2019, completed a self-administered questionnaire to assess their knowledge related to the provision of FP counseling, and injectable and implant contraceptive services at three points in time: 1) before the training; 2) immediately after the training; and 3) 9-months after the training in Kaduna and Lagos states, Nigeria. Adjusted multivariate logistic regression analysis was used to assess the effect of provider characteristics and receipt of job aids on FP knowledge retention 9 months after the training. 95% confidence intervals and p-values were used to assess statistical significance. RESULTS: Majority of study participants were females (60.3%) and between 30 and 49 years old (63.4%). The study revealed the importance of jobs aids as influence on knowledge retention. CPs and PPMVs who reported having the Balanced Counseling Strategy plus (BCS+) counseling cards, were more likely to retain knowledge (AOR: 2.92; 95% CI: 1.01-8.40, p-value = 0.05) at 9 months follow-up. Similarly, in terms of knowledge of injectable contraceptives, CPs and Tier 2 PPMVs who reported receiving the Medical Eligibility Criteria (MEC) Wheel were 2.1 times more likely to retain knowledge of injectable contraceptives 9-months later on (95% CI: 1.14-3.99, p-value = 0.02). CONCLUSION: Community Pharmacists and Proprietary Medicine Vendors had good retention of family planning knowledge, especially when combined with job aids. Training and providing them with job aids on FP will therefore support task shifting and task sharing on family planning services provision in Nigeria.

Nigerian stakeholders' perceptions of a pilot tier accreditation system for Patent and Proprietary Medicine Vendors to expand access to family planning services.

BACKGROUND: Community Pharmacists (CPs) and Patent and Proprietary Medicine Vendors (PPMVs) are often the first point of care for many Nigerians, and when sufficiently trained, they contribute to the expansion of family planning services. Nigeria's task shifting policy and existing regulatory and licensing bodies provide the enabling environment for PPMVs to be stratified and trained. This study explored the perceptions of stakeholders toward the pilot three-tier accreditation system instituted by the Pharmacists Council of Nigeria with support from the IntegratE project. METHODS: Two rounds of qualitative phone interviews were conducted among stakeholders in Kaduna and Lagos states in 2020 and 2021. In addition, there were two rounds of phone interviews with CPs and PPMVs (program recipients) from Lagos and Kaduna states. All participants were purposively selected, based on their involvement in the IntegratE project activities. Interviews were recorded, transcribed, and coded using Atlas.ti software. Thematic analysis was conducted. RESULTS: Fifteen stakeholders and 28 program recipients and 12 stakeholders and 30 program recipients were interviewed during the first and second rounds of data collection respectively. The data are presented around three main themes: 1) the pilot three-tier accreditation system; 2) enabling environment; and 3) implementation challenges. The accreditation system that allows for the stratification and training of PPMVs to provide family planning services was perceived in a positive light by majority of participants. The integrated supportive supervision team that included representation from the licensing and regulatory body was seen as a strength. However, it was noted that the licensing process needs to be more effective. Implementation challenges that need to be addressed prior to scale up include bottlenecks in licensing procedures and the deep-rooted mistrust between CPs and PPMVs. CONCLUSION: Scale up of the three-tier accreditation system has the potential to expand access to family planning services in Nigeria. In other resource-poor settings where human resources for health are in short supply and where drug shops are ubiquitous, identifying drug shop owners, training them to offer a range of family planning services, and providing the enabling environment for them to function may help to improve access to family planning services.

How do changes in motivation to prevent pregnancy influence contraceptive continuation? Results from a longitudinal study with women who receive family planning services from Community Pharmacists and Patent and Proprietary Medicine Vendors in Nigeria.

BACKGROUND: Studies have shown that motivation to avoid pregnancy is associated with contraceptive use and continuation. These motivations can change, however, even within a short period of time. This paper uses longitudinal data to look at women's motivation to avoid pregnancy at two time points, and how changes in motivation influence contraceptive continuation. METHODS: Data for this analysis came from an evaluation of the IntegratE project which seeks to expand access to family planning (FP) in Nigeria through community pharmacies and drug shops. 491 women were interviewed within 10 days after receiving a FP service from these sources and again approximately 9 months later. The dependent variable was contraceptive continuation at the follow-up interview. A categorical independent variable was used to represent changes in motivation to avoid pregnancy from enrollment to the follow-up interview. Univariate and multivariate logistic regression models were used to assess the association between changes in motivation and contraceptive continuation. RESULTS: 89% of women continued using contraception approximately 9 months after the enrollment interview. Women who remained highly motivated to avoid pregnancy were significantly more likely to continue using contraception compared to women who became more motivated (AOR 2.5; 95% CI 1.0-6.0). Women who became less motivated were 64% less likely to continue using contraception compared to who became more motivated (AOR 0.36 95% CI 0.1-0.9). CONCLUSION: FP providers, including private sector pharmacists and drug shop owners, should continuously check-in with women about their motivations around pregnancy to support continuation among those who wish to avoid pregnancy.

Previous research has found women's motivations to avoid pregnancy- how important it is to avoid pregnancy now- is associated with their contraception use. Yet women's motivations to avoid pregnancy often change, even within a short period of time. This paper looks at whether changes in motivation to avoid pregnancy are associated with continued use of contraception in Nigeria.We used data from a larger evaluation of the IntegratE project which seeks to expand access to family planning (FP) in Nigeria through community pharmacies and drug shops. 491 women were interviewed within 10 days after receiving a FP service (counseling, referral or FP method) from these sources and again 9 months later. We then used logistic regression models to assess whether changes in motivation to avoid pregnancy between receiving a FP service to 9 months later is associated with continued use of FP.We found that many women (89%) continued using contraception approximately 9 months after the enrollment interview. Women who remained highly motivated (reported it was very important to avoid pregnancy at both interviews) were more likely to continue using contraception compared to women who became more motivated between the two interviews. Women who became less motivated were 64% less likely to continue using contraception compared to who became more motivated. Our results suggest that FP providers, including private sector pharmacists and drug shop owners, should continuously check in with women about their motivations around pregnancy to support continuation contraceptive use among those who wish to avoid pregnancy.

Not All Women Who Experience Side Effects Discontinue Their Contraceptive Method: Insights from a Longitudinal Study in India.

Side effects are a primary reason why women stop using contraception, even though they may still want to avoid a pregnancy. The Demographic and Health Surveys (DHS), the largest source of nationally representative data on contraceptive discontinuation, only asks women who discontinued a method their reasons for discontinuation, for which side effects is an option. Yet, side effects are also experienced by continued users. Using longitudinal data collected from a cohort of contraceptive users in Odisha and Haryana, India, this study explores the effect of side effect severity and frequency on six-month discontinuation. Among women who experienced side effects of their enrollment method, 49.7 percent continued to use it by the six-month interview. Women who experienced moderate/severe side effects infrequently were 67 percent (adjusted odds ratio [AOR]: 0.33; 95 percent confidence interval [CI]: 0.16-0.64) less likely to discontinue the enrollment method compared to women who experienced moderate/severe side effects always. Women who experienced mild side effects were even less likely to discontinue (AOR: 0.15; 95 percent CI: 0.06-0.37). Study results suggest side effect severity and frequency are more important factors than simply the experience of a side effect in understanding contraceptive discontinuation. DHS and other national surveys should expand their exploration of side effects to include questions asked of current users.

The role of unintended pregnancy in internalized stigma among women living with HIV in Kenya.

BACKGROUND: Kenya has successfully expanded HIV treatment, but HIV-related stigma and discrimination, and unintended pregnancy remain issues for many Kenyan women living with HIV. While HIV-related stigma can influence the health seeking behaviors of those living with HIV, less is known about how reproductive health outcomes influence internalized stigma among women living with HIV. METHODS: Baseline data only were used in this analysis and came from an implementation science study conducted in Kenya from 2015 to 2017. The analytic sample was limited to 1116 women who are living with HIV, between 18 to 44 years old, and have ever experienced a pregnancy. The outcome variable was constructed from 7 internalized stigma statements and agreement with at least 3 statements was categorized as medium/high levels of internalized stigma. Unintended pregnancy, categorized as unintended if the last pregnancy was mistimed or unwanted, was the key independent variable. Univariate and multivariate logistic regression models were used to assess the association between unintended pregnancy and internalized stigma. Associations between internalized stigma and HIV-related discrimination and violence/abuse were also explored. RESULTS: About 48% agreed with at least one internalized stigma statement and 19% agreed with at least three. Over half of women reported that their last pregnancy was unintended (59%). Within the year preceding the survey, 52% reported experiencing discrimination and 41% reported experiencing violence or abuse due to their HIV status. Women whose last pregnancy was unintended were 1.6 times (95% CI 1.2-2.3) more likely to have medium/high levels of internalized stigma compared to those whose pregnancy was wanted at the time, adjusting for respondents' characteristics, experiences of discrimination, and experiences of violence and abuse. Women who experienced HIV-related discrimination in the past 12 months were 1.8 times (95% CI 1.3-2.6) more likely to have medium/high levels of internalized stigma compared to those who experienced no discrimination. CONCLUSIONS: Results suggest that unintended pregnancy is associated with internalized stigma. Integrated HIV and FP programs in Kenya should continue to address stigma and discrimination while increasing access to comprehensive voluntary family planning services for women living with HIV.

Adolescent Fertility Is Lower than Expected in Rural Areas: Results from 10 African HDSS.

The adolescent birth rate (ABR) is an important indicator of maternal health, adolescent sexual health, and gender equity; it remains high in sub-Saharan Africa. While Demographic and Health Surveys (DHS) are the main source of ABR estimates, Health and Demographic Surveillance Systems (HDSS) also produce ABRs. Studies are lacking, however, to assess the ease of access and accuracy of HDSS ABR measures. In this paper, we use birth and exposure data from 10 HDSS in six African countries to compute local ABRs and compare these rates to DHS regional rates where the HDSS sites are located, standardizing by education and place of residence. In rural HDSS sites, the ABR measure is on average 44 percent lower than the DHS measure, after controlling for education and place of residence. Strong temporary migration of childless young women out of rural areas and different capacities in capturing temporarily absent women in the DHS and HDSS could explain this discrepancy. Further comparisons based on more strictly similar populations and measures seem warranted.

Validation of Two Quality of Care Measures: Results from a Longitudinal Study of Reversible Contraceptive Users in India.

Bruce's quality of care framework, developed nearly three decades ago, brought needed international attention to family planning services. Various data collection efforts exist to measure the quality of contraceptive services. Our study validates two process quality measures and tests their predictive validity related to contraceptive continuation among 2,699 married women who started to use a reversible contraceptive method in India. We assessed four process quality domains with 22 items, which were reduced to 10 items using exploratory factor analysis. Weighted additive indices were calculated for the 22- and 10-item measures. Scores were trichotomized into high, medium, and low process quality received. The predictive validity of the two measures was assessed related to modern contraceptive continuation three months later. The adjusted odds of continuing a modern contraceptive three months later was nearly three times greater (AOR: 2.78; 95% CI: 1.83-4.03) for women who received high process quality at enrollment compared with low quality with the 22-item measure, and 2.2 times greater (95% CI: 1.46-3.26) with the 10-item measure. Results suggest that the 22- and 10-item measures are valid, and while the larger 22-item measure can be used in special studies, the 10-item measure is more suited for routine data collection and monitoring.

The effect of job aids on knowledge retention among Patent and Proprietary Medicine Vendors trained to administer injectable contraceptives: longitudinal results from implementation science in Nigeria.

BACKGROUND: To increase access to voluntary family planning (FP) services, Nigerian policymakers are debating how to task share injectable contraceptive services to drug shop owners known as Patent and Proprietary Medicine Vendors (PPMVs). Task sharing FP services to drug shops is a promising practice, but information is needed on how to ensure high quality FP services. This analysis assesses the effects of job aids on PPMVs' knowledge of injectable contraceptives 9 months after receiving a standardized training. METHODS: One hundred ninety-four PPMVs were trained on FP counseling and administration of injectable contraceptives in Bauchi, Cross River, Ebonyi and Kaduna states. PPMVs were interviewed before, after, and 9 months after the training. Three variables were used to assess injectable contraceptive knowledge: 1) intramuscular depot-medroxyprogesterone acetate (DMPA-IM) knowledge: a combination of three questions related to device type, injection location, and reinjection frequency; 2) subcutaneous DMPA (DMPA-SC) knowledge: a combination of the same three questions but for DMPA-SC; and 3) knowledge of at least 4 of the 7 common injectable side effects. Three separate adjusted logistic regression models were conducted to determine the factors that influence PPMV knowledge of injectable contraceptives 9 months after the training. RESULTS: Over half of PPMVs (56%) reported using at least two job aids at 9 months. PPMVs' knowledge of DMPA-IM, DMPA-SC and side effects were low before the training but increased immediately after. Nine months later, knowledge remained higher than pre-test levels but generally reduced compared to posttest levels. PPMVs who reported using at least two FP job aids were 2.6 (95% CI: 1.4-5.1) times more likely to have DMPA-IM knowledge 9 months after the training compared to those who used one or no job aids, while adjusting for PPMV characteristics. Similar results were observed for knowledge of DMPA-SC (AOR: 2.5; 95% CI: 1.2-4.6) and side effects (AOR: 2.5; 95% CI: 1.3-4.8). CONCLUSION: PPMVs who used at least two FP job aids were more likely to correctly answer key injectable contraceptive questions 9 months after training. Incorporating proven job aids into routine trainings is a low-cost strategy that can reinforce knowledge and help PPMVs to retain information.

Stigma as a barrier to family planning use among married youth in Ethiopia.

Nearly 33 million female youths have an unmet need for voluntary family planning (FP), meaning they are sexually active and do not want to become pregnant. In Ethiopia, age at marriage remains low: 40% and 14% of young women aged 20-24 were married by the ages of 18 and 15, respectively. Despite increases in FP use by married 15- to 24-year-olds from 5% in 2000 to 37% in 2016, unmet need remains high at 19%. Supply-and-demand factors have been shown to limit FP use, yet little is known about how stigma influences FP use among youth. This study validates an anticipated stigma (expectation of discrimination from others) index and explores its effect on unmet need. A cross-sectional survey was implemented with 15- to 24-year-old female youth in Ethiopia in 2016. The analytic sample included married respondents with a demand (met and unmet need) for FP (n=371). A five-item anticipated stigma index (Cronbach's α=0.66) was developed using principal component factor analysis. These items related to fear, worry and embarrassment when accessing FP. The findings showed that 30% agreed with at least one anticipated stigma question; 44% had an unmet need; 58% were married before age 18; and 100% could name an FP method and knew where to obtain FP. In multivariate regression models, youth who experienced anticipated stigma were significantly more likely to have an unmet need, and those who lived close to a youth-friendly service (YFS) site were significantly less likely to have an unmet need. Interventions should address anticipated stigma while focusing on social norms that restrict married youth from accessing FP; unmet need may be mitigated in the presence of a YFS; and the anticipated stigma index appears valid and reliable but should be tested in other countries and among different adolescent groups.

Burden of care perceived by the principal caregivers of autistic children and adolescents visiting health facilities in Lucknow City.

BACKGROUND: Autism is extraordinarily difficult for families to cope with for various reasons. Perceived burden and care for the child with autism, available forms of social support, and the interactions between the autistic child and other family members are areas of significant concern for families. OBJECTIVE: The objective of this study was to determine the burden of care perceived by the principal caregivers of autistic children or adolescent visiting health facilities in Lucknow city. METHODS: The cross-sectional study was conducted from October 2016 to September 2017 with a sample of 90 principal caregivers (aged <60 years) of autistic children and adolescents aged 3-19 years and diagnosed with autism, attending government and private health facilities providing treatment for autism in Lucknow, Uttar Pradesh, India. Validated tools were used to assess the burden of care and disability level of autistic children. Data were analyzed using the software SPSS version 16. RESULTS: The caregivers of autistic children and adolescents perceived the burden of care in different domains in varying extent with "caregiver's routine" and "taking responsibility" domains affected the most. The burden perceived was found to be affected by the permanent residence of caregiver, rural/urban dwelling, type of family, socioeconomic status, age at which diagnosis was made, knowledge about autism and the severity of autism. CONCLUSIONS: Availability and easy accessibility of autism treatment facilities must be the most probable reason for less burden perceived in three domains, by caregivers of urban settings and those belonging to Lucknow. Furthermore, better knowledge on autism and family and friends' support led to decrease in the burden perceived by the caregivers in various domains. Thus, it was found that the burden perceived can be reduced by universal availability of evidence-based early diagnosis and treatment of autism and improving the knowledge of caregivers about autism.

Condom use at last sex by young men in Ethiopia: the effect of descriptive and injunctive norms.

BACKGROUND: Condoms are an important prevention method in the transmission of HIV and sexually transmitted infections as well as unintended pregnancy. Individual-level factors associated with condom use include family support and connection, strong relationships with teachers and other students, discussions about sexuality with friends and peers, higher perceived economic status, and higher levels of education. Little, however, is known about the influence of social norms on condom use among young men in Ethiopia. This study examines the effect of descriptive and injunctive norms on condoms use at last sex using the theory of normative social behavior. METHODS: A cross-sectional survey was implemented with 15-24 year old male youth in five Ethiopian regions in 2016. The analytic sample was limited to sexually active single young men (n = 260). Descriptive statistics, bivariate and multivariate logistic regressions were conducted. An interaction term was included in the multivariate model to assess whether injunctive norms moderate the relationship between descriptive norms and condom use. RESULTS: The descriptive norm of knowing a friend who had ever used condoms significantly increased respondents' likelihood of using condoms at last sex. The injunctive norm of being worried about what people would think if they learned that the respondent needed condoms significantly decreased their likelihood to use condoms. The injunctive norm did not moderate the relationship between descriptive norms and condom use. Young men who lived closer to a youth friendly service (YFS) site were significantly more likely to have used condoms at last sex compared to those who lived further away from a YFS site. CONCLUSIONS: Social norms play an important role in decision-making to use condoms among single young men in Ethiopia. The interplay between injunctive and descriptive norms is less straightforward and likely varies by individual. Interventions need to focus on shifting community-level norms to be more accepting of sexually active, single young men's use of condoms and need to be a part of a larger effort to delay sexual debut, decrease sexual violence, and increase gender equity in relationships.

Understanding the use of India's National Health Insurance Scheme for family planning and reproductive health services in Uttar Pradesh.

India's National Health Insurance Scheme, Rashtriya Swasthya Bima Yojana (RSBY), expands health services to families living below the poverty line by enrolling them into the scheme through selected health facilities. Use and reasons for nonuse of RSBY for family planning (FP) and reproductive health (RH) services have not been explored previously. This cross-sectional study explored the use of RSBY for FP/RH services at private health facilities, knowledge of FP/RH service availability, and factors influencing knowledge among RSBY enrolled families. A total of 726 women and 640 men from enrolled families living in 3 cities of Uttar Pradesh, India, were interviewed. Use of FP/RH services at private hospitals enrolled in the RSBY was 2%. Nearly 20% of respondents used FP or delivery services from unenrolled private hospitals but could have accessed these services through the scheme. Over 75% of respondents were unaware of FP/RH service availability through RSBY. Respondents with some education were more likely to have this knowledge, while poorer families were less likely to have this knowledge. Findings suggest that for RSBY to reach the most vulnerable families, efforts need to be made to better educate enrolled families about their entitlements and benefits of the scheme.

Differences in Quality of Care of Family Planning Services Received by Age and Contraceptive Continuation Among Young Mothers in India.

PURPOSE: Youth face barriers that affect their use of family planning (FP) services, including low quality of care and provider bias. Although young women have the highest unmet need for FP in India, little is known about the effect of age on quality of care received. Additionally, although youth have higher contraceptive discontinuation than older women, the factors associated with continuation, including the effect of quality of care, are not well known. This study aims to assess differences in quality of care received by young mothers aged 15-24 and mothers aged 25-48, and to examine factors associated with modern contraceptive continuation 6 months after initiation among young mothers. METHODS: Data come from a 12-month longitudinal study of married reversible contraceptive users in India. Multinomial logistic regression was conducted to examine adjusted associations of age and reported receipt of low, medium, or high quality of care. Logistic regression was used to assess factors associated with modern contraceptive continuation after 6 months. RESULTS: Results showed that young mothers were less likely to receive high quality of care than older mothers, and that among young mothers, motivation to prevent pregnancy was significantly associated with continued use after 6 months. DISCUSSION: As India aims to improve quality of care and increase access to services for youth, special attention should be paid to care received by young mothers, as well as options to support them in continuing to use contraceptive methods as long as they desire to prevent pregnancy.

What Distinguishes Women Who Choose to Self-Inject? A Prospective Cohort Study of Subcutaneous Depot Medroxyprogesterone Acetate Users in Ghana.

Depot medroxyprogesterone acetate administered subcutaneously (DMPA-SC) is an all-in-one injectable contraceptive administered every 3 months, either by a trained health care provider or community health worker or by training a client to self-inject. Using a prospective cohort of family planning (FP) clients in Ghana, this study explores patterns of DMPA-SC use and mode of injection administration over a 6-month period. This study also examines the predictors of self-injection adoption 6 months after initiating DMPA-SC. Our analysis focuses on 378 women who were using DMPA-SC at the 6-month interview. Adjusted odds ratios accounting for clustering show that clients who were new FP users, never married, or attended high school/attained higher education were significantly more likely to self-inject by the third injection. Results of this study suggest that in Ghana, adding DMPA-SC to the method mix may improve access to FP, especially among new users. Results of this study may inform FP projects and programs aiming to improve access to contraceptive methods and increase contraceptive prevalence by introducing or scaling up DMPA-SC self-injection. The findings also provide a sociodemographic profile of FP clients most likely to adopt DMPA-SC self-injection over time, which could serve as an evidence base for social marketing strategies.

Changes in clients' perceptions of family planning quality of care in Kaduna and Lagos States, Nigeria: A mixed methods study.

Community Pharmacists (CPs) and Patent and Proprietary Medicine Vendors (PPMVs) are crucial to improving access to family planning (FP) services in Nigeria. Although the private sector is preferred for convenience, availability of commodity, privacy, and timeliness, less well known is the quality of care received by clients who obtain FP services from CPs and PPMVs. This paper seeks to explore the use of validated quality of care measures for programming in Kaduna and Lagos States and to assess how these measures worked in capturing changes in quality of care using client exit interviews implemented at two time points. Using validated measures of quality of care, 598 and 236 exit interviews in rounds 1 and 2 were conducted with FP clients aged 18-49 years old. The quality of care domains were assessed using 22 questions. A weighted additive quality score was created, and scores were grouped into three: low, medium, and high quality. Changes in quality of care received were examined using χ 2 test. A subset of 53 clients were selected for in-depth interviews. Deductive and inductive approaches were used for coding, and data analysis was thematic. In Lagos, we observed increases in 16 out of 22 items while in Kaduna increases were only observed in 8 items. For instance, increases were observed in the proportion of women who experienced visual privacy between rounds 1 and 2 in Lagos (74%-89%) and Kaduna (66%-82%). The quality of care received by clients changed over time. Women who reported high quality care in Lagos increased from 42% to 63%, whereas women who reported high quality care in Kaduna decreased from 35% to 21%. In both states, in-depth interviews revealed that women felt they were treated respectfully, that their sessions with providers were visually private, that they could ask questions, and that they were asked about their preferred method. This study demonstrates that clients received high quality of care services from providers (CPs and PPMVs) especially in Lagos, and such services can be improved over time. Continuous support may be required to maintain and prevent reduction in quality of FP counseling and services, particularly in Kaduna.

Reaching women at work with health programming in Bangladesh: results of difference-in-differences analysis among female factory workers.

The rapid growth of Bangladesh's ready-made garment sector has transformed the country's economy while also employing a predominantly female workforce. Companies have begun collaborating with NGOs to provide health messages to and expand health services for workers. This study evaluates the effect of the Health Enables Return (HER) health model's approach of using peer health educators to deliver health messages and increased availability of health products. Using repeated cross-sectional data from female workers in HERhealth and comparison factories between May 2015 and March 2017, baseline (n = 1704) and endline (n = 1503) samples were matched on eight characteristics and then difference-in-differences estimations were used to determine the effect of the HERhealth model on knowledge and behaviours. The average changes over time in knowledge and behaviours were statistically different between the HERhealth and comparison factories. Knowledge of when a woman is at higher risk for pregnancy during her menstrual cycle increased from baseline to endline in both groups but was 12 percentage points greater in the HERhealth factories than in the comparison. An increase in family planning use among ever-married women was observed in the HERhealth factories but decreased in the comparison factories leading to a 12 percentage point difference-in-differences. The greatest effect of the HERhealth model was observed on women's use of sanitary products for menstrual management which significantly increased in both groups, but the increase was 35% greater in the HERhealth factories. The HERhealth model is effective in increasing knowledge and in improving health behaviours when health products are available in factory infirmaries.

Evaluation of 2 Intervention Models to Integrate Family Planning Into Worker Health and Livelihood Programs in Egypt: A Difference-in-Differences Analysis.

Recent increases in fertility rates in Egypt and an increase in desired fertility among unmarried young people highlight the need for renewed attention to awareness of and demand for family planning (FP) among young people. Between 2017 and 2018, the United States Agency for International Development-funded Evidence Project tested 2 intervention models to increase awareness of and demand for FP and reproductive health (RH) services among people aged 18-35 years in Souhag and Port Said governorates, Egypt. In Souhag, FP/RH information was integrated into a 5-day livelihood training program for job seekers. In Port Said, garment factory workers received FP/RH information through trained peer educators, social and behavior change materials, and social media. Workshop participants and factory workers interested in FP services were referred to private project-trained physicians and pharmacists. We present the results of an evaluation of the impact of each intervention on young people's reported exposure to FP messages and their FP knowledge, attitudes, and behaviors. Phone interviews were conducted with participants in intervention and comparison groups before and after the intervention. In Souhag, 1,519 intervention group participants (778 at baseline; 741 at endline) and 1,082 comparison group participants (699 at baseline; 383 at endline) completed the phone interview. In Port Said 1,958 participants from intervention factories (1,145 at baseline; 813 at endline) and 1,047 participants from comparison factories (621 at baseline; 426 at endline) completed the phone interview. A difference-in-differences analysis compared intervention and comparison groups between baseline and endline. Results showed significant differences in knowledge and attitudes over time between the intervention and comparison groups in Souhag but less so in Port Said. FP use did not change among project participants in either governorate. We discuss lessons learned from integrating FP into worker health and livelihood training programs and methodological considerations for evaluating such interventions.