Men's needs and women's fears: gender-related power dynamics in contraceptive use and coping with consequences in a rural setting in Kenya.

This paper examines gender-related power influences on contraceptive use and coping with consequences in a rural setting in Kenya. Data come from in-depth interviews conducted in 2018 with 42 women who participated in a longitudinal study implemented in Homa Bay County. Data were analysed using an exploratory inductive content analytic approach. The findings show that the key drivers of gender-related power influence on contraceptive use and coping with consequences included: 1) the extent to which the women managed to provide sex and sexual pleasure to their partners when they were using contraception; 2) men's readiness to provide permission and resources that women needed and the latter's ability to overcome challenges in obtaining the same from their partners; and 3) women's fears concerning infidelity and partner violence, which influenced the actions they took to reduce instances that could make their partners suspect them of engaging in extra-marital affairs, drive their partners into such affairs, or encourage their partners to direct emotional or physical violence on them. Findings suggest the need for gender-transformative actions combining empowerment programmes for women with information, education and communications activities targeting both men and women.

Factors influencing women's decisions regarding birth planning in a rural setting in Kenya and their implications for family planning programmes.

Evidence suggests that socio-cultural barriers that limit the ability of women in sub-Saharan Africa to make decisions regarding contraceptive use and childbearing contribute to the slow uptake of contraception in this region. This paper explores factors influencing women's decisions regarding contraceptive uptake, switching and discontinuation, and the implications of those decisions for family planning programmes. Data were from in-depth interviews that were conducted in 2018 with 42 women who participated in a longitudinal research project implemented in Homa Bay County of Kenya. Participants comprised women who were aged 15-39 years at the time of recruitment into the study and who discontinued using injectables or implants between the first and second rounds of data collection. Data were analysed using an exploratory inductive content analytic approach. The findings show that uptake of contraception was largely driven by concerns about the negative consequences of frequent childbirth on individual health and household socioeconomic well-being. Most women discontinued methods because of dissatisfaction but, instead of abandoning contraception altogether, switched to alternative methods, albeit sometimes less-effective ones. However, some women had difficulties in identifying an appropriate new method after experiencing side-effects, contraceptive failure or stock-out of their current method. Securing the cooperation of sexual partners was an additional problem especially for women whose partners did not support contraception. The findings suggest that concerns about the negative consequences of frequent childbirth outweigh challenges associated with contraceptive use. This presents an opportunity for family planning programmes to improve contraceptive uptake and continuation by addressing the health system challenges related to commodity stock-out and poor quality of care, as well as the concerns of men.

Exploring the Demand-Side Factors Associated with the Use of Implants in Kenya.

We explore the demand-side factors associated with the use of implants in Kenya given the notable rapid increase in uptake of the method in the country. Data are from a longitudinal study conducted among married or cohabiting women aged 15-39 years at the time of recruitment in one rural (2,424 women) and one urban (2,812 women) site. Analysis entails descriptive statistics and estimation of multivariate logistic regression models. The results show that the key demand-side factors associated with the use of implants were low discontinuation of the method compared with alternatives and strong motivation on the part of the women for long-term spacing of births. However, implants had no perceived advantages over the main alternative methods in terms of beliefs about possible damage to health or unpleasant side effects or in terms of satisfaction with use. The findings suggest that addressing concerns about safety for long-term use and for health may increase demand for implants in particular and long-acting reversible contraceptives in general in the study settings or in similar contexts, especially among women who desire long-term spacing of births.

Factors influencing satisfaction with oral contraceptive pills and injectables among past users in Kenya.

This study examines factors associated with satisfaction with oral pills and injectables among past users in Kenya based on a baseline survey for the 2-year prospective longitudinal study Improving Measurement of Unintended Pregnancy and Unmet Need for Family Planning conducted in 2016. Married women aged 15-39 years were interviewed using a structured questionnaire that captured information on reproduction, contraceptive knowledge and beliefs and attitudes towards contraception in general and towards specific methods. A multivariate logistic regression analysis was used to examine factors that influenced satisfaction with oral pills and injectables among past users in one urban site (Nairobi slums) and one predominantly rural site (Homa Bay in western Kenya). Results showed that dissatisfaction with pills and injectables is common among past users in both rural and urban Kenya (ranging from 39% to 56%). The distinctive contribution of the study lies in its ability to relate method-specific beliefs to overall satisfaction. Perception of effectiveness, ease of use and safety for long-term use had statistically significant influences on satisfaction with pills in both urban and rural sites while partner's approval was only important in Nairobi. For injectables, the perception of safety for long-term use was significant in the urban but not the rural site. Unlike pills, the belief that members of a woman's social network had used a method and found it satisfactory was a particularly powerful influence on satisfaction (AOR=2.8 in rural and 3.2 in urban). Perception of accessibility and fears about infertility were not found to be statistically associated with satisfaction for either pills or injectables. Surprisingly, the effects of all perceived contraceptive attributes were the same for major socio-demographic strata of the populations. The findings underscore the need for targeted counselling and community-based communication interventions to address negative and erroneous perceptions about family planning methods.

Assessing the community-level impact of a decade of user fee policy shifts on health facility deliveries in Kenya, 2003-2014.

BACKGROUND: The long-term impact of user fee removal policies on health service utilization in low- and middle-income countries may vary depending on the context in which they are implemented, including whether there are policy actions to support implementation. We examined the community-level impact of a decade of user fee policy shifts on health facility delivery among poorest and rural women and compared the changes with those among the richest and urban women in Kenya using data from three rounds of nationally representative surveys. METHODS: Data are from births occurring in the 5 years preceding the survey to women aged 15-49 years who were interviewed in the 2003, 2008-2009 and 2014 Kenya Demographic and Health Surveys. A total of 5949, 6079 and 20,964 births were reported in respective surveys. We conducted interrupted time series analysis predicting changes in quarterly proportions of births occurring in public and private health facilities as well as at home before and after the 2004, 2007 and 2013 user fee policy shifts in Kenya. RESULTS: There were no statistically significant immediate changes in the proportion of births occurring in public facilities following the 2004, 2007 and 2013 user fee policy shifts among poor or rural women. There was, however, a statistically significant increase in home deliveries among all women and among those from the poorest households immediately following the 2004 policy. There was also a statistically significant increase in public facility deliveries among women from the two top quintiles, which was accompanied by a statistically decline in home deliveries immediately after the 2007 policy shift. Differences in trends in public facility deliveries between pre- and post-policy periods were not statistically significant for all sub-groups of women, indicating that even among the sub-group that experienced significant immediate increase after the 2007 policy shift, this pattern was not sustained over time. CONCLUSION: The findings of this paper provide empirical evidence that poorly implemented user fee removal policies benefit more well-off than poor women and in cases where there are significant immediate effects on uptake of facility delivery, this trend is not sustained over time.

Do Women Find the Progesterone Vaginal Ring Acceptable? Findings from Kenya, Nigeria, and Senegal.

The progesterone vaginal ring (PVR) is a contraceptive designed for use by breastfeeding women in the first year postpartum. This Report presents results of an acceptability study of the PVR in Kenya, Nigeria, and Senegal. Women seeking postpartum family planning services were offered various contraceptive options including the PVR. Of the 174 participating women, 110 (63 percent) used one ring and 94 (54 percent) completed the study by using two rings over a six-month period. Women were interviewed up to three times: at the time they entered the study, at 3 months (the end of the first ring cycle), and at 6 months (the end of the second ring cycle or when they exited if they had discontinued earlier). Many participants found the ring to be acceptable, with over three-quarters reporting that it was easy to insert, remove, and reinsert. While a small proportion of women experienced ring expulsion, the majority did not. These findings suggest that even in countries with little or no use of vaginal health products, contraceptive vaginal rings offer women a new option that they are able and willing to use.

Attitudes towards help-seeking for sexual and gender-based violence in humanitarian settings: the case of Rwamwanja refugee settlement scheme in Uganda.

BACKGROUND: Sexual and gender-based violence (SGBV) remains a silent epidemic in many humanitarian settings with many survivors concealing their experiences. Attitudes towards help-seeking for SGBV is an important determinant of SGBV service use. This paper examined the association between attitudes towards seeking care and knowledge and perceptions about SGBV among men and women in a humanitarian setting in Uganda. METHODS: A cross-sectional survey was conducted from May to June 2015 among 601 heads of refugee households (261 females and 340 males) in Rwamwanja Refugees Settlement Scheme, South West Uganda. Analysis entails cross-tabulation with chi-square test and estimation of a multivariate logistic regression model. RESULTS: Results showed increased odds of having a favorable attitude toward seeking help for SGBV among women with progressive attitudes towards SGBV (OR = 2.78, 95% CI: 1.56-4.95); who felt that SBGV was not tolerated in the community (OR = 2.03, 95% CI: 1.03-4.00); those who had not experienced violence (OR = 2.08, 95% CI: 1.06-4.07); and those who were aware of the timing for post-exposure prophylaxis (OR = 3.08, 95% CI: 1.57-6.04). In contrast, results for men sample showed lack of variations in attitude toward seeking help for SGBV for all independent variables except timing for PEP (OR = 2.57, 95% CI: 1.30-5.10). Among individuals who had experienced SGBV, the odds of seeking help was more likely among those with favorable attitude towards seeking help (OR = 4.22, 95% CI: 1.47-12.06) than among those with unfavorable help-seeking attitudes. CONCLUSION: The findings of the paper suggest that targeted interventions aimed at promoting awareness and progressive attitudes towards SGBV are likely to encourage positive help-seeking attitudes and behaviors in humanitarian contexts.

Women's attitudes and beliefs towards specific contraceptive methods in Bangladesh and Kenya.

BACKGROUND: Missing from the huge literature on women's attitudes and beliefs concerning specific contraceptive methods is any detailed quantitative documentation for all major methods in low- and middle-income countries. The objectives are to provide such a documentation for women living in Matlab (rural Bangladesh), Nairobi slums and Homa Bay (rural Kenya) and to compare the opinions and beliefs of current, past and never users towards the three most commonly used methods (oral contraceptives, injectables and implants). METHODS: In each site, 2424 to 2812 married women aged 15-39 years were interviewed on reproduction, fertility preferences, contraceptive knowledge and use, attitudes and beliefs towards family planning in general and specific methods. We analysed the data from round one of the prospective cohort study. RESULTS: While current users typically expressed satisfaction and held more positive beliefs about their method than past or never users, nevertheless appreciable minorities of current users thought the method might pose serious damage to health, might impair fertility and was unsafe for prolonged use without taking a break. Larger proportions, typically between 25% and 50%, associated their method with unpleasant side effects. Past users of pills and injectables outnumbered current users and their beliefs were similar to those of never users. In all three sites, about half of past injectable users reported satisfaction with the method and the satisfaction of past implant users was lower. CONCLUSIONS: High levels of contraceptive use can clearly co-exist with widespread misgivings about methods, even those that are widely used. Serious concerns about damage to health, long term fertility impairment, and dangers of prolonged use without taking a break were particularly common in the Kenyan sites and these beliefs may explain the high levels of discontinuation observed in Kenya and elsewhere in Africa. This documentation of beliefs provides useful guidance for counselling and informational campaigns. The generally negative views of past users imply that programmes may need not only to improve individual counselling but also strengthen community information campaign to change the overall climate of opinion which may have been influenced by dissatisfaction among past users.

Stakeholder perspectives regarding transfer of free maternity services to National Health Insurance Fund in Kenya: Implications for universal health coverage.

BACKGROUND: Kenya is developing strategies to finance health care through prepayment to achieve universal health coverage (UHC). Plans to transfer free maternity services (FMS) from the Ministry of Health to the National Health Insurance Fund (NHIF) are a step towards UHC. We examined views of health workers and women regarding the transition of FMS to NHIF to inform the process. METHODS: In-depth interviews among 14 facility-level managers and providers, 11 county-level managers, and 21 focus group discussions with women who gave birth before and after the introduction of FMS. Data were analyzed thematically. RESULTS: The transfer is a mechanism of achieving UHC, eliminating dependency on free services, and encouraging people to take responsibility of their health. However, skepticism regarding the efficiency of NHIF may limit support. Diverse and robust systems were recommended for enrollment of clients while standardization of services through accreditation and quality assurance linked to performance-based reimbursement would improve greater predictability in the payment schedule and better coverage of referrals and complications. CONCLUSION: Transitioning FMS to NHIF provides an opportunity for the Ministry of Health to sharpen its role as policymaker and develop a comprehensive health care financing strategy for the country towards achieving UHC.

Introducing the Progesterone Vaginal Ring (PVR) as a New Option for Postpartum Family Planning in Sub-Saharan Africa: Insights from Engagements with Stakeholders.

The progesterone vaginal ring (PVR) is a ring-shaped device designed for use by women in the postpartum period to regulate fertility by complementing and extending the contraceptive effectiveness of lactational amenorrhea to suppress ovulation.1 It is available in eight Latin American countries for use by breastfeeding women who want more effective modern contraceptives in addition to contraceptive benefits provided by lactational amenorrhea alone.1 The PVR is a method that can be suitable to women in sub-Saharan Africa, given the near-universal practice of breastfeeding and the current level of unmet need for contraception in the postpartum period. Efforts are currently underway to introduce the PVR in Africa and south Asia. To ensure a seamless introduction, scale up and sustainability of the PVR in the region, the Population Council conducted pre-introductory activities with stakeholders in Kenya, Nigeria and Senegal to determine the level of interest in the ring, potential facilitating and mitigating factors and identify solutions to address challenges. The research team combined three approaches: in-depth interviews with family planning stakeholders; desk review of reports and policy guidelines; and in-group meetings. The stakeholders reached included public sector officials including policy makers and program managers, implementing partners, regulators, women and religious networks. All three countries had a promising policy and programmatic context that was supportive to PVR introduction. The exercise provided insights on socio-cultural and religious factors that could potentially impact how the PVR is perceived within communities and identified possible remedies to address misperceptions. It also paved the way for the conduct of an acceptability study of the PVR among breastfeeding women in these countries. The high acceptability rate in each country and the support expressed by government and other stakeholders have provided impetus for registration of the product in each country. Learning from this process could also direct how other family planning and reproductive health commodities would be introduced in the future.

Health care providers' perspectives regarding the use of chlorhexidine gel for cord care in neonates in rural Kenya: implications for scale-up.

BACKGROUND: This paper explores the perspectives of health care providers regarding the use of 7.1% Chlorhexidine Digluconate (CHX) gel that releases 4% chlorhexidine for newborn umbilical cord care under a managed access program (MAP) implemented in Bungoma County of Kenya. Understanding the perspectives of providers regarding CHX is important since they play a key role in the health system and the fact that their views could be influenced by prior beliefs and inconsistent practices regarding umbilical cord care. METHODS: Data are from in-depth interviews conducted between April and June 2016 with 39 service providers from 21 facilities that participated in the program. The data were transcribed, typed in Word and analyzed for content. Analysis entailed identifying recurring themes based on the interview guides. RESULTS: Use of CHX gel for cord care in neonates was acceptable to the health care providers, with all of them supporting scaling up its use throughout the country. Their views were largely influenced by positive outcomes of the medication including fast healing of the cord as reported by mothers, minimal side effects, reduced newborn infections based on what their records showed and mothers' reports, ease of use that made it simple for them to counsel mothers on how to apply it, positive feedback from mothers which demonstrated satisfaction with the medication, and general acceptance of the medication by the community. They further noted that successful scale-up of the medication required community sensitization, adequate follow-up mechanisms to ensure mothers use the medication correctly, addressing issues of staffing levels and staff training, developing guidelines and protocols for provision of the medication, adopting appropriate service delivery approaches to ensure all groups of mothers are reached, and ensuring constant supply of the medication. CONCLUSION: Use of CHX gel for cord care in neonates is likely to be acceptable to health care workers in settings with high prevalence of neonatal morbidity and mortality arising from cord infections. In scaling up the use of the medication in such settings, some of the health systems requirements for successful roll-out can be addressed by programs while others are likely to be a persistent challenge.

Reasons for unmet need for family planning, with attention to the measurement of fertility preferences: protocol for a multi-site cohort study.

BACKGROUND: Unmet need for family planning points to the gap between women's reproductive desire to avoid pregnancy and contraceptive behaviour. An estimated 222 million women in low- and middle-income countries have unmet need for modern contraception. Despite its prevalence, there has been little rigorous research during the past fifteen years on reasons for this widespread failure to implement childbearing desires in contraceptive practice. There is demographic survey data on women's self-reported reasons for non-use, but these data provide limited insight on the full set of possible obstacles to use, and one may doubt the meaningfulness of explanations provided by non-users alone. To rectify this evidence gap, this study will gather extensive information on women's perceptions of contraception (generic and method-specific) and their past contraceptive experience, and it will allow for more complexity in fertility preferences than is standard in demographic surveys. METHODS: A multi-site cohort study will be conducted in urban Kenya, rural Kenya, and rural Bangladesh. In each setting trained fieldworkers will recruit and interview 2600 women, with participants re-interviewed at 12 and 18 months. Data will be collected using a questionnaire whose development was informed by a review of existing literature and instruments from past studies in both developed and developing countries. Dozens of experts in the field were consulted as the instrument was developed. The questionnaire has three main components: a sub-set of Demographic and Health Survey items measuring socio-demographic characteristics, reproductive history, and sexual activity; additional questions on prospective and retrospective fertility preferences designed to capture ambivalence and uncertainty; and two large blocks of items on (i) generic concerns about contraception and (ii) method-specific attributes. The method-specific items encompass eight modern and traditional methods. DISCUSSION: Policy and programmes intended to reduce unmet need for contraception in developing countries should be informed by clear understanding of the causes of this phenomenon to better reflect the population needs and to more effectively target planning and investments. To this end, this study will field an innovative instrument in Kenya and Bangladesh. The information to be collected will support a rigorous assessment of reasons for unmet need for family planning.

A cross sectional comparison of postnatal care quality in facilities participating in a maternal health voucher program versus non-voucher facilities in Kenya.

BACKGROUND: Health service fees constitute substantial barriers for women seeking childbirth and postnatal care. In an effort to reduce health inequities, the government of Kenya in 2006 introduced the output-based approach (OBA), or voucher programme, to increase poor women's access to quality Safe Motherhood services including postnatal care. To help improve service quality, OBA programmes purchase services on behalf of the poor and marginalised, with provider reimbursements for verified services. Kenya's programme accredited health facilities in three districts as well as in two informal Nairobi settlements. METHODS: Postnatal care quality in voucher health facilities (n = 21) accredited in 2006 and in similar non-voucher health facilities (n = 20) are compared with cross sectional data collected in 2010. Summary scores for quality were calculated as additive sums of specific aspects of each attribute (structure, process, outcome). Measures of effect were assessed in a linear regression model accounting for clustering at facility level. Data were analysed using Stata 11.0. RESULTS: The overall quality of postnatal care is poor in voucher and non-voucher facilities, but many facilities demonstrated 'readiness' for postnatal care (structural attributes: infrastructure, equipment, supplies, staffing, training) indicated by high scores (83/111), with public voucher facilities scoring higher than public non-voucher facilities. The two groups of facilities evinced no significant differences in postnatal care mean process scores: 14.2/55 in voucher facilities versus 16.4/55 in non-voucher facilities; coefficient: -1.70 (-4.9, 1.5), p = 0.294. Significantly more newborns were seen within 48 hours (83.5% versus 72.1%: p = 0.001) and received Bacillus Calmette-Guerin (BCG) (82.5% versus 76.5%: p < 0.001) at voucher facilities than at non-voucher facilities. CONCLUSIONS: Four years after facility accreditation in Kenya, scores for postnatal care quality are low in all facilities, even those with Safe Motherhood vouchers. We recommend the Kenya OBA programme review its Safe Motherhood reimbursement package and draw lessons from supply side results-based financing initiatives, to improve postnatal care quality.

Community-level effect of the reproductive health vouchers program on out-of-pocket spending on family planning and safe motherhood services in Kenya.

BACKGROUND: Although vouchers can protect individuals in low-income countries from financial catastrophe and impoverishment arising from out-of-pocket expenditures on healthcare, their effectiveness in achieving this goal depends on whether both service and transport costs are subsidized as well as other factors such as service availability in a given locality and community perceptions about the quality of care. This paper examines the community-level effect of the reproductive health vouchers program on out-of-pocket expenditure on family planning, antenatal, delivery and postnatal care services in Kenya. METHODS: Data are from two rounds of cross-sectional household surveys in voucher and non-voucher sites. The first survey was conducted between May 2010 and July 2011 among 2,933 women aged 15-49 years while the second survey took place between July and October 2012 among 3,094 women of similar age groups. The effect of the program on out-of-pocket expenditure is determined by difference-in-differences estimation. Analysis entails comparison of changes in proportions, means and medians as well as estimation of multivariate linear regression models with interaction terms between indicators for study site (voucher or non-voucher) and period of study (2010-2011 or 2012). RESULTS: There were significantly greater declines in the proportions of women from voucher sites that paid for antenatal, delivery and postnatal care services at health facilities compared to those from non-voucher sites. The changes were also consistent with increased uptake of the safe motherhood voucher in intervention sites over time. There was, however, no significant difference in changes in the proportions of women from voucher and non-voucher sites that paid for family planning services. The results further show that there were significant differences in changes in the amount paid for family planning and antenatal care services by women from voucher compared to those from non-voucher sites. Although there were greater declines in the average amount paid for delivery and postnatal care services by women from voucher compared to those from non-voucher sites, the difference-in-differences estimates were not statistically significant. CONCLUSIONS: The reproductive health vouchers program in Kenya significantly contributed to reductions in the proportions of women in the community that paid out-of-pocket for safe motherhood services at health facilities.

Using verbal and social autopsies to explore health-seeking behaviour among HIV-positive women in Kenya: a retrospective study.

BACKGROUND: There is limited understanding of the factors that influence decisions to seek HIV care and treatment services in community settings. The aim of this study was to explore the socio-cultural and health system factors affecting health-seeking behaviour among deceased women in Kenya who were living with HIV at the time of death. METHODS: Out of a total of 796 deaths for which a caregiver was available to provide information, retrospective data were drawn from verbal and social autopsies administered to caregivers of 218 women who had died of AIDS-related illnesses aged 15 to 49 years. Information was collected on essential elements of the care-seeking process from the onset of severe illness episodes and analysed using qualitative and quantitative techniques. RESULTS: Results from the quantitative data showed that poor women were less likely to access formal health services (OR = 0.2; p < 0.001) compared to non-poor women. The qualitative data showed that socioeconomic status, poor knowledge and understanding of AIDS-related illness, distance to facility and transportation costs, medical pluralism, stigma, low HIV risk perception, lack of family support and health care system barriers contributed to delays/constraints in seeking care. CONCLUSIONS: The findings highlight important issues that have implications for addressing challenges faced by women living with HIV, including non-adherence to treatment regimen and late diagnosis of HIV. Provision of transportation subsidies as part of the national social safety-net strategy can help in addressing financial constraints associated with transportation costs among poor women living with HIV.

Individual, partner, and community variables associated with method-specific contraceptive beliefs in urban and rural Kenya.

OBJECTIVES: Global unmet need for contraception remains high. Contraceptive health-related beliefs are a barrier to contraceptive use but are poorly understood. This study examined quantitative differences in two health-related beliefs between pills, injectables, and implants. STUDY DESIGN: We used cross-sectional baseline data collected between August and December 2016 from Nairobi (urban) and Homa Bay (rural) Kenya among women aged 15 to 39 years (N = 5081). Dichotomous outcome variables were constructed for two health-related beliefs (infertility and serious health problems) for the three methods. Using a socioecological framework, possible risk factors at individual, relationship, and community levels were identified a priori. We used logistic regression to identify factors associated with method-specific beliefs. RESULTS: Roughly a quarter of participants believed the methods caused serious health problems, while a smaller overall proportion believed the methods caused infertility. Risk factors patterned similarly across methods but differed between beliefs. In adjusted models, perceived partner approval of a method was associated with lower odds of believing it caused infertility or serious health problems. Unsatisfactory or mixed social network experiences predicted serious health problems but not infertility beliefs. Current use was associated with lower odds of believing all three methods caused serious health problems, but only implant users were more likely to believe they caused infertility. Past use was associated with higher odds of serious health problems but not infertility beliefs. CONCLUSIONS: Across three methods, negative community and perceived partner attitudes toward specific contraceptive methods were associated with higher individual-level odds of contraceptive health beliefs in Kenya. IMPLICATIONS: Efforts to support women who want to use contraception should focus on providing information on contraceptive health and fertility concerns, ideally targeting partners and women of all ages in addition to potential contraceptive users. It is reasonable to address these concerns broadly across commonly used contraceptive methods.

Highlights from the first-ever violence against children and youth survey conducted exclusively in a humanitarian setting.

BACKGROUND: Violence against children (VAC) has garnered attention as a priority issue, in part, due to the Violence Against Children and Youth Surveys (VACS). Although children are disproportionately represented among forcibly displaced people, VACS are a novelty in humanitarian settings. OBJECTIVE: This paper presents the approach to the first-ever VACS conducted exclusively in a humanitarian setting (HVACS) in Uganda, in addition to providing an overview of the results of this novel survey, along with their implications. PARTICIPANTS AND SETTING: Participants included 1338 females and 927 males aged 13-24 years living in refugee settlements in Uganda. METHODS: This was a cross-sectional representative household survey conducted in all 13 refugee settlements in Uganda between March and April 2022. A three-stage sampling process was used to identify participants. Descriptive analysis was conducted, involving the application of sample weights to obtain estimates that are representative of the study population. RESULTS: VAC in refugee settings is pervasive, with females being more likely than males to experience sexual violence and males being more likely than females to experience physical violence. VAC perpetrators were mostly people who were known to child survivors. Whereas knowledge of where to seek help for violence was relatively high (more so for males compared to females), the levels of disclosure and help-seeking were very low for both groups. CONCLUSION: Robust surveys that have traditionally excluded humanitarian settings can be conducted in these contexts. Data emanating from such surveys are critical for developing relevant guidance on interventions to appropriately address major public health issues, such as VAC.

Community experiences and perceptions of reproductive health vouchers in Kenya.

BACKGROUND: Research on demand-side health care financing approaches such as output-based aid (OBA) programs have focused on evaluating the role of the programs improving such outcomes as utilization of services and quality of services with limited focus on the experiences and perceptions of the target communities. This paper examines community members' views of the output-based aid voucher program in Kenya. METHODS: A household survey was conducted in 2010 among 1,336 women aged 15-49 years living in the catchment areas of contracted health facilities in three districts participating in the voucher program (Kisumu, Kiambu and Kitui). Twenty seven focus group discussions were conducted with voucher users, non-users, opinion leaders and voucher distributors in the three districts as well as in Nairobi. Analysis of the quantitative data involved frequency distributions and cross-tabulations. Qualitative data were transcribed and analyzed by adopting framework analysis and further triangulation of themes across respondents. RESULTS: Majority (84%) of survey respondents had heard about the safe motherhood voucher compared to 24% and 1% that had heard about the family planning and gender-based violence recovery services (GBVRS) vouchers respectively. Similarly, 20% of the respondents had used the safe motherhood voucher compared to 2% for family planning and none for the GBVRS vouchers. From the community members' perspectives, the voucher program is associated with improvements in access to health services for poor women, improved quality of care, and empowerment of women to make health care decisions. However, community members cited difficulties in accessing some accredited health facilities, limitations with the system of selling vouchers, lack of male involvement in women's reproductive health issues, and poor understanding of the benefits associated with purchasing the voucher. CONCLUSION: The findings of this paper showed that the voucher program in Kenya is viewed by the community members as a feasible system for increasing service utilization, improving quality of care, and reducing financial barriers to accessing reproductive health services. However, the techniques of program execution such as proper information and availability of the distributors as well as local attitudes influence whether vouchers are purchased and used.

An assessment of opportunities and challenges for public sector involvement in the maternal health voucher program in Uganda.

BACKGROUND: Continued inequities in coverage, low quality of care, and high out-of-pocket expenses for health services threaten attainment of Millennium Development Goals 4 and 5 in many sub-Saharan African countries. Existing health systems largely rely on input-based supply mechanisms that have a poor track record meeting the reproductive health needs of low-income and underserved segments of national populations. As a result, there is increased interest in and experimentation with results-based mechanisms like supply-side performance incentives to providers and demand-side vouchers that place purchasing power in the hands of low-income consumers to improve uptake of facility services and reduce the burden of out-of-pocket expenditures. This paper describes a reproductive health voucher program that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the program to include public sector facilities. METHODS: Data presented here describes the results of interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher program in southwestern Uganda. Interviews were transcribed and organized thematically, barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the program by involving public sector facilities were investigated. RESULTS: The findings show that access to sexual and reproductive health services in southwestern Uganda is constrained by both facility and individual level factors which can be addressed by inclusion of the public facilities in the program. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher program with other services is likely to address some of the barriers. The public sector facilities were also seen as being well positioned to provide voucher services because of their countrywide reach, enhanced infrastructure, and referral networks. The voucher program also has the potential to address public sector constraints such as understaffing and supply shortages. CONCLUSIONS: Accrediting public facilities has the potential to increase voucher program coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening linkages between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilization of resources to support the sustainability of the programs. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher program.

Women's beliefs about methods and contraceptive discontinuation: Results from a prospective study from Nairobi and Homa Bay counties in Kenya.

Background: Rates of contraceptive discontinuation are high in many low and middle countries contributing to unmet need for contraception and other adverse reproductive health outcomes. Few studies have investigated how women's beliefs about methods and strength of fertility preferences affect discontinuation rates. This study examines this question using primary data collected in Nairobi and Homa Bay counties in Kenya. Methods: We used data from two rounds of a longitudinal study of married women ages 15-39 years (2,812 and 2,424 women from Nairobi and Homa Bay respectively at round 1). Information on fertility preferences, past and current contraceptive behavior, and method-related beliefs about six modern contraceptive methods were collected, along with a monthly calendar of contraceptive use between the two interviews. The analysis focused on discontinuation of the two most commonly used methods in both sites, injectables and implants. We carry out competing risk survival analysis to identify which method related beliefs predict discontinuation among women using at the first round. Results: The percentages of episodes discontinued in the 12 months between the two rounds was 36%, with a higher rate of discontinuation in Homa Bay (43%) than in the Nairobi slums (32%) and higher for injectables than implants. Method related concerns and side effects were the major self-reported reasons for discontinuation in both sites. The competing risk survival analysis showed that the probability of method related discontinuation of implants and injectables was significantly lower among respondents who believed that the methods do not cause serious health problems (SHR = 0.78, 95% CI: 0.62-0.98), do not interfere with regular menses (SHR = 0.76, 95% CI: 0.61-0.95) and do not cause unpleasant side effects (SHR = 0.72, 95% CI 0.56-0.89). By contrast, there were no net effects of three method related beliefs that are commonly cited as obstacles to contraceptive use in African societies: safety for long-term use, ability to have children after stopping the method, and the approval of the husband. Conclusion: This study is unique in its examination of the effect of method-specific beliefs on subsequent discontinuation for a method-related reason, using a longitudinal design. The single most important result is that concerns about serious health problems, which are largely unjustified and only moderately associated with beliefs about side effects, are a significant influence on discontinuation. The negative results for other beliefs show that the determinants of discontinuation differ from the determinants of method adoption and method choice.