The impact of community and provider-driven social accountability interventions on contraceptive use: findings from a cohort study of new users in Ghana and Tanzania.

BACKGROUND: Although contraceptive use has increased over 15 years, discontinuation rates remain high. Contraceptive use is becoming more important when addressing unmet need for family planning. Social accountability, defined here as collective processes for holding duty bearers to account for their actions, is a rights-based participatory process that supports service provision and person-centred care, as well as, informed decision-making among community members regarding their health. A study implemented in Ghana and Tanzania was designed to understand and evaluate how social accountability and participatory processes influences quality of care and client satisfaction and whether this results in increased contraceptive uptake and use. We report here on the relationship between social accountability and the use of modern contraceptives, i.e., contraceptive method discontinuation, contraceptive method switching, and contraceptive discontinuation. METHODS: As part of Community and Provider driven Social Accountability Intervention (CaPSAI) Project, a cohort of women aged 15 to 49 years who were new users of contraception and accessing family planning and contraceptives services at the study facilities across both intervention and control groups were followed-up over a 12-month period to measure changes contraceptive use. RESULTS: In this cohort study over a one-year duration, we did not find a statistically significant difference in Ghana and Tanzania in overall method discontinuation, switching, and contraceptive discontinuation after exposure to a social accountability intervention. In Ghana but not in Tanzania, when stratified by the type of facility (district level vs. health centre), there were significantly less method and contraceptive discontinuation in the district level facility and significantly more method and contraceptive discontinuation in the health centres in the intervention group. In Ghana, the most important reasons reported for stopping a method were fear of side-effects, health concerns and wanting to become pregnant in the control group and fear of side-effects wanting a more effective method and infrequent sex in the intervention group. In Tanzania, the most important reasons reported for stopping a method were fear of side-effects, wanting a more effective method, and method not available in the control group compared to wanting a more effective method, fear of side-effects and health concerns in the intervention group. CONCLUSIONS: We did not demonstrate a statistically significant impact of a six-month CaPSAI intervention on contraceptives use among new users in Tanzania and Ghana. However, since social accountability have important impacts beyond contraceptive use it is important consider results of the intermediate outcomes, cases of change, and process evaluation to fully understand the impact of this intervention. TRIAL REGISTRATION: The CaPSAI Project has been registered at Australian New Zealand Clinical Trials Registry (ACTRN12619000378123, 11/03/2019).

The role of social accountability in changing service users' values, attitudes, and interactions with the health services: a pre-post study.

This study evaluated the effects of community engagement through social accountability on service users' values, attitudes and interactions. We conducted a pre-post study of the community and provider driven social accountability intervention (CaPSAI) over a 12-month period among 1,500 service users in 8 health facilites in Ghana and in Tanzania (n = 3,000).In both countries, there were significant improvements in women's participation in household decision-making and in how service users' perceive their treatment by health workers. In both settings, however, there was a decline in women's knowledge of rights, perception of service quality, awareness of accountability mechanisms and collective efficacy in the community. Though CaPSAI intervention set out to change the values, attitudes, and interactions between community members and those providing contraceptive services, there were changes in different directions that require closer examination.

Research and implementation interactions in a social accountability study: utilizing guidance for conducting process evaluations of complex interventions.

BACKGROUND: In recent years, researchers and evaluators have made efforts to identify and use appropriate and innovative research designs that account for the complexity in studying social accountability. The relationship between the researchers and those implementing the activities and how this impacts the study have received little attention. In this paper, we reflect on how we managed the relationship between researchers and implementers using the United Kingdom Medical Research Council (MRC) guidance on process evaluation of a complex intervention. MAIN BODY: The MRC guidance focuses on three areas of interaction between researchers and stakeholders involved in developing and delivering the intervention: (i) working with program developers and implementers; (ii) communication of emerging findings between researchers/evaluators and implementers; and (iii) overlapping roles of the intervention and research/evaluation. We summarize how the recommendations for each of the three areas were operationalized in the Community and Provider driven Social Accountability Intervention (CaPSAI) Project and provide reflections based on experience. We co-developed various tools, including standard operating procedures, contact lists, and manuals. Activities such as training sessions, regular calls, and meetings were also conducted to enable a good working relationship between the different partners. CONCLUSIONS: Studying social accountability requires the collaboration of multiple partners that need to be planned to ensure a good working relationship while safeguarding both the research and intervention implementation. The MRC guidance is a useful tool for making interaction issues explicit and establishing procedures. Planning procedures for dealing with research and implementers' interactions could be more comprehensive and better adapted to social accountability interventions if both researchers and implementers are involved. There is a need for social accountability research to include clear statements explaining the nature and types of relationships between researchers and implementers involved in the intervention.

Impact of community and provider-driven social accountability interventions on contraceptive uptake in Ghana and Tanzania.

BACKGROUND: Social accountability, which is defined as a collective process for holding duty bearers and service providers to account for their actions, has shown positive outcomes in addressing the interrelated barriers to quality sexual and reproductive health services. The Community and Provider driven Social Accountability Intervention (CaPSAI) Project contributes to the evidence on the effects of social accountability processes in the context of a family planning and contraceptive programme. METHODS: A quasi-experimental study utilizing an interrupted time series design with a control group (ITS-CG) was conducted to determine the actual number of new users of contraception amongst women 15-49 years old in eight intervention and eight control facilities per country in Ghana and Tanzania. A standardized facility audit questionnaire was used to collect facility data and completed every year in both intervention and control groups in each country from 2018-2020. RESULTS: In Ghana, the two-segmented Poisson Generalized Estimating Equation (GEE) model demonstrated no statistically significant difference at post-intervention, between the intervention and control facilities, in the level of uptake of contraceptives (excess level) (p-value = 0.07) or in the rate of change (excess rate) in uptake (p-value = 0.07) after adjusting for baseline differences. Similarly, in Tanzania, there was no statistical difference between intervention and control facilities, in the level of uptake of contraceptives (excess level) (p-value = 0.20), with the rate of change in uptake (p-value = 0.05) after adjusting for the baseline differences. There was no statistical difference in the level of or rate of change in uptake in the two groups in a sensitivity analysis excluding new users recruited in outreach activities in Tanzania. CONCLUSIONS: The CAPSAI project intervention did not result in a statistically significant increase in uptake of contraceptives as measured by the number of or increase in new users. In evaluating the impact of the intervention on the intermediate outcomes such as self-efficacy among service users, trust and countervailing power among social groups/networks, and responsiveness of service providers, cases of change and process evaluation should be considered. TRIAL REGISTRATION: The CaPSAI Project has been registered at the Australian New Zealand Clinical Trials Registry (ACTRN12619000378123, 11/03/2019).

Adaptation and validation of social accountability measures in the context of contraceptive services in Ghana and Tanzania.

BACKGROUND: Changes in the values, attitudes, and interactions of both service users and health care providers are central to social accountability processes in reproductive health. However, there is little consensus on how best to measure these latent changes. This paper reports on the adaptation and validation of measures that capture these changes in Tanzania and Ghana. METHODS: The CaPSAI theory of change determined the dimensions of the measure, and we adapted existing items for the survey items. Trained data collectors used a survey to collect data from 752 women in Tanzania and 750 women in Ghana attending contraceptive services. We used reliability analysis, exploratory, and confirmatory factor analysis to assess the validity and reliability of these measures in each country. RESULTS: The measure has high construct validity and reliability in both countries. We identified several subscales in both countries, 10 subscales in Tanzania, and 11 subscales in Ghana. Many of the domains and items were shared across both settings. CONCLUSION: The study suggests that the multi-dimensional scales have high construct validity and reliability in both countries. Though there were differences in the two country contexts and in items and scales, there was convergence in the analysis that suggests that this measure may be relevant in different settings and should be validated in new settings. TRIAL REGISTRATION: ACTRN12619000378123 .

Child marriage in Ghana: evidence from a multi-method study.

BACKGROUND: Child marriage remains a challenge in Ghana. Over the years, government and development partners have made various commitments and efforts to curb the phenomenon of child marriage. However, there is little empirical evidence on the predictors, norms and practices surrounding the practice to support their efforts, a gap this study sought to fill. METHODS: The study employed a multiple-method approach to achieve the set objectives. Data from the women's file of the 2014 Ghana Demographic and Health Survey (GDHS) was used to examine the predictors of child marriage using frequencies and logistic regression methods. Data from Key Informant Interviews (KIIs) and Focus Group Discussions (FGDs) collected in Central and Northern regions of Ghana were used to examine norms and practices surrounding child marriage using thematic analysis. RESULTS: Two in ten (20.68%) girls in the quantitative sample married as children. The results revealed that girls who had never attended school compared to those who had ever attended school were more likely to marry as children (OR, 3.01). Compared with girls in the lowest wealth quintile, girls in the middle (OR, 0.59), fourth (OR, 0.37) and highest (OR, 0.32) wealth quintiles were less likely to marry as children. From the qualitative data, the study identified poverty, teenage pregnancy, and cultural norms such as betrothal marriage, exchange of girls for marriage and pressure from significant others as the drivers of child marriage. CONCLUSIONS: The findings show that various socio-economic and cultural factors such as education, teenage pregnancy and poverty influence child marriage. Hence, efforts to curb child marriage should be geared towards retention of girls in school, curbing teenage pregnancy, empowering girls economically, enforcing laws on child marriage in Ghana, as well as designing tailored advocacy programs to educate key stakeholders and adolescent girls on the consequences of child marriage. Additionally, there is the need to address socio-cultural norms/practices to help end child marriage.

Improving provider and client communication around family planning in Togo: Results from a cross-sectional survey.

Previous research has shown that clients are better able to achieve their reproductive intentions when family planning (FP) services meet their needs and they have satisfying client provider interactions. There are several areas of quality provider-client communication, including providers taking a complete reproductive history of their clients to best gauge their needs, communication around alternative FP methods and side effects captured in the method information index, and communication around sexually transmitted infections and HIV risk as it relates to FP choices. This study examines data from a clinic-based intervention in Togo that focuses on strengthening health provider counseling related to FP, including improving in these three areas of provider-client communication. A clustered sampling approach was used to select 650 FP clients from 23 intervention facilities and 235 clients from 17 control facilities in the Lomé and Kara districts of Togo. The FP clients' interactions with providers were observed and clients exit interviews were conducted in December 2021. For each communication area measured through client interviews and observations, principal components analysis and Cronbach's alpha scores were used to ensure that the individual components could be indexed. Outcomes variables based on an index of sub-questions were then created for those who had fulfilled each of the components within an index. Multivariate multilevel mixed-effects logit models accounted for clients nested within facilities and included independent variables capturing client demographic and facility variables. Multivariate results show that all three outcome variables representing the three provider-client communication areas were statistically significantly better for FP clients in intervention clinics versus control clinics (p<0.05). The results speak to the emphasis that the Togo Ministry of Health has placed on building the provider capacity to provide quality counseling and administration of FP methods and working to assist in achieving health programming goals through well-designed interventions.

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.

The use of segmented regression for evaluation of an interrupted time series study involving complex intervention: the CaPSAI project experience.

An interrupted time series with a parallel control group (ITS-CG) design is a powerful quasi-experimental design commonly used to evaluate the effectiveness of an intervention, on accelerating uptake of useful public health products, and can be used in the presence of regularly collected data. This paper illustrates how a segmented Poisson model that utilizes general estimating equations (GEE) can be used for the ITS-CG study design to evaluate the effectiveness of a complex social accountability intervention on the level and rate of uptake of modern contraception. The intervention was gradually rolled-out over time to targeted intervention communities in Ghana and Tanzania, with control communities receiving standard of care, as per national guidelines. Two ITS GEE segmented regression models are proposed for evaluating of the uptake. The first, a two-segmented model, fits the data collected during pre-intervention and post-intervention excluding that collected during intervention roll-out. The second, a three-segmented model, fits all data including that collected during the roll-out. A much simpler difference-in-difference (DID) GEE Poisson regression model is also illustrated. Mathematical formulation of both ITS-segmented Poisson models and that of the DID Poisson model, interpretation and significance of resulting regression parameters, and accounting for different sources of variation and lags in intervention effect are respectively discussed. Strengths and limitations of these models are highlighted. Segmented ITS modelling remains valuable for studying the effect of intervention interruptions whether gradual changes, over time, in the level or trend in uptake of public health practices are attributed by the introduced intervention. Trial Registration: The Australian New Zealand Clinical Trials registry. Trial registration number: ACTRN12619000378123. Trial Registration date: 11-March-2019.

Rationale and design of a complex intervention measuring the impact and processes of social accountability applied to contraceptive programming: CaPSAI Project.

Background: There are numerous barriers leading to a high unmet need for family planning and contraceptives (FP/C).  These include limited knowledge and information, poor access to quality services, structural inefficiencies in service provision and inadequately trained and supervised health professionals. Recently, social accountability programs have shown promising results in addressing barriers to accessing sexual and reproductive health services. As a highly complex participatory process with multiple and interrelated components, steps and actors, studying social accountability poses methodological challenges. The Community and Provider driven Social Accountability Intervention (CaPSAI) Project study protocol was developed to measure the impact of a social accountability intervention on contraceptive uptake and use and to understand the mechanisms and contextual factors that influence and generate these effects (with emphasis on health services actors and community members). Methods: CaPSAI Project is implementing a social accountability intervention where service users and providers assess the quality of local FP/C services and jointly identify ways to improve the delivery and quality of such services. In the project, a quasi-experimental study utilizing an interrupted time series design with a control group is conducted in eight intervention and eight control facilities in each study country, which are Ghana and Tanzania. A cross-sectional survey of service users and health care providers is used to measure social accountability outcomes, and a cohort of women who are new users of FP/C is followed up after the completion of the intervention to measure contraceptive use and continuation. The process evaluation utilizes a range of methods and data sources to enable a fuller description of how the findings were produced. Conclusion: This complex study design could provide researchers and implementers with the means to better measure and understand the mechanisms and contextual factors that influence social accountability processes in reproductive health, adding important findings to the evidence base.