Feasibility and acceptability of integrating mass distribution of azithromycin to children 1-11 months into a trachoma mass drug administration campaign to reduce child mortality in Côte d'Ivoire.

Evidence suggests that bi-annual mass drug administration (MDA) of single-dose azithromycin to 1-11 month-old children reduces child mortality in high child-mortality settings. Several countries conduct annual MDAs to distribute azithromycin to individuals ages 6 months and older to prevent trachoma infection. This study examined the feasibility and acceptability of reaching 1-11 months-old children during a trachoma MDA in Côte d'Ivoire by extending azithromycin distribution to infants 1-5 months old during the campaign. In November 2020, the study piloted single-dose azithromycin for 1-5 month-olds during a trachoma MDA in one health district. Monitoring data included the number of children reached and occurrences of adverse drug reactions. Feasibility, the extent to which the target population received the intervention (coverage), was assessed through a population-based, household survey with parents/caregivers of eligible children conducted after the MDA. Acceptability was explored through in-depth interviews (IDIs) with parents/caregivers of eligible children, focus group discussions (FGDs) with community drug distributors (CDDs), and IDIs with their supervisors. CDD FGDs and supervisor IDIs also documented implementation challenges and recommendations for scale-up. 1,735 1-5 month-olds received azithromycin during the pilot activity (estimated population coverage of 90.2%). Adverse drug reactions were reported for 1% (n = 18) infants; all were mild and self-limited. The post-MDA coverage survey interviewed 267 parents/caregivers; survey-based intervention coverage was 95.4% of 1-5 month-olds. Qualitative data revealed high intervention acceptability among parents, CDDs, and supervisors. Implementation challenges included the need to weigh babies to calculate dosage for 1-5 month-olds and the need to obtain written informed consent from parents to provide the drug to 1-5 month-olds. CDDs also indicated the need for more information on azithromycin and possible side effects during training. Delivering azithromycin to younger infants appears acceptable to parents and implementers; >90% coverage indicates feasibility to integrate into a trachoma MDA. (Clinicaltrials.gov ID number: NCT04617626).

Adopting Data to Care to Identify and Address Gaps in Services for Children and Adolescents Living With HIV in Mozambique.

BACKGROUND: The Data to Care (D2C) strategy uses multiple sources of complementary data on HIV clients and related services to identify individuals with gaps in HIV treatment. Although D2C has been widely used in the United States, there is no evidence on its use in other settings, such as countries most affected by the epidemic. STRATEGY IMPLEMENTATION: The D2C strategy was implemented within the context of a project that provided community-based support to children and adolescents living with HIV (C/ALHIV) in Mozambique. A data tracking tool and a standard operating procedure manual for local partner community organizations and health care facilities were developed to support the effort. Project staff met with local project implementing partners to discuss and coordinate the intervention in pilot health facilities. STRATEGY PILOTING: The project initiated a pilot D2C intervention in 2019, working with 14 health facilities across 5 additional districts within 1 province. COVida project data were compared with clinical data from facilities serving C/ALHIV. The D2C intervention identified gaps in HIV treatment for a substantial number of C/ALHIV, and targeted support services were provided to address those gaps. Viral load (VL) monitoring was added in March 2020. Before the intervention, 71% of C/ALHIV reported to be on HIV treatment by their caregivers were documented as on treatment in health facilities. Support interventions targeted those not on treatment, and this proportion increased to 96% within 1 year of implementation. Additionally, 12 months later, the proportion of C/ALHIV with a documented VL test increased from 52% to 72%. CONCLUSION: Introducing the D2C pilot intervention was associated with substantial improvements in HIV treatment for C/ALHIV, including increased linkage to and continuity in treatment and increased VL testing. D2C may be a useful approach to improve health outcomes for C/ALHIV in settings outside of the United States.

Organizational readiness to implement task-strengthening strategy for hypertension management among people living with HIV in Nigeria.

BACKGROUND: Hypertension (HTN) is highly prevalent among people living with HIV (PLHIV), but there is limited access to standardized HTN management strategies in public primary healthcare facilities in Nigeria. The shortage of trained healthcare providers in Nigeria is an important contributor to the increased unmet need for HTN management among PLHIV. Evidence-based TAsk-Strengthening Strategies for HTN control (TASSH) have shown promise to address this gap in other resource-constrained settings. However, little is known regarding primary health care facilities' capacity to implement this strategy. The objective of this study was to determine primary healthcare facilities' readiness to implement TASSH among PLHIV in Nigeria. METHODS: This study was conducted with purposively selected healthcare providers at fifty-nine primary healthcare facilities in Akwa-Ibom State, Nigeria. Healthcare facility readiness data were measured using the Organizational Readiness to Change Assessment (ORCA) tool. ORCA is based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework that identifies evidence, context, and facilitation as the key factors for effective knowledge translation. Quantitative data were analyzed using descriptive statistics (including mean ORCA subscales). We focused on the ORCA context domain, and responses were scored on a 5-point Likert scale, with 1 corresponding to disagree strongly. FINDINGS: Fifty-nine healthcare providers (mean age 45; standard deviation [SD]: 7.4, 88% female, 68% with technical training, 56% nurses, 56% with 1-5 years providing HIV care) participated in the study. Most healthcare providers provide care to 11-30 patients living with HIV per month in their health facility, with about 42% of providers reporting that they see between 1 and 10 patients with HTN each month. Overall, staff culture (mean 4.9 [0.4]), leadership support (mean 4.9 [0.4]), and measurement/evidence-assessment (mean 4.6 [0.5]) were the topped-scored ORCA subscales, while scores on facility resources (mean 3.6 [0.8]) were the lowest. CONCLUSION: Findings show organizational support for innovation and the health providers at the participating health facilities. However, a concerted effort is needed to promote training capabilities and resources to deliver services within these primary healthcare facilities. These results are invaluable in developing future strategies to improve the integration, adoption, and sustainability of TASSH in primary healthcare facilities in Nigeria. TRIAL REGISTRATION: NCT05031819.

Feasibility and acceptability of a video library tool to support community health worker counseling in rural Afghan districts: a cross-sectional assessment.

BACKGROUND: Rural Afghan populations have low skilled birth attendance rates and high maternal and infant mortality. Insecurity and armed conflict, geographic barriers, and cultural norms often hinder women's access to facility-based reproductive, maternal, newborn, and child health (RMNCH) services. Community health workers (CHWs) are critical agents for behavioral change in this and similarly fragile settings, where RMNCH information exposure is limited by low literacy and mass media access. We assessed the feasibility and acceptability of a computer tablet-based health video library (HVL) to enhance CHW counseling on RMNCH topics in three rural Afghan districts. METHODS: The HVL was introduced by trained CHWs in 10 pilot communities within one rural district in each of Balkh, Herat, and Kandahar provinces. We used a mixed-methods study design to assess exposure to and perception of the HVL 6 months post-introduction. We surveyed married women (n = 473) and men (n = 468) with at least one child under 5 years and conducted in-depth interviews with CHWs and community leaders (shuras and Family Health Action groups) within pilot communities (n = 80). Program improvement needs were summarized using quantitative and qualitative data. RESULTS: Higher proportions of women in Balkh (60.3%) and Herat (67.3%) reported viewing at least one HVL video compared to women in Kandahar (15%), while male HVL exposure was low (8-17%) across all districts. Most HVL-exposed clients (85-93% of women and 74-92% of men) reported post-video counseling by CHWs. Nearly all (94-96% of women and 85-92% of men) were very interested in watching videos on other health topics in the future. Participants recommended increasing the number of videos and range of topics, using tablets with larger screens, and translating videos into additional local languages to improve the HVL program. CONCLUSION: The HVL was a highly acceptable tool for relaying health information, but coverage of female audiences in Kandahar and male audiences broadly was low. The HVL should better engage men and other key influencers to engineer local solutions that directly facilitate male HVL exposure, indirectly improve women's HVL access, and support collaborative spousal health decision-making. A larger efficacy trial is warranted to measure the HVL's effect on knowledge and health-related behavioral outcomes.

Feasibility and Acceptability of an Adapted Mobile Phone Message Program and Changes in Maternal and Newborn Health Knowledge in Four Provinces of Afghanistan: Single-Group Pre-Post Assessment Study.

BACKGROUND: Mobile phone apps for health promotion have expanded in many low- and middle-income countries. Afghanistan, with high maternal and newborn morbidity and mortality rates, a fragile health infrastructure, and high levels of mobile phone ownership, is an ideal setting to examine the utility of such programs. We adapted messages of the Mobile Alliance for Maternal Action (MAMA) program, which was designed to promote healthy behaviors during pregnancy and a newborn's first year of life, to the Afghan context. We then piloted and assessed the program in the provinces of Kabul, Herat, Kandahar, and Balkh. OBJECTIVE: The aim of this study was to assess the feasibility and acceptability of the MAMA pilot program, and to examine changes in reported maternal, newborn, and child health (MNCH) knowledge and attitudes among participants from baseline to follow up. METHODS: We conducted a single-group study with data collected within 10 weeks of enrollment, and data collection was repeated approximately 6 months later. Data were collected through face-to-face interviews using structured questionnaires. Eligible participants included pregnant women who had registered to receive fully automated mobile health messages and their husbands. Assessment questionnaires queried sociodemographic details; knowledge, attitudes, and health care-seeking practices; and intervention experience and acceptability at follow up. The number of messages received by a given phone number was extracted from the program database. We descriptively analyzed the feasibility and acceptability data and compared the change in MNCH knowledge between baseline and follow-up measures using the McNemar Chi square test. RESULTS: Overall, 895 women were enrolled in the MAMA program. Data from 453/625 women (72.5% of the pretest sample) who received voice (n=302) or text (n=151) messages, and 276/427 men (64.6% of the pretest sample) who received voice (n=185) or text (n=91) messages contributing data at both time points were analyzed. At follow up, 699/729 (95.9%) participants were still enrolled in the MAMA program; voice message and SMS text messaging subscribers received 43 and 69 messages on average over the 6-month period, respectively. Participants who were voice message subscribers and female participants more commonly reported missing messages compared with the text message subscribers and men; predominant reasons for missed messages were the subscribers being busy with chores or not having their shared phone with them. Over 90% of men and women reported experiencing benefits from the program, mainly increased knowledge, and 226/453 (49.9%) of the female participants reported referring someone else to the program. Most of the participants (377/453, 83.2% women and 258/276, 93.5% men) believed it was beneficial to include husbands in the program. Joint decision making regarding maternal and child health care increased overall. The proportions of participants with correct knowledge significantly increased for all but one MNCH measure at follow up. CONCLUSIONS: This assessment indicates that the pilot MAMA program is feasible and acceptable in the Afghan context. Further research should be conducted to determine whether program participation leads to improved MNCH knowledge, health practices, and health service utilization in this fragile setting prior to larger scale up.

A Social Media-Based Support Group for Youth Living With HIV in Nigeria (SMART Connections): Randomized Controlled Trial.

BACKGROUND: Youth living with HIV (YLHIV) enrolled in HIV treatment experience higher loss to follow-up, suboptimal treatment adherence, and greater HIV-related mortality compared with younger children or adults. Despite poorer health outcomes, few interventions target youth specifically. Expanding access to mobile phone technology, in low- and middle-income countries (LMICs) in particular, has increased interest in using this technology to improve health outcomes. mHealth interventions may present innovative opportunities to improve adherence and retention among YLHIV in LMICs. OBJECTIVE: This study aimed to test the effectiveness of a structured support group intervention, Social Media to promote Adherence and Retention in Treatment (SMART) Connections, delivered through a social media platform, on HIV treatment retention among YLHIV aged 15 to 24 years and on secondary outcomes of antiretroviral therapy (ART) adherence, HIV knowledge, and social support. METHODS: We conducted a parallel, unblinded randomized controlled trial. YLHIV enrolled in HIV treatment for less than 12 months were randomized in a 1:1 ratio to receive SMART Connections (intervention) or standard of care alone (control). We collected data at baseline and endline through structured interviews and medical record extraction. We also conducted in-depth interviews with subsets of intervention group participants. The primary outcome was retention in HIV treatment. We conducted a time-to-event analysis examining time retained in treatment from study enrollment to the date the participant was no longer classified as active-on-treatment. RESULTS: A total of 349 YLHIV enrolled in the study and were randomly allocated to the intervention group (n=177) or control group (n=172). Our primary analysis included data from 324 participants at endline. The probability of being retained in treatment did not differ significantly between the 2 study arms during the study. Retention was high at endline, with 75.7% (112/163) of intervention group participants and 83.4% (126/161) of control group participants active on treatment. HIV-related knowledge was significantly better in the intervention group at endline, but no statistically significant differences were found for ART adherence or social support. Intervention group participants overwhelmingly reported that the intervention was useful, that they enjoyed taking part, and that they would recommend it to other YLHIV. CONCLUSIONS: Our findings of improved HIV knowledge and high acceptability are encouraging, despite a lack of measurable effect on retention. Retention was greater than anticipated in both groups, likely a result of external efforts that began partway through the study. Qualitative data indicate that the SMART Connections intervention may have contributed to retention, adherence, and social support in ways that were not captured quantitatively. Web-based delivery of support group interventions can permit people to access information and other group members privately, when convenient, and without travel. Such digital health interventions may help fill critical gaps in services available for YLHIV. TRIAL REGISTRATION: ClinicalTrials.gov NCT03516318; https://clinicaltrials.gov/ct2/show/NCT03516318.

Adapting a health video library for use in Afghanistan: provider-level acceptability and lessons for strengthening operational feasibility.

BACKGROUND: Community health workers (CHWs) in Afghanistan are a critical care extender for primary health services, including reproductive, maternal, neonatal, and child health (RMNCH) care. However, volunteer CHWs face challenges including an ever-expanding number of tasks and insufficient time to conduct them. We piloted a health video library (HVL) intervention, a tablet-based tool to improve health promotion and counseling by CHWs. We qualitatively assessed provider-level acceptability and operational feasibility. METHODS: CHWs implemented the HVL pilot in three rural districts of Balkh, Herat, and Kandahar provinces. We employed qualitative methods, conducting 47 in-depth interviews (IDIs) with male and female CHWs and six IDIs with community health supervisors. We used semi-structured interview guides to explore provider perceptions of program implementation processes and solicit feedback on how to improve the HVL intervention to inform scale-up. We conducted a thematic analysis. RESULTS: CHWs reported that the HVL increased time efficiencies, reduced work burden, and enhanced professional credibility within their communities. CHWs felt video content and format were accessible for low literacy clients, but also identified challenges to operational feasibility. Although tablets were considered easy-to-use, certain technical issues required continued support from supervisors and family. Charging tablets was difficult due to inconsistent electricity access. Although some CHWs reported reaching most households in their catchment area for visits with the HVL, others were unable to visit all households due to sizeable populations and gender-related barriers, including women's limited mobility. CONCLUSIONS: The HVL was acceptable and feasible for integration into existing CHW duties, indicating it may improve RMNCH counseling, contributing to increased care-seeking behaviors in Afghanistan. Short-term challenges with technology and hardware can be addressed through continued training and provision of solar chargers. Longer-term challenges, including tablet costs, community coverage, and gender issues, require further consideration with an emphasis on equitable distribution.

Addressing broader reproductive health needs of female sex workers through integrated family planning/ HIV prevention services: A non-randomized trial of a health-services intervention designed to improve uptake of family planning services in Kenya.

BACKGROUND: Despite considerable efforts to prevent HIV and other sexually transmitted infections (STI) among female sex workers (FSW), other sexual and reproductive health (SRH) needs, such preventing unintended pregnancies, among FSW have received far less attention. Programs targeting FSW with comprehensive, accessible services are needed to address their broader SRH needs. This study tested the effectiveness of an intervention to increase dual contraceptive method use to prevent STIs, HIV and unintended pregnancy among FSW attending services in drop-in centers (DIC) in two cities in Kenya. The intervention included enhanced peer education, and routine screening for family planning (FP) needs plus expanded non-condom FP method availability in the DIC. METHODS: We conducted a two-group, pre-/posttest, quasi-experimental study with 719 FSW (360 intervention group, 359 comparison group). Participants were interviewed at baseline and 6 months later to examine changes in condom and non-condom FP method use. RESULTS: The intervention had a significant positive effect on non-condom, FP method use (OR = 1.38, 95%CI (1.04, 1.83)), but no effect on dual method use. Consistent condom use was reported to be high; however, many women also reported negotiating condom use with both paying and non-paying partners as difficult or very difficult. The strongest predictor of consistent condom use was partner type (paying versus non-paying/emotional); FSW reported both paying and non-paying partners also influence non-condom contraceptive use. Substantial numbers of FSW also reported experiencing sexual violence by both paying and non-paying partners. CONCLUSIONS: Self-reported difficulties with consistent condom use and the sometimes dangerous conditions under which they work leave FSW vulnerable to unintended pregnancy STIs/HIV. Adding non-barrier FP methods to condoms is crucial to curb unintended pregnancies and their potential adverse health, social and economic consequences. Findings also highlight the need for additional strategies beyond condoms to reduce HIV and STI risk among FSW. TRIAL REGISTRATION: Clinicaltrials.gov NCT01957813.

Getting health information to internally displaced youth in Afghanistan: can mobile phone technology bridge the gap?

Background: Afghanistan ranks among the most disadvantaged globally for many key reproductive, maternal, newborn and child health (RMNCH) indicators, despite important gains in the past decade. Youth (15 to 24 years) are a key audience for RMNCH information as they enter adulthood, marry and begin families; however, reaching Afghan youth with health information is challenging. Internally displaced persons (IDPs), including youth, experience additional challenges to obtaining health-related information and services. This study measured current and preferred RMNCH information channels to explore the feasibility of using mobile phone technology to provide RMNCH information to IDP youth in Afghanistan. Methods: We conducted a sub-group analysis of survey data from a mixed-methods, cross-sectional, formative assessment to understand current access to RMNCH information. The target population for this analysis includes 15-25-year-old male and female IDP youth from three Afghan Provinces. Survey data were collected using a structured questionnaire administered through face-to-face interviews. Data were analyzed descriptively. Results: A total of 450 IDP youth were surveyed in the three provinces (225 male and 225 female). Access to RMNCH information outside of health facilities was limited. Mobile phone ownership was nearly universal among male participants, yet considerably lower among females; nearly all participants without personal phones reported access to phones when needed. Although few participants spontaneously mentioned mobile phones as a preferred source of RMNCH information, most male and female respondents reported they would be very or somewhat likely to use a free, mobile-phone-based system to access such information if offered. Conclusions: Given widespread access and considerable interest voiced by participants, mobile phones may be a viable way to reach IDP youth with important RMNCH health information in this fragile setting. Interventions should be designed and pilot-tested to identify the most appropriate platforms and information content and to further document feasibility and acceptability.

An Online Support Group Intervention for Adolescents Living with HIV in Nigeria: A Pre-Post Test Study.

BACKGROUND: Adolescents living with HIV (ALHIVs) enrolled in HIV treatment services experience greater loss to follow-up and suboptimal adherence than other age groups. HIV-related stigma, disclosure-related issues, lack of social support, and limited HIV knowledge impede adherence to antiretroviral therapy (ART) and retention in HIV services. The 90-90-90 goals for ALHIVs will only be met through strategies targeted to meet their specific needs. OBJECTIVES: We aimed to evaluate the feasibility of implementing a social media-based intervention to improve HIV knowledge, social support, ART adherence, and retention among ALHIV aged 15-19 years on ART in Nigeria. METHODS: We conducted a single-group pre-post test study from June 2017 to January 2018. We adapted an existing support group curriculum and delivered it through trained facilitators in 5 support groups by using Facebook groups. This pilot intervention included five 1-week sessions. We conducted structured interviews with participants before and after the intervention, extracted clinical data, and documented intervention implementation and participation. In-depth interviews were conducted with a subset of participants at study completion. Quantitative data from structured interviews and group participation data were summarized descriptively, and qualitative data were coded and summarized. RESULTS: A total of 41 ALHIV enrolled in the study. At baseline, 93% of participants reported existing phone access; 65% used the internet, and 64% were Facebook users. In addition, 37 participants completed the 5-session intervention, 32 actively posted comments in at least one session online, and at least half commented in each of the 5 sessions. Facilitators delivered most sessions as intended and on-time. Participants were enthusiastic about the intervention. Aspects of the intervention liked most by participants included interacting with other ALHIVs; learning about HIV; and sharing questions, experiences, and fears. The key recommendations were to include larger support groups and encourage more group interaction. Specific recommendations on various intervention components were made to improve the intervention. CONCLUSIONS: This novel intervention was feasible to implement in a predominantly suburban and rural Nigerian setting. Social media may be leveraged to provide much-needed information and social support on platforms accessible and familiar to many people, even in resource-constrained communities. Our findings have been incorporated into the intervention, and an outcome study is underway. TRIAL REGISTRATION: ClinicalTrials.gov NCT03076996; https://clinicaltrials.gov/ct2/show/NCT03076996 (Archived by WebCite at http://www.webcitation.org/73oCCEBBC).

Interventions to improve antiretroviral therapy adherence among adolescents in low- and middle-income countries: A systematic review of the literature.

INTRODUCTION: Globally, an estimated 30% of new HIV infections occur among adolescents (15-24 years), most of whom reside in sub-Saharan Africa. Moreover, HIV-related mortality increased by 50% between 2005 and 2012 for adolescents 10-19 years while it decreased by 30% for all other age groups. Efforts to achieve and maintain optimal adherence to antiretroviral therapy are essential to ensuring viral suppression, good long-term health outcomes, and survival for young people. Evidence-based strategies to improve adherence among adolescents living with HIV are therefore a critical part of the response to the epidemic. METHODS: We conducted a systematic review of the peer-reviewed and grey literature published between 2010 and 2015 to identify interventions designed to improve antiretroviral adherence among adults and adolescents in low- and middle-income countries. We systematically searched PubMed, Web of Science, Popline, the AIDSFree Resource Library, and the USAID Development Experience Clearinghouse to identify relevant publications and used the NIH NHLBI Quality Assessment Tools to assess the quality and risk of bias of each study. RESULTS AND DISCUSSION: We identified 52 peer-reviewed journal articles describing 51 distinct interventions out of a total of 13,429 potentially relevant publications. Forty-three interventions were conducted among adults, six included adults and adolescents, and two were conducted among adolescents only. All studies were conducted in low- and middle-income countries, most of these (n = 32) in sub-Saharan Africa. Individual or group adherence counseling (n = 12), mobile health (mHealth) interventions (n = 13), and community- and home-based care (n = 12) were the most common types of interventions reported. Methodological challenges plagued many studies, limiting the strength of the available evidence. However, task shifting, community-based adherence support, mHealth platforms, and group adherence counseling emerged as strategies used in adult populations that show promise for adaptation and testing among adolescents. CONCLUSIONS: Despite the sizeable body of evidence for adults, few studies were high quality and no single intervention strategy stood out as definitively warranting adaptation for adolescents. Among adolescents, current evidence is both sparse and lacking in its quality. These findings highlight a pressing need to develop and test targeted intervention strategies to improve adherence among this high-priority population.

Improving retention in HIV care among adolescents and adults in low- and middle-income countries: A systematic review of the literature.

INTRODUCTION: Adolescents living with HIV are an underserved population, with poor retention in HIV health care services and high mortality, who are in need of targeted effective interventions. We conducted a literature review to identify strategies that could be adapted to meet the needs of adolescents living with HIV. METHODS: We searched PubMed, Web of Science, Popline, USAID's AIDSFree Resource Library, and the USAID Development Experience Clearinghouse for relevant studies published within a recent five-year period. Studies were included if they described interventions to improve the retention in care of HIV-positive patients who are initiating or already receiving antiretroviral therapy in low- and middle-income countries. To assess the quality of the studies, we used the NIH NHLBI Study Quality Assessment Tools. RESULTS AND DISCUSSION: Of 13,429 potentially relevant citations, 23 were eligible for inclusion. Most studies took place in sub-Saharan Africa. Only one study evaluated a retention intervention for youth (15-24 years); it found no difference in loss to follow-up between a youth-friendly clinic and a family-oriented clinic. A study of community-based service delivery which was effective for adults found no effect for youths. We found no relevant studies conducted exclusively with adolescent participants (10-19 years). Most studies were conducted with adults only or with populations that included adults and adolescents but did not report separate results for adolescents. Interventions that involved community-based services showed the most robust evidence for improving retention in care. Several studies found statistically significant associations between decentralization, down-referral of stable patients, task-shifting of services, and differentiated care, and retention in care among adults; however, most evidence comes from retrospective, observational studies and none of these approaches were evaluated among adolescents or youth. CONCLUSIONS: Interventions that target retention in care among adolescents living with HIV are rare in the published literature. We found only two studies conducted with youth and no studies with adolescents. Given the urgent need to increase the retention of adolescents in HIV care, interventions that are effective in increasing adult retention in care should be considered for adaptation and evaluation among adolescents and interventions specifically targeting the needs of adolescents must be developed and tested.

Meeting Postpartum Women's Family Planning Needs Through Integrated Family Planning and Immunization Services: Results of a Cluster-Randomized Controlled Trial in Rwanda.

OBJECTIVE: The primary objective of this study was to test the effectiveness of integrating family planning service components into infant immunization services to increase modern contraceptive method use among postpartum women. METHODS: The study was a separate sample, parallel, cluster-randomized controlled trial. Fourteen randomly selected primary health facilities were equally allocated to intervention (integrated family planning and immunization services at the same time and location) and control groups (standard immunization services only). At baseline (May-June 2010), we interviewed postpartum women attending immunization services for their infant aged 6 to 12 months using a structured questionnaire. A separate sample of postpartum women was interviewed 16 months later after implementation of the experimental health service intervention. We used linear mixed regression models to test the study hypothesis that postpartum women attending immunization services for their infants aged 6-12 months in the intervention facilities will be more likely to use a modern contraceptive method than postpartum women attending immunization services for their infants aged 6-12 months in control group facilities. RESULTS: We interviewed and analyzed data for 825 women from the intervention group and 829 women from the control group. Results showed the intervention had a statistically significant, positive effect on modern contraceptive method use among intervention group participants compared with control group participants (regression coefficient, 0.15; 90% confidence interval [CI], 0.04 to 0.26). Although we conducted a 1-sided significance test, this effect was also significant at the 2-sided test with alpha = .05. Among those women who did not initiate a contraceptive method, awaiting the return of menses was the most common reason cited for non-use of a method. Women in both study groups overwhelmingly supported the concept of integrating family planning service components into infant immunization services (97.9% in each group), and service data collected during the intervention period did not indicate that the intervention had any negative effect on infant immunization service uptake. CONCLUSION: Integrating family planning service components into infant immunization services can be an acceptable and effective strategy to increase contraceptive use among postpartum women. Additional research is needed to examine the extent to which this integration strategy can be replicated in other health care settings. Future research should also explore persistent misconceptions regarding the relationship between return of menses and return to fertility during the postpartum period.

Contraceptive service delivery in Kenya: A qualitative study to identify barriers and preferences among female sex workers and health care providers.

OBJECTIVE: Female sex workers (FSWs) need access to contraceptive services, yet programs often focus on HIV prevention and less on the broader sexual and reproductive health needs of FSWs. We aimed to identify barriers to accessing contraceptive services among FSWs and preferences for contraceptive service delivery options among FSWs and health care providers (HCPs) in order to inform a service delivery intervention to enhance access to and use of contraceptives for FSWs in Kenya. STUDY DESIGN: Twenty focus group discussions were conducted with FSWs and HCPs in central Kenya. RESULTS: Three barriers were identified that limited the ability of FSWs to access contraceptive services: (1) an unsupportive clinic infrastructure, which consisted of obstructive factors such as long wait times, fees, inconvenient operating hours and perceived compulsory HIV testing; (2) discriminatory provider-client interactions, where participants believed negative and differential treatment from female and male staff members impacted FSWs' willingness to seek medical services; and (3) negative partner influences, including both nonpaying and paying partners. Drop-in centers followed by peer educators and health care facilities were identified as preferred service delivery options. CONCLUSIONS: FSWs may not be able to regularly access contraceptive services until interpersonal (male partners) and structural (facilities and providers) barriers are addressed. Alternative delivery options, such as drop-in centers coupled with peer educators, may be an approach worth evaluating. IMPLICATIONS STATEMENT: An unsupportive clinic infrastructure, discriminatory provider-client interactions and negative partner influences are barriers to FSWs accessing the contraception services they need. Alternative service delivery options, such integrating contraceptive service delivery at drop-in centers designed for FSWs and information delivery through peer educators, might provide improved access and better service quality to FSWs seeking contraception.

Reducing vertical HIV transmission in Kinshasa, Democratic Republic of Congo: trends in HIV prevalence and service delivery.

Scale-up of vertical HIV transmission prevention has been too slow in sub-Saharan Africa. We describe approaches, challenges, and results obtained in Kinshasa. Staff members of 21 clinics managed by public servants or non-governmental organizations were trained in improved basic antenatal care (ANC) including nevirapine (NVP)-based HIV transmission prevention. Program initiation was supported on-site logistically and technically. Aggregate implementation data were collected and used for program monitoring. Contextual information was obtained through a survey. Among 45,262 women seeking ANC from June 2003 through July 2005, 90% accepted testing; 792 (1.9%) had HIV of whom 599 (76%) returned for their result. Among 414 HIV+ women who delivered in participating maternities, NVP coverage was 79%; 92% of newborns received NVP. Differences were noted by clinic management in program implementation and HIV prevalence (1.2 to 3.0%). Initiating vertical HIV transmission prevention embedded in improved antenatal services in a fragile, fragmented, severely resource-deprived health care system was possible and improved over time. Scope and quality of service coverage should further increase; strategies to decrease loss to follow-up of HIV+ women should be identified to improve program effectiveness. The observed differences in HIV prevalence highlight the importance of selecting representative sentinel surveillance centers.

Substance abuse issues among women in domestic violence programs: findings from North Carolina.

This article discusses the results of a survey of North Carolina domestic violence programs that found that substance abuse problems are common among program clients, yet only half of the programs had policies concerning substance-abusing clients, and one fourth had memoranda of agreement with substance abuse treatment providers. Most programs with shelters asked clients about substance use; however, one third of the shelters would not admit women if they were noticeably under the influence of substances while seeking shelter residence, instead referring them to substance abuse programs. Approximately one tenth of the domestic violence programs did not have any staff or volunteers with training in substance abuse issues. Implications are discussed.

Mental health issues among female clients of domestic violence programs in North Carolina.

OBJECTIVE: This study estimated the prevalence of mental health problems among clients of domestic violence programs in North Carolina, determined whether domestic violence program staff members routinely screen clients for mental health problems, described how domestic violence programs respond to clients who have mental health problems, and ascertained whether domestic violence program staff members and volunteers have been trained in mental health-related issues. METHODS: A survey was mailed to all known domestic violence programs in North Carolina. RESULTS: A total of 71 of the 84 known programs responded to the survey (85 percent response rate). A majority of programs estimated that at least 25 percent of their clients had mental health problems (61 percent) and stated that they routinely asked their clients about mental health issues (72 percent). More than half the programs (54 percent) reported that less than 25 percent of their staff members and volunteers had formal training on mental health issues. An even smaller percentage of programs (23 percent) reported that they had a memorandum of agreement with a local mental health center. CONCLUSIONS: The substantial percentage of domestic violence clients with concurrent mental health needs and the limited mental health services that are currently available have important implications for domestic violence and mental health service delivery.

Helping women with disabilities and domestic violence: strategies, limitations, and challenges of domestic violence programs and services.

PURPOSE: To describe the types of services provided to women with disabilities at community-based domestic violence programs in the state of North Carolina, the challenges faced, and strategies used to provide the services. METHODS: We conducted a statewide cross-sectional survey of community domestic violence programs and had a response rate of 85%. RESULTS: Of the participating programs, 99% provided services to at least one woman with a physical or mental disability in the preceding 12 months; 85% offered shelter services to women with physical or mental disabilities. Most respondents (94%-99%) reported that their programs were either somewhat able or very able to provide effective services and care to women with disabilities. The respondents also described challenges to serving women with disabilities, including lack of funding, lack of training, and structural limitations of service facilities. Strategies used by the programs to overcome these challenges were networking and coordinating care with organizations that specifically serve disabled populations. CONCLUSIONS: Domestic violence programs in North Carolina provide services to women with disabilities but are faced with challenges stemming from limited funding, physical space, and training. Collaborations between domestic violence and disability service providers are necessary to improving the services and care delivered to women with disabilities who experience domestic violence.