Couple-Years of Protection Indicator: New Global Guidance for Updating Existing Methods and Adding New Methods.

BACKGROUND: Couple-years of protection (CYP) is an indicator that allows for monitoring and evaluating of family planning (FP) program performance through simple calculations. The CYP for each contraceptive method is calculated by multiplying the number of contraceptive commodity units distributed to clients over a 1-year period by a conversion factor that quantifies the duration of contraceptive protection provided per unit distributed. CYP calculations across methods were previously updated in 2000 and 2011, resulting in changes in methodology, factor inclusion, and specific methods. Since the 2011 update, changes and additions to the modern contraceptive method mix required new CYP conversion factors for 4 methods of contraception: Levoplant implant, progestin-only pills (POPs), Caya diaphragm, and the hormonal intrauterine device. METHODS: We conducted literature reviews of both published and gray literature and consulted with experts to identify updated data on continuation rates, duration of efficacy, and method effectiveness for the 4 methods. New CYP conversion factors were calculated for the 4 methods either by using the same calculation used previously for the method considering new data or, for new methods, using calculations for similar methods. RESULTS: New CYP conversion factors were assigned to the 4 methods of contraception covered in this update: Levoplant, 2.5 CYP per implant inserted; POPs, 0.0833 CYP per pack (i.e., 12 cycles per CYP); Caya diaphragm, 1 CYP per device, and hormonal intrauterine device, 4.8 CYP per device inserted. CONCLUSIONS: CYP is an important indicator for FP programs. As new methods of contraception are developed and new evidence is generated for current methods, the indicator may need to be updated. A standard process for updating and documenting future CYP updates is recommended.

The interaction of healthcare service quality and community-based health insurance in Ethiopia.

Community-based health insurance (CBHI) as a demand-side intervention is presumed to drive improvements in health services quality, and the quality of health services is an important supple-side factor in motivating CBHI enrollment and retention. There is, however, limited evidence on this interaction. This study examined the interaction between quality of health services and CBHI enrollment and renewal. A mixed-method comparative study was conducted in four agrarian regions of Ethiopia. The study followed the Donabedian model to compare quality of health services in health centers located in woredas/districts that implemented CBHI with those that did not. Data was collected through facility assessments, client-exit interviews, and key informant interviews. In addition to manual thematic analysis of qualitative data, quantitative descriptive and inferential analyses were done using SPSS vs 25. The process related (composite index including provider-client interpersonal communication) and outcome related (client satisfaction) measures of service quality in CBHI woreda/districts differed significantly from non-CBHI woredas/districts, but there were no significant differences in overall measures of structural quality between the two. The study found better diagnostic test capacity, availability of tracer drugs, provider interpersonal communication, and service quality standards in CBHI woredas. A higher proportion of clients at CBHI health centers gave high ratings of overall satisfaction with services. Individual and household factors including family size, age, household health care-related expenditures, and educational status, played a more significant role in CBHI enrollment and renewal decisions than health service quality. Key-informants reported in interviews that participation in the scheme increased accountability of health facilities in CBHI woredas/districts, because they promised to provide quality services using the CBHI premium collected at the beginning of the year from all enrolled households. This study indicates a need for follow-up research to understand the nuanced linkages between quality of care and CBHI enrollment.

Socioeconomic inequality in exclusive breastfeeding behavior and ideation factors for social behavioral change in three north-western Nigerian states: a cross-sectional study.

BACKGROUND: Socioeconomic inequalities could mitigate the impact of social and behavior change (SBC) interventions aimed at improving positive ideation towards the practice of exclusive breastfeeding. This study explores the empirical evidence of inequalities in the practice of exclusive breastfeeding (EBF) and associated ideational dimensions and domains of the theory of Strategic Communication and Behavior Change in three north-western Nigeria states. METHODS: We used cross-sectional data from 3007 randomly selected women with under-two-year-old children; the convenient regression method was applied to estimate the concentration indexes (CIxs) of exclusive breastfeeding behavior, ranked by household wealth index. Inequality was decomposed to associated ideational factors and sociodemographic determinants. Avoidable inequalities and the proportion of linear redistribution to achieve zero inequality were estimated. RESULTS: Women from wealthier households were more likely to practice exclusive breastfeeding CIx = 0.1236, p-value = 0.00). Attendance of at least four antenatal clinic visits (ANC 4+) was the most significant contributor to the inequality, contributing CIx = 0.0307 (p-value = 0.00) to the estimated inequality in exclusive breastfeeding practice. The elasticity of exclusive breastfeeding behavior with respect to partners influencing decision to breastfeed and ANC4+, were 0.1484 (p-value = 0.00) and 0.0825 (p-value = 0.00) respectively. Inequality in the regular attendance at community meetings (CIx = 0.1887, p-value =0.00); ANC 4+) (CIx = 0.3722, p-value = 0.00); and maternal age (CIx = 0.0161, p-value = 0.00) were pro-rich. A 10.7% redistribution of exclusive breastfeeding behavior from the wealthier half to the poorer half of the population could eliminate the inequality (line of zero inequality). Inequalities were mainly in the cognitive and social norms dimension and were all pro-poor. CONCLUSION: Socioeconomic inequalities exist in exclusive breastfeeding behaviors and in associated ideation factors in the three states but are mostly avoidable. A 10.7% redistribution from wealthier to the poorer half of the population will achieve elimination. Messaging for SBC communication interventions to improve breastfeeding practices could be more effective by targeting the mitigation of these inequalities.

Can married or cohabiting women negotiate protective sex? Findings from Demographic and Health Surveys of two West African countries.

Can married or cohabitating women in patriarchal societies, who are often disproportionately affected by STI/HIV infections, negotiate protective sex when perceived necessary by refusing sex or asking for condom use during sex? Protective sex negotiation was examined through measures of power relations related to whether or not a woman has a say in sexual activities within marriage. The study hypothesis was that women who are more able to refuse sex or ask for condom use before sexual intercourse will be more able to discuss and reach agreement with their spouses on protective sex practices when needed. The study used data from DHS surveys conducted in Cote d'Ivoire and Nigeria in 2012 and 2013 respectively. Multivariate logistic regression models were used to predict women's ability to negotiate protective sex in Cote d'Ivoire and Nigeria. The findings show that moderately high percentages of women in both countries reported the ability to negotiate protective sex, with a higher percentage reporting the ability to refuse sex compared with the ability to ask partners to use a condom. The logistic regression results showed that, in the two countries, women's ability to refuse sex or ask their partners to use a condom, varied by gender- and power-mediating factors, women's characteristics and behavioural factors. The study draws attention to the need to intensify efforts to promote more-egalitarian relationships between partners through culturally appropriate interventions.

HIV prevalence and risk behaviors of male injection drug users in Cairo, Egypt.

OBJECTIVE: To measure HIV prevalence and related risk behaviors among male injection drug users (IDUs) in Cairo, Egypt in the context of the first survey wave of an integrated biological and behavioral surveillance system. DESIGN AND METHODS: Given the hidden nature of injection drug use, we used the peer-referral methodology of respondent-driven sampling in a cross-sectional study to recruit a sample of male IDUs in Cairo between May and August 2006. Behavioral data were collected through face-to-face interviews and serum was obtained for HIV antibody testing. Population estimates were produced using respondent-driven sampling Analysis Tool. RESULTS: The study enrolled 413 male IDUs. The population estimated HIV prevalence was 0.6% (95% confidence interval 0.1-1.8). More than half (53.0%) reported injecting drugs with used needles or syringes and nearly one-third (32.4%) shared their used needle or syringe with one or more persons in the preceding month. Overall, 70.5% had sex in the preceding year, of whom 9.4% reported sex with male partners and 13.2% reported sex with commercial sex workers in the preceding 12 months. Ever use of a condom during sex was low with all partner types and only 5.8% ever had an HIV test. CONCLUSION: This first survey wave of integrated biological and behavioral surveillance system in Egypt to track the HIV epidemic among male IDUs found relatively low prevalence of infection compared to global estimates, though the figure is many times higher than the general population. In addition, risky injection practices and unprotected sex were high with sexual networks including men who have sex with men, female sex workers, wives, and other regular and casual partners. The respondent-driven sampling method was effective in recruiting male IDUs and the results are being used to inform surveillance and prevention programs.

Prevalence of and factors associated with extramarital sex among Nigerian men.

This study used data on currently married and cohabiting men aged 15 to 64 years from the 2003 Nigeria Demographic and Health Survey to examine the prevalence of and factors associated with extramarital sex. The results show that 16% engaged in extramarital sex in the 12 months preceding the survey and had an average of 1.82 partners. The results also show statistically significant association between extramarital sex and ethnicity, religion, age, age at sexual debut, education, occupation, and place of residence. Based on the study results, it could be concluded that significant proportions of Nigerians are exposed to HIV infection through extramarital sex. A fundamental behavioral change expected in the era of HIV/AIDS is the inculcation of marital fidelity and emotional bonding between marital partners. The promotion of condom use among married couples should be intensified to protect women, a large number of whom are exposed to HIV infection from their spouses who engage in unprotected extramarital sex. And, because of gender-based power imbalances within the family, a large number of the women are unable to negotiate consistent condom use by their partners.

Factors affecting ever-married men's contraceptive knowledge and use in Nigeria.

African men play important roles in the decisions about family life, including fertility and family planning. However, fertility and family planning research and programmes have ignored their roles in the past, focusing only on women's behaviours. Since the 1994 International Conference on Population and Development (ICPD), interest in men's involvement in reproductive health has increased. Unfortunately, data on their knowledge and use of contraception are generally scanty. This paper examines knowledge and use of contraception among ever-married men in Nigeria. A total of 1451 ever-married men aged 18-55 were interviewed in Imo and Ondo States, Nigeria. The findings reveal that men's level of contraceptive knowledge is high in the study areas. About 90% knew at least one method of family planning. Furthermore, the level of contraceptive use among married men is such that men could participate in family planning activities if there were adequate programmes to involve them. Men in the sample areas were found not only to support their spouses' use of contraceptives, but were actually using condoms to delay or prevent pregnancy. Age, education, place of residence, number of living children and being counselled for family planning were identified as key factors determining contraceptive knowledge and use among married men in the study areas. To ensure increased participation of men in family planning, programmes must be designed to educate them on the need for family size limitation and involve them in service delivery, even if only to their male counterparts.