Progress toward the UNAIDS 90-90-90 targets among female sex workers and sexually exploited female adolescents in Juba and Nimule, South Sudan.

BACKGROUND: Little is known about HIV in South Sudan and even less about HIV among female sex workers (FSW). We characterized progress towards UNAIDS 90-90-90 targets among female sex workers (FSW) and sexually exploited female adolescents in Juba and Nimule, South Sudan. METHODS: We conducted a biobehavioral survey of FSW and sexually exploited female adolescents using respondent-driven sampling (RDS) in Juba (November 2015-March 2016) and in Nimule (January-March 2017) to estimate achievements toward the UNAIDS 90-90-90 targets (90% of HIV-positive individuals know their status; of these, 90% are receiving antiretroviral therapy [ART]; and of these, 90% are virally suppressed). Eligibility criteria were girls and women who were aged ≥15 years; spoke English, Juba Arabic, or Kiswahili; received money, goods, or services in exchange for sex in the past 6 months; and resided, worked, or socialized in the survey city for ≥1 month. Data were weighted for RDS methods. RESULTS: We sampled 838 FSW and sexually exploited female adolescents in Juba (HIV-positive, 333) and 409 in Nimule (HIV-positive, 108). Among HIV-positive FSW and sexually exploited female adolescents living in Juba, 74.8% self-reported being aware of their HIV status; of these, 73.3% self-reported being on ART; and of these, 62.2% were virally suppressed. In Nimule, 79.5% of FSW and sexually exploited female adolescents living with HIV self-reported being aware of their HIV status; of these, 62.9% self-reported being on ART; and of these, 75.7% were virally suppressed. CONCLUSIONS: Although awareness of HIV status is the lowest of the 90-90-90 indicators in many countries, treatment uptake and viral suppression were lowest among FSW and sexually exploited female adolescents in South Sudan. Differentiated service delivery facilitate linkage to and retention on treatment in support of attainment of viral suppression.

Behavioral barriers to the use of modern methods of contraception among unmarried youth and adolescents in eastern Senegal: a qualitative study.

BACKGROUND: Many unmarried young people in low- and middle-income countries (LMIC) want to avoid pregnancy but do not use modern methods of contraception-as a result, half of teen births in these countries are unintended. Researchers have identified numerous barriers that prevent youth from using contraception. However, much of the research in West Africa is narrowly focused on married women, and relatively little research has been done to understand the needs, preferences, barriers, and solution set for sexually active unmarried young people who would like to avoid pregnancy. The purpose of this study was to gain insight into the behavioral barriers that prevent unmarried young people in eastern Senegal from using modern methods of contraception. METHODS: This qualitative study conducted in 2017 in the Tambacounda and Kedougou regions in Senegal explores attitudes and beliefs relating to sex and contraception among unmarried young women and men through 48 in-depth individual interviews with young people aged 15-24 and parents of youth and 5 sex-segregated focus groups with 6-9 young people per group. The research team conducted a thematic content analysis and synthesized the findings by major theme following the behavioral diagnosis methodology. RESULTS: Drawing insights from behavioral science, the analysis yields five key findings: (1) unmarried young people avoid making a decision about contraception because thinking about contraceptive use provokes uncomfortable associations with a negative identity (i.e., being sexually active before marriage); (2) unmarried young people see modern methods as inappropriate for people like them; (3) unmarried young people are overconfident in their ability to prevent pregnancy through traditional and folk methods; (4) unmarried young people overestimate the social and health risks of modern contraceptive methods; and (5) unmarried young people fail to plan ahead and are not prepared to use modern contraceptive methods before every sexual encounter. CONCLUSIONS: Interventions aimed at increasing uptake of contraceptives among unmarried young people in eastern Senegal must address several significant behavioral barriers in addition to structural, informational, and socio-cultural barriers in order to be successful.

Provider and client perspectives on maternity care in Namibia: results from two cross-sectional studies.

BACKGROUND: Disrespectful and abusive maternity care is a complex phenomenon. In Namibia, HIV and high maternal mortality ratios make it vital to understand factors affecting maternity care quality. We report on two studies commissioned by Namibia's Ministry of Health and Social Services. A health worker study examined cultural and structural factors that influence maternity care workers' attitudes and practices, and a maternal and neonatal mortality study explored community perceptions about maternity care. METHODS: The health worker study involved medical officers, matrons, and registered or enrolled nurses working in Namibia's 35 district and referral hospitals. The study included a survey (N = 281) and 19 focus group discussions. The community study conducted 12 focus groups in five southern regions with recently delivered mothers and relatives. RESULTS: Most participants in the health worker study were experienced maternity care nurses. One-third (31%) of survey respondents reported witnessing or knowing of client mistreatment at their hospital, about half (49%) agreed that "sometimes you have to yell at a woman in labor," and a third (30%) agreed that pinching or slapping a laboring woman can make her push harder. Nurses were much more likely to agree with these statements than medical officers. Health workers' commitment to babies' welfare and stressful workloads were the two primary reasons cited to justify "harsh" behaviors. Respondents who were dissatisfied with their workload were twice as likely to approve of pinching or slapping. Half of the nurses surveyed (versus 14% of medical officers) reported providing care above or beneath their scope of work. The community focus group study identified 14 negative practices affecting clients' maternity care experiences, including both systemic and health-worker-related practices. CONCLUSIONS: Namibia's public sector hospital maternity units confront health workers and clients with structural and cultural impediments to quality care. Negative interactions between health workers and laboring women were reported as common, despite high health worker commitment to babies' welfare. Key recommendations include multicomponent interventions that address heavy workloads and other structural factors, educate communities and the media about maternity care and health workers' roles, incorporate client-centered care into preservice education, and ensure ongoing health worker mentoring and supervision.

Understanding and addressing contraceptive stockouts to increase family planning access and uptake in Senegal.

BACKGROUND: Senegal's government has pledged to reduce contraceptive stockouts, which have been frequent in public sector health facilities. An innovative distribution system called the Informed Push Model (IPM) addresses supply chain obstacles through direct regional-to-facility delivery of contraceptives and use of private sector logistics operators. Following promising pilot results, Senegal's Ministry of Health and Social Action committed to a three-year (2013-2016) expansion of IPM to all public health facilities nationwide. METHODS: From August 2014-July 2016, IPM's six logisticians made 29,319 visits to restock public sector health facilities. During these regular facility visits, the logisticians conducted a physical inventory to flag contraceptive stockouts (no usable stock of any single method available) and asked facility staff to identify the primary reason for documented stockouts. Our descriptive study examines stockout trends over the course of IPM scale-up. We also describe trends in contraceptive consumption over the three-year period using facility-level data collected by the logisticians. RESULTS: Contraceptive consumption rose by 91% over 35 months in the first three IPM regions, and by 118% in the next five regions (over 26 months). After scale-up to 1,394 health facilities, nationwide consumption rose by 48% over one year. On average, logisticians documented stockouts at fewer than 2% of facility visits. In comparison, two pre-IPM studies in 2011 identified stockouts of selected modern contraceptives at 60-70% of facilities visited, with 84% of clients reporting stockouts in the past year. Six factors (including consumption spikes, IPM-preventable causes, and community outreach) explained most remaining stockouts. CONCLUSIONS: IPM has been highly successful in ensuring full availability of contraceptives across regions and health facilities. The model also has facilitated the flow of essential data on consumption and stockouts from facilities up to district, regional, and central-level managers. These achievements highlight the relevance of professionalizing supply chain management while continuing to mitigate stockouts through enhanced stakeholder communication and improved training, coaching, and supervision of third-party logistics operators. Supply reliability is critical in shaping demand for and regular use of contraception. The government is transitioning the IPM to full management by the National Supply Pharmacy.

Balancing workload, motivation and job satisfaction in Rwanda: assessing the effect of adding family planning service provision to community health worker duties.

BACKGROUND: Task shifting from higher cadre providers to CHWs has been widely adopted to address healthcare provider shortages, but the addition of any service can potentially add to an already considerable workload for CHWs. Objective measures of workload alone, such as work-related time and travel may not reflect howCHWs actually perceive and react to their circumstances. This study combined perception and objectivemeasures of workload to examine their effect on quality of services, worker performance, and job and clientsatisfaction. METHODS: Three hundred eighty-three CHWs from control and intervention districts, where the intervention group was trained to provide contraceptive resupply, completed diaries of work-related activities for one month. Interviews were also conducted with a subset of CHWs and their clients. RESULTS: CHW diaries did not reveal significant differences between intervention and control groups in time spent on service provision or travel. Over 90% of CHWs reported workload manageability, job satisfaction, and motivation to perform their jobs. Clients were highly satisfied with CHW services and most stated preference for future services from CHWs. CONCLUSION: The study demonstrated that adding resupply of hormonal contraceptives to CHWs' tasks would not place undue burden on them. Accordingly, the initiative was scaled up in all 30 districts in the country.

Volunteer Community Health and Agriculture Workers Help Reduce Childhood Malnutrition in Tajikistan.

Childhood malnutrition is a nationally-recognized problem in Tajikistan. In 2017, 6% of children under 5 years were wasted and 18% were stunted. Through the Tajikistan Health and Nutrition Activity (THNA), funded by the U.S. Agency for International Development's Feed the Future, IntraHealth International trained 1,370 volunteer community health workers (CHWs) and 500 community agricultural workers (CAWs) in 500 rural communities to improve nutrition among children and pregnant and breastfeeding women. CHWs and CAWs mutually encourage health behavior change, reinforce better agricultural practices, and promote maternal and child health and nutritious diets through household visits, community events, and peer support groups. CHWs refer children with malnutrition and diarrhea and pregnant women who are not registered for antenatal care to health facilities. THNA supported CHWs/CAWs through peer learning, refresher trainings, supportive supervision, and quarterly material incentives. We observed gains in knowledge, attitudes, and practices across health; nutrition; water, sanitation, and hygiene (WASH); and agriculture in target communities. From 2016 to 2019, we observed statistically significant (P<.05) improvements in children receiving a minimum acceptable diet; children with diarrhea receiving more liquids; women making 4 or more antenatal care visits; women reporting improved WASH; and farmers demonstrating improved agricultural practices. A February 2020 screening of 94.6% of children under 5 years in target communities found the prevalence of children with signs of wasting at 2.2%. Partnerships between CHWs, CAWs, and rural health workers facilitated these results. Paired agricultural and health interventions proved successful in improving nutrition of children and may be applicable in other contexts. Although effective in delivering interventions, CHWs/CAWs experience attrition, need motivation, and require intensive support. Assuming responsibility for this community-based volunteer workforce presents a major challenge for Tajikistan's national and local governments.

Measuring the usefulness of family planning job aids following distribution at training workshops.

A job aid is a tool, such as a flowchart or checklist, that makes it easier for staff to carry out tasks by providing quick access to needed information. Many public health organizations are engaged in the production of job aids intended to improve adherence to important medical guidelines and protocols, particularly in resource-constrained countries. However, some evidence suggests that actual use of job aids remains low. One strategy for improving utilization is the introduction of job aids in training workshops. This paper summarizes the results of two separate evaluations conducted in Uganda and the Dominican Republic (DR) which measured the usefulness of a series of four family planning checklists 7-24 months after distribution in training workshops. While more than half of the health care providers used the checklists at least once, utilization rates were sub-optimal. However, the vast majority of those providers who utilized the checklists found them to be very useful in their work.

Integrated mental health screening for obstetric fistula patients in Mali: From evidence to policy.

BACKGROUND: Obstetric fistula significantly impacts women's mental health and well-being. Routine screening for mental health in fistula repair programs can be a gateway to link patients to services, and can produce routine data to inform programmatic investments. This study observed the integration of a mental health screening program into an obstetric fistula repair program in Mali, with two specific objectives: 1) to describe the social and mental health well-being of women presenting with obstetric fistulas in Mali, and 2) to document the impact of the mental health screening pilot on policy change in Mali. METHODS: Seven fistula repair campaigns were conducted between June 2016 and May 2017. All individuals presenting for fistula repair completed a mental health assessment at intake, including a depression screener (PHQ-9) and an assessment of psycho-social impacts of fistula. The depression screener was repeated three months following inpatient discharge. Findings were shared with stakeholders in Mali and impacts on policy were documented. RESULTS: Of 207 women who presented for fistula repair, 167 patients completed the mental health assessment at surgical intake, and 130 patients repeated the screener at 3-month follow-up. At intake, 36.5% of women had moderate or severe depression, decreasing to 16.9% at follow-up. The mean depression score differed significantly by timepoint (9.14 vs. 6.72, p <0.001). Results were shared in a report with stakeholders, and consultations with the Mali Ministry of Health. As a result of advocacy, mental health was a key component of Mali's National Fistula Prevention and Treatment Strategy (2018-2022). CONCLUSION: The high prevalence of depression in Malian fistula patients underscores a need for more robust mental health support for patients after surgery. Data on mental health from routine screening informs community reintegration strategies for individual patients, elevates the overall quality of care of fistula repair programs by addressing patients' holistic health needs, and contributes to evidence-informed decision-making and data-driven policy change within the larger health system.

High HIV and syphilis prevalence among female sex workers in Juba, South Sudan.

HIV prevalence is estimated to be 2.7% in South Sudan; however, little is known about the young country's epidemic. We conducted a respondent-driven sampling biobehavioral survey in Juba of female sex workers (FSW) aged ≥15 years who sold or exchanged sex in the last 6 months to learn more about this population. We enrolled 838 FSW from November 2015 to March 2016 and estimated HIV prevalence to be 37.8%. Prevalence of active syphilis was 7.3%. FSW were from South Sudan and most neighboring countries. Comprehensive knowledge of HIV was 11.1% and 64.2% of FSW had never spoken with an outreach worker. In multivariable analysis, HIV was associated with being from Uganda (aOR: 3.3, 95% CI: 1.7-6.1) or Kenya (aOR: 4.3, 95% CI: 1.5-13.0) versus from South Sudan. Our survey suggests that FSW may play a critical role in South Sudan's HIV epidemic and highlights the importance of tailoring services to the unique needs of FSW of all nationalities in Juba.

Novel Approaches for Estimating Female Sex Worker Population Size in Conflict-Affected South Sudan.

BACKGROUND: Limited data exist describing the population size of female sex workers (FSW) in South Sudan. A population size estimation exercise among FSW was undertaken in Juba and Nimule during the Eagle Survey. OBJECTIVE: The study aimed to estimate the number of FSW in Juba and Nimule to inform resource allocation and service provision for FSW. METHODS: We utilized service and unique object multipliers, and 3-source capture-recapture methods in conjunction with a respondent-driven sampling (RDS) survey to estimate the number of FSW in Juba and Nimule. For service multiplier, the number of FSW testing for HIV in 2015 (Juba) and 2016 (Nimule) was obtained from the LINKAGES program targeting FSW. Survey participants were asked whether they had been tested for HIV by LINKAGES during the relevant period. A total of 2 separate unique object distributions were conducted in Juba and Nimule. In Nimule, these were combined to produce a 3-source capture-recapture estimate. The exercise involved distribution of key chains and bangles to FSW, documentation of the number of those who received unique objects, and questions during RDS survey to assess whether participants received unique objects. RESULTS: In Juba, the service multiplier method yielded an estimate of 5800 (95% CI 4927-6673) FSW. The unique object estimate (key chain and RDS participation) yielded 5306 (95% CI 4673-5939). Another estimate using RDS participation and receipt of a bangle yielded a much lower estimate of 1863 (95% CI 1776-1951), as did a 2-source estimate of key chain and bangle (2120, 95% CI 2028-2211). A 3-source capture-recapture estimate could not be produced because aggregate rather than individual level data were collected during the third capture. The multiplier estimate using key chain and RDS participation was taken as the final population estimate for FSW in Juba, which constitutes more than 6% of the female population aged 15 to 64 years. In Nimule, the service multiplier method yielded an estimate of 9384 (95% CI 8511-10,257). The 2-source estimates for key chain and RDS yielded 6973 (95% CI 4759-9186); bangles and RDS yielded a higher estimate of 13,104 (95% CI 7101-19,106); key chains and bangles yielded a lower estimate of 1322 (95% CI 1223-1420). The 3-source capture-recapture method using Bayesian nonparametric latent-class model-based estimate yielded a population of 2694 (95% CI 1689-6945), and this was selected as the final estimate for Nimule, which constitutes nearly 40% of female population aged 15 to 64 years. CONCLUSIONS: The service and unique object multiplier, and 3-source capture-recapture methods were successfully used to estimate the number of FSW in Nimule, whereas service and unique object multiplier methods were successfully used in Juba. These methods yielded higher than previously estimated FSW population sizes. These estimates will inform resource allocation and advocacy efforts to support services for FSW.

How the introduction of a human resources information system helped the Democratic Republic of Congo to mobilise domestic resources for an improved health workforce.

The Democratic Republic of Congo has flagged health workforce management and compensation as issues requiring attention, including the problem of ghost workers (individuals on payroll who do not exist and/or show up at work). Recognising the need for reliable health workforce information, the government has worked to implement iHRIS, an open source human resources information system that facilitates health workforce management. In Kasaï Central and Kasaï Provinces, health workers brought relevant documentation to data collection points, where trained teams interviewed them and entered contact information, identification, photo, current job, and employment and education history into iHRIS on laptops. After uploading the data, the Ministry of Public Health used the database of over 11 500 verified health worker records to analyse health worker characteristics, density, compensation, and payroll. Both provinces had less than one physician per 10 000 population and a higher urban versus rural health worker density. Most iHRIS-registered health workers (57% in Kasaï Central and 73% in Kasaï) reported receiving no regular government pay of any kind (salaries or risk allowances). Payroll analysis showed that 27% of the health workers listed as salary recipients in the electronic payroll system were ghost workers, as were 42% of risk allowance recipients. As a result, the Ministries of Public Health, Public Service, and Finance reallocated funds away from ghost workers to cover salaries (n = 781) and risk allowances (n = 2613) for thousands of health workers who were previously under- or uncompensated due to lack of funds. The reallocation prioritised previously under- or uncompensated mid-level health workers, with 49% of those receiving salaries and 68% of those receiving risk allowances representing cadres such as nurses, laboratory technicians, and midwifery cadres. Assembling accurate health worker records can help governments understand health workforce characteristics and use data to direct scarce domestic resources to where they are most needed.

Provider views on the acceptability of an IUD checklist screening tool.

INTRODUCTION: Family Health International developed a simple checklist to help family planning providers apply the new medical eligibility criteria (MEC) of the World Health Organization (WHO) for the use of the intrauterine device (IUD) contraceptive method. METHODS: One hundred thirty-five providers in four countries participated in focus groups to field test the checklist. Before participating in a discussion about the checklist, each provider was given a copy of the checklist, its instructions and hypothetical client scenarios. Providers used the checklist to answer questions about the client scenarios in order to determine if they understood the checklist and if they would correctly determine IUD eligibility for women in updated categories of eligibility on the basis of the checklist. RESULTS: Providers found the checklist easy to use and thought that it would enhance identification of eligible IUD users. Nevertheless, many providers relied on prior knowledge of IUD eligibility rather than the checklist recommendations. Providers only correctly determined eligibility for new categories of IUD use 69% of the time. CONCLUSIONS: The IUD checklist is a useful job tool for providers, but training and effective dissemination of the WHO MEC should precede its introduction to ensure that it is correctly used.

Association of sexual risk behaviour with previous HIV testing among voluntary HIV counselling and testing clients in Kigali, Rwanda.

With increased coverage of voluntary HIV counselling and testing (VCT) in Rwanda and a greater focus on repeat testing of key populations, it is important to understand whether the right clients are returning for repeat testing and if repeat testing is effective at reducing risk. We assessed the association between repeat testing and recent sexual risk behaviours among 1852 first time or repeat HIV testing clients in Kigali who had had sex, using data from a cross-sectional survey. Repeat testing was associated with being female, older and type of occupation. Multivariable analyses indicate that individuals who tested for HIV 1-2 times (aOR = 1.52, 95% CI: 1.08, 2.15) and 3+ times (aOR = 1.51, 95% CI: 1.06, 2.17) previously were more likely to report recent unprotected sex. Those with 3+ previous tests were more likely to have recently had multiple sexual partners (aOR = 2.19, 95% CI: 1.22, 3.92). However, a significant decrease in HIV prevalence is shown as individuals receive more HIV tests in their lifetime (p < 0.001). These findings show that individuals who report high-risk behaviours are returning for repeat tests. However, VCT may not be successful at addressing certain sexual risk behaviours. Therefore more intensive counselling or additional HIV prevention services may be needed.

Mentoring, Task Sharing, and Community Outreach Through the TutoratPlus Approach: Increasing Use of Long-Acting Reversible Contraceptives in Senegal.

BACKGROUND: To broaden access to family planning in rural areas and improve contraceptive prevalence, Senegal, in the context of wide method choice, is promoting implants and the intrauterine device, currently used throughout the country by only 5.6% of women of reproductive age who are in union, primarily urban women. METHODS: The TutoratPlus performance improvement approach strengthens family planning clinical skills, particularly for long-acting reversible contraceptives (LARCs), through mentoring, task sharing, and community outreach. Following a 2013 baseline situation analysis, 290 participating facilities in 12 of Senegal's 14 regions developed action plans to address gaps identified in 3 areas: provider performance, equipment, and infrastructure. Between 2013 and 2014, 85 trained mentors coached, demonstrated skills, and observed 857 providers, including nurses, nonclinical family planning counselors, and community health workers (CHWs), in LARC service provision through two 5-day visits per facility at 21-day intervals. We used routine service delivery data and TutoratPlus mentoring data to assess changes in contraceptive use, including LARCs, 6 months before and 6 months after the mentoring intervention among 100 of the facilities with complete data. RESULTS: The baseline assessment of 290 facilities found that fewer than half (47%) had a provider who could offer at least 1 LARC method, and 64% to 69% lacked kits. Post-intervention, all 290 facilities were adequately equipped and clinically able to offer LARCs. Among the 552 clinical providers, the percentage with acceptable LARC performance (at least 80% of observation checklist items correct) doubled from 32% to 67% over the 2 mentoring visits. In the 100 facilities with available comparison data, the number of new LARC users rose from 1,552 to 2,879 in the 6 months pre- and post-intervention-an 86% increase. CONCLUSION: Success of the TutoratPlus approach in Senegal is likely in part attributable to addressing facility-specific needs, using on-site mentoring to assess provider capacity, and achieving workplace enhancements through community engagement. Without CHW-initiated community outreach, LARC uptake might have been lower. Although task sharing requires institutionalization within national health systems, TutoratPlus demonstrates that provider skills can be improved, facilities can be better equipped, and demand can be promoted using existing government and community resources.

Who chooses vasectomy in Rwanda? Survey data from couples who chose vasectomy, 2010-2012.

BACKGROUND: Vasectomy is safe and highly effective; however, it remains an underused method of family planning (FP) in Africa. In view of this, three Rwandan physicians were trained in no-scalpel vasectomy with thermal cautery and fascial interposition on the prostatic end as vasectomy trainers in 2010, and this initiative has resulted in over 2900 vasectomy clients from February 2010 to December 2012. STUDY DESIGN: This cross-sectional descriptive study describes vasectomy clients (n=316) and their wives (n=300) from 15 randomly selected hospitals in Rwanda. RESULTS: The vasectomy clients were mainly over age 40, had young children (age <3) and were married and cohabiting. Limited financial resources, satisfaction with existing family size and avoiding side effects from hormonal methods (wives') were key motivators for vasectomy uptake. High rates of previous FP use and high degree of interspousal communication are known correlates of higher FP use. CONCLUSIONS: Future and current Rwandan FP programs and other interested parties will benefit from understanding which couples elect vasectomy, their motivations for doing so and their service utilization experiences. Better integration of vasectomy counseling and postvasectomy procedures will benefit the program. IMPLICATIONS: Until this project, vasectomy projects in sub-Saharan Africa were viewed as unrealistic. This study confirms factors influencing vasectomy uptake identified in earlier research, but does so within a robust sample of vasectomy users and their wives and provides a strong understanding of who likely vasectomy users are in this context. Promotion of vasectomy services should be considered as an essential element of a healthy contraceptive method mix.

Policy and programmatic considerations for introducing a longer-acting injectable contraceptive: perspectives of stakeholders from Kenya and Rwanda.

BACKGROUND: More than 40 million women use injectable contraceptives to prevent pregnancy, and most current or previous injectable users report being satisfied with the method. However, while women may find injectables acceptable, they may not always find them accessible due to stock-outs and difficulties with returning to the clinic for reinjections. FHI 360 is spearheading efforts to develop a longer-acting injectable (LAI) contraceptive that could provide at least 6 months of protection against pregnancy. This article addresses systems-level considerations for the introduction of a new LAI. METHODS: We conducted qualitative case studies in Kenya and Rwanda-two countries that have high levels of injectable use but with different service delivery contexts. Between June and September 2012, we conducted in-depth interviews with 27 service providers and 19 policy makers and program implementers focusing on 4 themes: systems-level barriers and facilitators to delivering LAI services; process for introducing an LAI; LAI distribution approaches; and potential LAI characteristics. We also obtained electronic feedback from 28 international family planning opinion leaders. RESULTS: Respondents indicated strong interest in an LAI and thought it would appeal to existing injectable users as well as new family planning clients, both for spacing and for limiting births. Providers appreciated the potential for a lighter workload due to fewer follow-up visits, but they were concerned that fewer visits would also decrease their ability to help women manage side effects. The providers also appreciated the 1-month grace period for follow-up LAI injections; some seemed unaware of the latest international guidance that had increased the grace period from 2 weeks to 4 weeks for the currently available 3-month injectable. The majority of policy makers and program implementers were supportive of letting community health workers provide the method, but many nurses and midwives in Kenya had reservations about the approach. At the policy level, respondents indicated that obtaining regulatory approvals before introducing the new method could be costly and time-consuming. Manufacturing and procurement decisions could also affect cost and availability. CONCLUSIONS: Successful introduction of a potential longer-acting injectable may be enhanced by considering broader systemic issues, including managing cost to the health system and users, expanding access through community-based distribution, and training providers on the latest service delivery guidelines.

Getting to 70%: barriers to modern contraceptive use for women in Rwanda.

OBJECTIVE: To identify reasons for non-use of modern family planning in Rwanda, to examine specific barriers to contraception, and to explore psychosocial factors influencing modern contraceptive use. METHODS: In total, 637 in-union, parous, and non-pregnant women aged 21-49 years participated in a cross-sectional community-based survey in 5 districts. In-depth interviews (IDIs) were conducted with 54 women and 27 male partners. Multivariate logistic regression examined correlates of current non-use. IDI transcripts were analyzed independently and compared thematically with survey findings. RESULTS: Overall, 50% of survey respondents were using a modern method. Fertility- and partner-related variables were key correlates of non-use. The most commonly reported reasons for non-use were related to perceived fecundity. Men were mostly supportive of contraceptive use and had an important role in a woman's decision to use contraception. Women's IDIs revealed misperceptions about fertility leading to gaps in contraceptive coverage, particularly postpartum. Those IDIs also highlighted how provider practices, including screening for pregnancy through direct observation of menses, may hamper contraceptive use. CONCLUSION: Programmatic recommendations include increasing information efforts aimed at men; developing effective messages about postpartum risk of pregnancy and training providers on postpartum contraceptive eligibility and needs; and reinforcing use of alternative pregnancy-screening methods.

Strengthening vasectomy services in Rwanda: introduction of thermal cautery with fascial interposition.

BACKGROUND: Recent developments in vasectomy research indicate that occluding the vas using cautery combined with fascial interposition (FI) significantly lowers failure rates and is an appropriate technology for low-resource settings. We report the introduction of this technique in Ministry of Health (MOH) vasectomy services in Rwanda. DESIGN: In February 2010, an international vasectomy expert trained three Rwandan physicians to become trainers in no-scalpel vasectomy (NSV) with thermal cautery and FI. The training took place over 5 days in five rural health centers. RESULTS: A total of 67 men received vasectomies (11-16 per day) and trainees successfully mastered the new occlusion technique. The MOH is now scaling up NSV with cautery and FI services nationwide. The initial cadre of trainers has subsequently trained 46 other physicians in this vasectomy technique across 27 districts of Rwanda. CONCLUSIONS: No-scalpel vasectomy with thermal cautery and FI was successfully introduced in vasectomy services in Rwanda, and a similar initiative should be evaluated in other national vasectomy services worldwide.

Reaching providers is not enough to increase IUD use: a factorial experiment of 'academic detailing' in Kenya.

Although the IUD is an extremely effective and low-cost contraceptive method, its use has declined sharply in Kenya in the past 20 years. A study tested the effectiveness of an outreach intervention to family planning providers and community-based distribution (CBD) agents in promoting use of the IUD in western Kenya. Forty-five public health clinics were randomized to receive the intervention for providers only, for CBD agents only, for both providers and CBD agents, or no detailing at all. The intervention is based on pharmaceutical companies' "detailing" models and included education/motivation visits to providers and CBD programmes, as well as provision of educational and promotional materials. District health supervisors were given updates on contraceptives, including the IUD, and were trained in communication and message development prior to making their detailing visits. Detailing only modestly increased the provision of IUDs, and only when both providers and CBD agents were targeted. The two detailing visits do not appear sufficient to sustain the effect of the intervention or to address poor provider attitudes and lack of technical skills. The cost per 3.5 years of pregnancy protection was US$49.57 for the detailing intervention including the cost of the IUD, compared with US$15.19 for the commodity costs of the current standard of care--provision of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA). The effectiveness of provider-based activities is amplified when concurrent demand creation activities are carried out. However, the cost of the detailing in comparison to the small number of IUDs inserted indicates that this intervention is not cost-effective.