Trends in and Correlates of Short-Acting Contraceptive Stock-Outs: Multicountry Analysis of Performance Monitoring for Action Agile Platform Data.

Understanding trends in contraceptive stock-outs, as well as their structural and demand-side correlates, is critical for policymakers and program managers to identify strategies to further anticipate, reduce, and prevent stock-outs. We analyzed trends as well as supply- and demand-side correlates of short-acting contraceptive method stock-outs by using data from multiple rounds of Performance Monitoring for Action Agile surveys. These data longitudinally measured contraceptive availability over 2 years (between November 2017 and January 2020) across 2,134 public and private service delivery points (SDPs) from urban areas of 5 countries (Burkina Faso, Democratic Republic of the Congo [DRC], India, Kenya, and Nigeria). For each country, we analyzed the trends and used multilevel mixed-effect logistic regression to model the odds of short-acting contraceptive stock-outs, adjusting for key structural and demand-side factors of the SDPs. Stock-outs in short-acting contraceptive methods were common in health facilities and varied markedly, ranging from as low as 2.9% (95% confidence interval [CI]=1.7%, 5.1%) in India to 51.0% (95% CIs=46.8%, 56.0%) in Kenya. During the observation period, stock-out rates decreased by 28% in the SDP samples in India (aOR=0.72, P<.001) and 8% in Nigeria (aOR=0.92, P<.001) but increased by 15% in DRC (aOR=1.15; P=036) and 5% in Kenya (aOR=1.05, P=003) with each round of data collection. Correlates of stock-out rates included the facility managerial authority (private versus public), whether the facility was rated high quality, whether the facility was at an advanced tier, and whether there was high demand for short-acting contraceptives. In conclusion, stock-outs of short-acting contraceptives are still common in many settings. Measuring and monitoring contraceptive stock-outs is crucial for identifying and addressing issues related to the availability and supply of short-acting contraceptives.

Effect of chest wall mobilization on respiratory muscle function in patients with severe chronic obstructive pulmonary disease (COPD): A randomized controlled trial.

BACKGROUND: Clinical trials have demonstrated positive correlation between pulmonary function and chest wall expansion in COPD. Decrease in chest wall expansion in patients with COPD compromises rib cage mobility and functional length of respiratory muscles that ultimately jeopardize the efficacy and function of respiratory system. METHOD: Thirty male adults (mean age: 74.97 ± 6.29) suffered with severe COPD were randomly allocated to either experimental group (chest wall mobilizations) or control group. Both groups received standardized education and walking exercise (twice/week) for 6 weeks. Patients in experimental group received additional chest wall mobilizations that include stretching and joints mobilization. Pulmonary function, respiratory muscle strength, thoracic excursion, cervical and thoracic range of movement were evaluated at baseline, post-program and at 3-month follow-up. RESULTS: There were significantly greater improvements in respiratory muscle strength, thoracic excursion and thoracic range of movement (p < 0.01) except thoracic flexion. Lower thoracic excursion is strongly associated with increase in maximum inspiratory pressure (ß = 13.64, p < 0.001) and maximum expiratory pressure (ß = 16.23, p < 0.001). Thoracic range of movement especially extension (p < 0.001) and bilateral rotation (p < 0.01) exhibit a strong relationship with increase in lower thoracic excursion (adjusted R2 = 0.876) as shown in multiple regression analysis. CONCLUSION: Additional chest wall mobilization in the rehabilitation of patients with COPD is likely to enhance thoracic extension and rotation which increase lower thoracic excursion. This significant improvement in chest expansion capacity allows respiratory muscles to work at an optimal functional length which result in greater respiratory muscle strength in patients with severe COPD.

The relationship between client dissatisfaction and contraceptive discontinuation among urban family planning clients in three sub-Saharan African countries.

Although researchers and practitioners have suggested that the quality of family planning services impacts contraceptive discontinuation, establishing a causal relationship has been challenging, primarily due to data limitations and a lack of agreement on how to measure quality. This longitudinal study estimated the relationship of the dissatisfaction with family planning services on contraceptive discontinuation for a sample of 797 female clients who sought family planning services at urban facilities across Kenya, Nigeria, and Burkina Faso. Clients who sought family planning services were first interviewed in person at private and public health facilities and received a follow-up phone interview four to six months later. In our sample, 18.2% of clients who were using a modern contraceptive at baseline stopped using it by follow-up. At baseline, nearly 14% of clients reported experiencing a problem with service convenience, nearly 12% with the availability of medicines and contraceptives, and nearly 6% with facility cleanliness and/or staff treatment. We hypothesized that client dissatisfaction with the family planning services received informed their decision to discontinue contraception and estimated univariate and bivariate probit regression models, controlling for individual and health facility characteristics. We found that client's perceptions of staff treatment and facility cleanliness informed their expectations about service and contraceptive standards, affecting subsequent contraceptive discontinuation. The difference in the probability of discontinuing contraception was 8.2 percentage-points between dissatisfied and satisfied clients. Examining client dissatisfaction with family planning services can inform the family planning community on needed improvements to increase contraceptive adherence for women in need, which can prevent unplanned pregnancies and unwanted births in the long run.

Males' Awareness of Female and Male Contraception Methods, Information, Outreach, and Acquisition Locations in Abidjan, Côte d'Ivoire, Nairobi, Kenya, and Lagos, Nigeria.

PURPOSE: The aim of this study is to describe modern female and male method awareness, information sources, outreach exposures, and acquisition source awareness among young men aged 15-24 by sexual behavior status in sub-Saharan Africa. METHODS: Cross-sectional surveys were conducted with unmarried, young men aged 15-24 recruited via respondent-driven sampling in Abidjan, Côte d'Ivoire (n = 1,028), Nairobi, Kenya (n = 691), and Lagos, Nigeria (n = 706). Descriptive statistics characterized contraception awareness of male and female methods and information sources, outreach exposures, acquisition source awareness, and preferred contraception source. Multivariate regressions characterized factors associated with awareness of each method. RESULTS: Majority of respondents were aged 15-20 (59%), sexually active (65%), and had secondary or more education (89%). Awareness was low for all methods (short-acting reversible contraception, 47%; emergency contraception, 35%; long-acting reversible contraception, 32%; withdrawal, 18%), except condoms (85%). Respondents reported low levels of contraception information sources, recent outreach exposures, and acquisition location awareness that varied by sexual behavior (higher among sexually active than nonsexually active respondents). Multivariate analyses demonstrated common factors associated across awareness of all methods included information sources (teacher, friend, Internet, social media for all respondents; pharmacist for sexually active respondents) and acquisition locations (private healthcare, pharmacy, market/store for all respondents; public healthcare, mobile clinic, faith-based organizations for sexually active respondents). Sexually active respondents' rank order for preferred contraception source was doctors/nurses followed by teachers, friends, mothers, and fathers; and for nonsexually active respondents' rank order was teachers followed by friends, mothers, doctors/nurses, and health centers. DISCUSSION: Findings have implications for increasing young men's method awareness, specific sources, and settings to target contraceptive outreach.

Missed opportunities for family planning counselling among postpartum women in eleven counties in Kenya.

BACKGROUND: Mothers may access medical facilities for their babies and miss opportunities to access family planning (FP) services. This study was undertaken to describe missed opportunities for FP among women within the extended (0-11 months) postpartum period from counties participating in Performance Monitoring and Accountability 2020 (PMA2020) surveys. DESIGN AND SETTING: This study analysed cross-sectional household survey data from 11 counties in Kenya between 2014 and 2018. PMA2020 uses questions extracted from the Demographic and Health survey (DHS) and DHS definitions were used. Multivariable logistic regression was used for inferential statistics with p-value of < 0.05 considered to be significant. PARTICIPANTS: Women aged 15-49 years from the households visited. PRIMARY OUTCOME MEASURE: Missed opportunity for family planning/contraceptives (FP/C) counselling. RESULTS: Of the 34,832 women aged 15-49 years interviewed, 10.9% (3803) and 10.8% (3746) were in the period 0-11 months and 12-23 months postpartum respectively, of whom, 38.8 and 39.6% respectively had their previous pregnancy unintended. Overall, 50.4% of women 0-23 months postpartum had missed opportunities for FP/C counselling. Among women who had contact with health care at the facility, 39.2% of women 0-11 months and 44.7% of women 12-23 months had missed opportunities for FP/C counselling. Less than half of the women 0-11 months postpartum (46.5%) and 64.5% of women 12 - 23 months postpartum were using highly efficacious methods. About 27 and 18% of the women 0-11 months and 12 - 23 months postpartum respectively had unmet need for FP/C. Multivariable analysis showed that being low parity and being from the low wealth quintile significantly increased the odds of missed opportunities for FP/C counselling among women in the extended postpartum period, p < 0.05. CONCLUSIONS: A large proportion of women have missed opportunities for FP/C counselling within 2 years postpartum. Programs should address these missed opportunities.

Effectiveness of a structured physical rehabilitation program on the physical fitness, mental health and pain for Chinese patients with major depressive disorders in Hong Kong - a randomized controlled trial with 9-month follow-up outcomes.

PURPOSE: The long-term and specific impacts on the physical and mental health for Chinese people with major depressive disorders (MDD) are not well-studied. The aim of the study is to investigate both short-and long-term effects of a structured physical rehabilitation program on the physical and mental health and pain for Chinese patients with MDD. METHODS: 84 Chinese patients with MDD were randomized to intervention (n = 42) or control group (n = 42). Intervention group received a 12-week physical rehabilitation program and the control group with 12-week waiting period followed the same pathway as the intervention group afterwards for longitudinal analysis. Data were collected at baseline (T1), end of 12-week program (T2) and 9-month follow-up period (T3). RESULTS: Significant pre- and post-intervention improvements were noted in cardiopulmonary function, depressive symptoms, pain, body composition, muscle strength and flexibility for the intervention group. Although mild attenuation is noted from T2 to T3, subjects without exercise habit experienced significant decline in cardiopulmonary function, depressive symptoms and pain (p < 0.05) but not in those who developed exercise habit (p > 0.05). CONCLUSION: Structured physical rehabilitation program could improve physical and mental fitness and pain for Chinese MDD patients. Its effects could be sustained up to 9 months after cessation of the program provided that people establish their own exercise habit.IMPLICATIONS FOR REHABILITATIONExercise is an effective means of improving physical and mental health and pain for people with major depressive disorders (MDD).People with MDD have multiple reasons, both physically and psychosocially, for physical deconditioning and hurdles for exercise.Structured supervised exercise program can enhance physical and mental health and may likely enhance exercise compliance in this population.

Gendered power dynamics and threats to sexual and reproductive autonomy among adolescent girls and young adult women: A cross-sectional survey in three urban settings.

BACKGROUND: Gendered economic and social systems can enable relational power disparities for adolescent girls and young women (AGYW), and undercut autonomy to negotiate sex and contraceptive use. Less is known about their accumulation and interplay. This study characterizes relationship power imbalances (age disparity, intimate partner violence [IPV], partner-related fear, transactional sex, and transactional partnerships), and evaluates associations with modern contraceptive use, and sexual/reproductive autonomy threats (condom removal/"stealthing", reproductive coercion, ability to refuse sex, and contraceptive confidence). METHODS: Cross-sectional surveys were conducted with unmarried, currently-partnered AGYW aged 15-24 recruited via respondent-driven sampling in Abidjan, Côte d'Ivoire (n = 555; 2018-19), Nairobi, Kenya (n = 332; 2019), and Lagos, Nigeria (n = 179; 2020). Descriptive statistics, Venn diagrams, and multivariate regression models characterized relationship power imbalances, and associations with reproductive autonomy threats and contraceptive use. FINDINGS: Relationship power imbalances were complex and concurrent. In current partnerships, partner-related fears were common (50.4%Nairobi; 54.5%Abidjan; 55.7%Lagos) and physical IPV varied (14.5%Nairobi; 22.1%Abidjan; 9.6%Lagos). IPV was associated with reproductive coercion in Nairobi and Abidjan. Age disparate relationships undermined confidence in contraception in Nairobi. In Nairobi and Lagos, transactional sex outside the relationship was associated with condom stealthing. INTERPRETATION: AGYW face simultaneous gendered power differentials, against the backdrop of gendered social and economic systems. Power imbalances were linked with coercive sexual/reproductive health experiences which are often underrecognized yet represent a potent link between gendered social systems and poor health. Pregnancy prevention efforts for AGYW must address reproductive autonomy threats, and the relational power imbalances and broader gendered systems that enable them.

The aggregate effect of implementation strength of family planning programs on modern contraceptive use at the health systems level in rural Malawi.

To explore the association between the strength of implementation of family planning (FP) programs on the use of modern contraceptives. Specifically, how strongly these programs are being implemented across a health facility's catchment area in Malawi and the odds of a woman in that catchment area is using modern contraceptives. This information can be used to assess whether the combined impact of multiple large-scale FP programs is leading to change in the health outcomes they aim to improve. We used data from the 2017 Implementation Strength Assessment (ISA) that quantified how much of family planning programs at the health facility and community health worker levels were being implemented across every district of Malawi. We used a summary measure developed in a previous study that employs quantitative methods to combine data across FP domains and health system levels. We tested the association of this summary measure for implementation strength with household data from the 2015 Malawi Demographic Health Survey (DHS). We found that areas with stronger implementation of FP programs had higher odds of women using modern contraceptives compared with areas with weaker implementation. The association of ISA with use of modern contraception was different by education, marital status, and geography. After controlling for these factors, we found that the adjusted odds of using a modern contraceptive was three times higher in catchment areas with high implementation strength compared to those with lower strength. Metrics that summarize how strongly FP programs are being implemented were used to show a statistically significantly positive relationship between increasing implementation strength and higher rates of modern contraceptive use. Decisionmakers at the various levels of health authority can use this type of summary measure to better understand the combined impact of their diverse FP programming and inform future programmatic and policy decisions. The findings also reinforce the idea that having a well-supported and supplied cadre of community health workers supplementing FP provision at the health facility can be an important health systems mechanism, especially in rural settings and to target youth populations.

Explaining withdrawal's persistence: correlates of withdrawal use in Albania, Armenia, Jordan, and Turkey observed in a cross-sectional study.

Background: Withdrawal dominates the contraceptive method mix in a geographical cluster of countries in South-Eastern Europe and Western Asia that have, in part, reached low fertility. This study examines the socio-demographic determinants associated with withdrawal use in Armenia, Albania, Jordan and Turkey that could explain withdrawal's persistence and inform contraceptive programs in these unique settings. Methods: Cross-sectional data on 31,569 married women 15 to 49 years were drawn from the Demographic and Health Surveys in Albania (2017-2018), Armenia (2015-2016), Jordan (2017-2018), and Turkey (2013). For each country, multinomial regression models estimating withdrawal use among all women and logistic regression models estimating withdrawal use among contraceptive users were used to evaluate the association with age, marital duration, parity, education, residence, and household wealth. Results: The socio-demographic determinants associated with withdrawal use varied by country among all women and among all contraceptive users. While these associations were not all significant for all four countries general trends included that women were more likely to use withdrawal than not use contraception, but less likely to use withdrawal than other methods with increasing parity, higher education, and greater household wealth. Measures of association are reported by country for each correlate. Conclusions: Despite the similar contraceptive mix in these four countries, no single set of factors was found to explain withdrawal's persistence. Withdrawal's prevalence in this geographical cluster may instead result from different balances of intertwined circumstances that include couples' fertility decisions, access to modern contraception and availability of abortion services.

Is Client Reporting on Contraceptive Use Always Accurate? Measuring Consistency and Change with a Multicountry Study.

The consistency of self-reported contraceptive use over short periods of time is important for understanding measurement reliability. We assess the consistency of and change in contraceptive use using longitudinal data from 9,390 urban female clients interviewed in DR Congo, India, Kenya, Niger, Nigeria, and Burkina Faso. Clients were interviewed in-person at a health facility and four to six months later by phone. We compared reports of contraceptive use at baseline with recall of baseline contraceptive use at follow-up. Agreement between these measures ranged from 59.1 percent in DR Congo to 84.4 percent in India. Change in both contraceptive method type (sterilization, long-acting, short-acting, nonuse) and use status (user, nonuser, discontinuer, adopter, switcher) was assessed comparing baseline to follow-up reports and retrospective versus current reports within the follow-up survey. More change in use was observed with panel reporting than within the cross section. The percent agreement between the two scenarios of change ranged from 64.8 percent in DR Congo to 84.5 percent in India, with cross-site variation. Consistently reported change in use status was highest for nonusers, followed by users, discontinuers, adopters, and switchers. Inconsistency in self-reported contraceptive use, even over four to six months, was nontrivial, indicating that studying measurement reliability of contraceptive use remains important.

Service delivery point and individual characteristics associated with the adoption of modern contraceptive: A multi-country longitudinal analysis.

BACKGROUND: Women who start using contraception ("adopters") are a key population for family planning goals, but little is known about characteristics that predict the adoption of contraception as opposed to current use. We used prospective data from women and facilities for five countries, (Democratic Republic of Congo, India, Kenya, Nigeria, and Burkina Faso) and identified baseline characteristics that predicted adoption of modern contraception in the short term. METHODS: We used data from the Performance Monitoring for Action (PMA) Agile Project. PMA Agile administered service delivery point (SDP) client exit interview (CEI) surveys in urban sites of these five countries. Female clients responding to the CEI were asked for phone numbers that were used for a phone follow-up survey approximately four months later. For our analysis, we used data from the SDP and CEI baseline surveys, and the phone follow up to compare women who start using contraception during this period with those who remain non-users. We used characteristics of the facility and the woman at baseline to predict her contraception adoption in the future. RESULTS: Discussing FP with a partner at baseline was associated with greater odds of adoption in DRC (OR 2.34; 95% CI 0.97-5.66), India (OR 2.27; 95% CI 1.05-4.93), and Kenya (OR 1.65; 95% CI 1.16-2.35). Women who discussed family planning with any staff member at the health facility had 1.72 greater odds (95% CI 1.13-2.67) of becoming an adopter in Nigeria. The odds of adoption were lower in Nigerian facilities that had a stockout (OR 0.66 95% CI 0.44-1.00) at baseline. Other characteristics associated with contraception adoption across settings were education, age, wealth, parity, and marital status. CONCLUSIONS: Characteristics of both the woman and the health facility were associated with adoption of modern contraception in the future. Some characteristics, like discussing family planning with a spouse, education, and parity, were associated with contraceptive adoption across settings. Other characteristics that predict contraceptive use, such as health facility measures, varied across countries.

Demand satisfied by modern contraceptive among married women of reproductive age in Kenya.

BACKGROUND: Demand for family planning met/satisfied with modern contraceptive methods (mDFPS) has been proposed to track progress in Family Planning (FP) programs for Sustainable Development Goals. This study measured mDFPS among married women of reproductive age (MWRA) in Kenya to identify which groups were not being reached by FP programs. MATERIALS AND METHODS: Performance, Monitoring and Accountability 2020 (PMA2020) survey data from 2014-2018 was used. PMA2020 surveys are cross-sectional including women 15-49 years. PMA2020 used a 2-stage cluster design with urban/rural regions as strata with random selection of households. Univariate and multivariate analysis was done using stata V15. RESULTS: Of the 34,832 respondents interviewed from 2014 to 2018, 60.2% were MWRA. There was a significant decrease in demand for FP from 2014 to 2018, p = 0.012. Lowest demand was among 15-19 and 45-49 years old women. Overall, modern contraceptive prevalence rate increased significantly from 54.6% to 60.8%, p = 0.004, being higher for women from urban areas, home visits by health care worker (HCW), educated, wealthy, visited health facilities and exposed to mass media. Unmet need for FP decreased from 23.0-13.8% over the 5-years, p<0.001. Married adolescent 15-19 had the highest unmet need and those from rural areas, poor, uneducated and not exposed to mass media. mDFPS increased significantly from 69.7-79.4% over the 5-years, p<0.001, with increase in long acting reversible contraception/permanent methods from 19.9-37.2% and decrease in short acting methods from 49.9-42.2%. Significant determinants of mDFPS were age, rural/urban residence, education, wealth, health facility visitation, exposure to FP messages via mass media in the last 12 months, year of study and county of residence. CONCLUSIONS: Results show a good progress in key FP indicators. However, not all MWRA are being reached and should be reached if Kenya is to achieve the desired universal health coverage as well as Sustainable Development Goals. Targeted home visits by HCW as well increase in mass media coverage could be viable interventions.

A Panel Study of Fertility Preferences and Contraceptive Dynamics in the Presence of Competing Pregnancy Risks in Uganda.

Although many studies have examined the influence of women's fertility preferences on subsequent fertility behavior and the role of contraceptive use intentions on unmet need, very few have explored their concurrent effects on contraceptive use dynamics. This study examines the independent concurrent effects of women's fertility preferences and contraceptive intentions on subsequent adoption and discontinuation, treating pregnancy as a competing risk factor that may alter contraceptive need. The data are derived from a 2018 follow-up survey of a 2014 national sample of 3,800 Ugandan female respondents of childbearing age. The survey included a contraceptive calendar that recorded pregnancy, birth, and contraceptive event episodes, including reasons for discontinuation. We use competing risk regression to estimate the effect of fertility preferences and contraceptive intentions on the cumulative incidence function of contraceptive behaviors, accounting for intervening pregnancy, female background covariates, loss to follow-up, and complex survey design. We find that women's contraceptive intentions significantly increase the rate of contraceptive adoption. After having adopted, women's contraceptive intentions have been realized and do not prolong use. The risk of discontinuation among women who adopted after baseline was significantly higher than for those using at baseline, irrespective of their initial intentions. The effectiveness of the type of contraceptive method chosen significantly lowered discontinuation risk. Fertility preferences were not significantly associated with either time to adoption or discontinuation. The pace of the fertility transition in this sub-Saharan African setting is likely being shaped by reproductive regulation through the intentional use of contraception that enables spacing births.

Modern contraceptive availability and stockouts: a multi-country analysis of trends in supply and consumption.

Approximately 214 million women of reproductive age lack adequate access to contraception for their family planning needs, yet patterns of contraceptive availability have seldom been examined. With growing demand for contraceptives in some areas, low contraceptive method availability and stockouts are thought to be major drivers of unmet need among women of reproductive age, though evidence for this is limited. In this research, we examined trends in stockouts, method availability and consumption of specific contraceptive methods in urban areas of four sub-Saharan African countries (Burkina Faso, Democratic Republic of Congo, Kenya and Nigeria) and India. We used representative survey data from the Performance Monitoring for Action Agile Project that were collected in quarterly intervals at service delivery points (SDP) stratified by sector (public vs private), with all countries having five to six quarters of surveys between 2017 and 2019. Among SDPs that offer family planning, we calculated the percentage offering at least one type of modern contraceptive method (MCM) for each country and quarter, and by sector. We examined trends in the percentage of SDPs with stockouts and which currently offer condoms, emergency contraception, oral pills, injectables, intrauterine devices and implants. We also examined trends of client visits for specific methods and the resulting estimated protection from pregnancy by quarter and country. Across all countries, the vast majority of SDPs had at least one type of MCM in-stock during the study period. We find that the frequency of stockouts varies by method and sector and is much more dynamic than previously thought. While the availability and distribution of long-acting reversible contraceptives (LARCs) were limited compared to other methods across countries, LARCs nonetheless consistently accounted for a larger portion of couple years of protection. We discuss findings that show the importance of engaging the private sector towards achieving global and national family planning goals.

A sexual and reproductive empowerment framework to explore volitional sex in sub-Saharan Africa.

Volitional sex is central to the sexual health and well-being of women and girls globally. To date, few studies have examined women's empowerment and its application to sexual health outcomes, including volitional sex. The aim of this study was to explore the relevance of a sexual and reproductive empowerment framework to volitional sex across four geographically and culturally diverse contexts in sub-Saharan Africa. Qualitative data were collected between July and August 2017 in four sites: Ethiopia, Nigeria (Anambra and Kano states) and Uganda. A total of 352 women aged 15-49 and 88 men aged 18 and older were interviewed through 120 in-depth interviews and 38 focus group discussions (n = 440 total participants). Results describe the substantial barriers restraining women's sexual choices, particularly norms that stigmatise women's requests for sex, even within marriage. Results further highlight women's internal sexual motivations, particularly related to the enjoyment of sex and the role of sex in strengthening partner relationships. Future empowerment research and measurement should focus not only on sexual constraints, but also integrate internal motivations, in order to fully understand the factors that shape women's sexual health outcomes.

Measuring contraceptive self-efficacy in sub-Saharan Africa: development and validation of the CSESSA scale in Kenya and Nigeria.

OBJECTIVES: Contraceptive self-efficacy, a women's belief about her own ability to complete the actions necessary for successful family planning, is a well-documented determinant of contraceptive use. However, there is currently no validated measure appropriate for low-resource settings. We developed and tested a new scale to measure Contraceptive Self-Efficacy among women in sub-Saharan Africa (CSESSA) using samples in Kenya and Nigeria. STUDY DESIGN: The CSESSA scale was administered to women in Kenya (n = 314) and Nigeria (n = 414). Reliability and validity were analyzed separately by setting. Validity analysis included assessment of the area under the curve (AUC) to demonstrate predictive capability of CSESSA score for contraceptive use. Logistic regression was employed to test the relationship between CSESSA score and contraceptive use. RESULTS: Item reduction resulted in 11 items in Kenya (α = 0.90) and 10 items in Nigeria (α = 0.93). Three domains of contraceptive self-efficacy emerged in both settings: (1) husband/partner communication, (2) provider communication and (3) choosing and managing a method. Items related to the first two subscales, but not the third, were identical across settings. The AUC indicated predictive capability as mild in Kenya (AUC = 0.58) and strong in Nigeria (AUC = 0.73). In both settings, CSESSA score was associated with use of a modern contraceptive method at 12 months postpartum. CONCLUSIONS: The CSESSA scale is a reliable and valid measure in two countries. Variation of the third subscale by site indicates that certain scale items may be more relevant in areas of low versus high contraceptive prevalence. Further research should be done to validate this subscale in other contexts. IMPLICATIONS: This study contributes a reliable, valid measure of contraceptive self-efficacy in two African countries. The CSESSA scale and subscales can be administered in research (for example for evaluation of interventions to increase contraceptive uptake) or in a clinical setting to inform and improve contraceptive counseling.

Reconceptualizing Women's and Girls' Empowerment: A Cross-Cultural Index for Measuring Progress Toward Improved Sexual and Reproductive Health.

CONTEXT: Improving women's empowerment is pivotal to public health and development programs; however, inconsistent definitions and lack of cross-cultural measures compromise monitoring efforts. METHODS: Data collected in 2017-2018 in Ethiopia, Uganda and two sites in Nigeria were used to develop a cross-cultural index of women's and girls' empowerment in sexual and reproductive health (WGE-SRH). Item development was grounded in qualitative interviews, and informed by a conceptual framework that included domains of existence of choice and exercise of choice related to sex, contraceptive use and pregnancy. Items were pilot tested among 1,229 women aged 15-49 across sites. Psychometric properties were explored to identify crosssite constructs, and logistic regression was used to assess the construct validity of each dimension. RESULTS: Analyses identified subscales for sexual existence of choice (Cronbach's alphas, 0.71-0.79) and contraceptive existence of choice (0.56-0.78). A pregnancy existence of choice subscale emerged for only two sites (0.61-0.80). Internal reliability of the exercise of choice subscales varied. Construct validity analyses found that for some sites, high scores on the sexual and contraceptive existence of choice subscales were associated with elevated odds of volitional sex and contraceptive use, respectively. Combining the existence of choice and exercise of choice summary scores for sex strengthened associations with volitional sex. CONCLUSIONS: The cross-cultural WGE-SRH index can be used to assess existence of choice related to contraception and volitional sex. Further work is needed to improve measures of SRH exercise of choice, and investigate the index's multidimensionality and associations with SRH outcomes.

RESUMEN Contexto: Mejorar el empoderamiento de las mujeres es fundamental para los programas de salud pública y de desarrollo; sin embargo, la existencia de definiciones inconsistentes y la falta de medidas interculturales dificultan los esfuerzos de monitoreo. Métodos: Utilizamos datos recolectados entre 2017 y 2018 en Etiopía, Uganda y dos sitios en Nigeria para desarrollar un índice intercultural del empoderamiento de mujeres y niñas en materia de salud sexual y reproductiva (EMN-SSR). El desarrollo de sus componentes se basó en entrevistas cualitativas y se sustentó en un marco conceptual que incluyó dominios de existencia de opciones y ejercicio del poder de decisión en relación con las relaciones sexuales, el uso de anticonceptivos y el embarazo. Los componentes del índice se sujetaron a pruebas piloto en 1,229 mujeres en edades de 15 a 49 años en todos los sitios. Se exploraron las propiedades psicométricas para identificar constructos intersitios y regresión logística para evaluar la validez de los constructos de cada dimensión. Resultados: Los análisis identificaron subescalas para la existencia de opciones sexuales (Cronbach's alphas, 0.71­0.79) y la existencia de opciones anticonceptivas (0.56­0.78). Una subescala de existencia de opciones de embarazo surgió para solo dos sitios (0.61­0.80). La confiabilidad interna de las subescalas del ejercicio del poder de decisión varió. El análisis de validez de constructos encontró que, para algunos sitios, los puntajes altos en las subescalas de existencia de opciones sexuales y anticonceptivas estuvieron asociados con altas probabilidades de relaciones sexuales voluntarias y uso de anticonceptivos, respectivamente. La combinación de los puntajes resumidos de la existencia de opciones y el ejercicio del poder de decisión para las relaciones sexuales fortaleció las asociaciones con las relaciones sexuales voluntarias. Conclusiónes: El índice intercultural EMN-SSR puede usarse para valorar la existencia de opciones relacionadas con la anticoncepción y las relaciones sexuales voluntarias. Se necesita trabajo adicional para mejorar las medidas del ejercicio del poder de decisión y para investigar la multidimensionalidad y las asociaciones del índice con los resultados de SSR.

RÉSUMÉ Contexte: Les programmes de santé publique et de développement dépendent fondamentalement d'une meilleure auto-nomisation des femmes. Le manque de cohérence dans les définitions et l'absence de mesures transculturelles limitent cependant les efforts de suivi. Méthodes: Des données collectées en 2017­2018 en Éthiopie, en Ouganda et sur deux sites nigérians ont servi à l'élaboration d'un indice transculturel de l'autonomisation des femmes et des filles sur le plan de la santé sexuelle et reproductive (l'indice WGE-SRH). Des entretiens qualitatifs ont servi de base à l'élaboration des questions, avec l'aide d'une cadre conceptuel comprenant les domaines d'existence du choix et d'exercice du choix en matière de rapports sexuels, de pratique contraceptive et de grossesse. Les questions ont été testées parmi 1 229 femmes âgées de 15 à 49 ans sur l'ensemble des sites. Les propriétés psychométriques ont été examinées pour identifier les facteurs inter-sites et la validité conceptuelle de chaque dimension a été évaluée par régression logistique. Résultats: Les analyses ont identifié des sous-échelles pour l'existence du choix sur le plan sexuel (alpha de Cronbach, 0,71­0,79) et sur celui de la contraception (0,56­0,78). Concernant la grossesse, une sous-échelle d'existence du choix n'est apparue que pour deux sites (0,61­0,80). La fiabilité interne des sous-échelles d'exercice du choix s'est révélée variable. Les analyses de validité conceptuelle ont indiqué que, pour certains sites, les hautes cotes sur les sous-échelles d'existence du choix sur les plans sexuel et contraceptif étaient associées à des probabilités élevées de rapports sexuels volontaires et de pratique contraceptive, respectivement. La combinaison des cotes sommaires d'existence du choix et d'exercice du choix concernant les rapports sexuels renforçait les associations avec les rapports volontaires. Conclusions: L'indice transculturel WGE-SRH peut servir à évaluer l'existence du choix concernant la contraception et les rapports sexuels volontaires. Il faut toutefois améliorer les mesures d'exercice du choix en matière de santé sexuelle et reproductive et étudier plus avant la multidimensionnalité de l'indice et les associations avec les résultats de santé sexuelle et reproductive.

Performance monitoring and accountability: The Agile Project's protocol, record and experience.

The Performance Monitoring and Accountability 2020 (PMA2020) project implemented a multi-country sub-project called PMA Agile, a system of continuous data collection for a probability sample of urban public and private health facilities and their clients that began November 2017 and concluded December 2019.  The objective was to monitor the supply, quality and consumption of family planning services.  In total, across 14 urban settings, nearly 2300 health facilities were surveyed three to six times in two years and a total sample of 48,610 female and male clients of childbearing age were interviewed in Burkina Faso, Democratic Republic of Congo, India, Kenya, Niger and Nigeria.  Consenting female clients with access to a cellphone were re-interviewed by telephone after four months; two rounds of the client exit, and follow-up interviews were conducted in nearly all settings.  This paper reports on the PMA Agile data system protocols, coverage and early experiences.  An online dashboard is publicly accessible, analyses of measured trends are underway, and the data are publicly available.

"You better use the safer one leave this one": the role of health providers in women's pursuit of their preferred family planning methods.

BACKGROUND: Universal access to quality sexual and reproductive health (SRH) services is pivotal to ensuring gender equality. In high-income countries, patient-provider interactions have been shown to shape women's decisions about contraception, with poor exchanges decreasing method uptake and satisfaction. While significant progress has been made to increase women's access to SRH services, in low- and middle-income countries, little is known about the quality of family planning patient-provider interactions. The primary objective of this analysis was to explore the role of health care providers in women's family planning decision-making in Ethiopia. METHODS: From July to August 2017, 10 focus group discussions (n = 80) and 30 in-depth interviews were conducted with women aged 15-49 and men aged 18+ recruited via purposive sampling from urban and rural sites in Ethiopia. Semi-structured interview guides explored women's and girls' empowerment in SRH surrounding sex, childbearing, and contraception. All interviews were conducted in Amharic, audio-recorded, and transcribed verbatim into English. Inductive thematic analysis was used to analyze data. Eleven codes specific to provider services for family planning were reviewed and matrixes creates for synthesis. RESULTS: Three primary themes emerged: the role of providers in women's awareness of and demand for family planning services; selection and uptake of contraceptive methods; and discontinuation and switching of contraceptive methods. Results indicate that health extension workers were central to women's awareness of family planning, and health providers' endorsements were instrumental in decisions to adopt methods. The majority of respondents described positive interactions with providers and appreciated thorough counseling when considering using or switching methods. Some women, however, described health providers directing them toward long-acting methods by communicating inaccurate information or emphasizing disadvantages of short-acting methods. A few women described provider reluctance or resistance to switching methods, especially from implants. CONCLUSIONS: Women shared many narratives about the central roles health providers played in their awareness and decision-making for family planning. Those narratives also included provider bias against women's preferred methods. Further research and program assessments are needed to ascertain the extent to which these biases hinder women's decision-making autonomy in using contraception.

The predictive utility of unmet need on time to contraceptive adoption: a panel study of non-contracepting Ugandan women.

OBJECTIVE: The predictive utility of the unmet contraceptive need indicator is not well known, despite being recognized as a key family planning indicator for showing the extant demand for birth control. This study assesses the dynamic influence of unmet need on time to contraceptive adoption, as compared with that of contraceptive intentions and their concordance. STUDY DESIGN: This observational study analyzed survey data, including a contraceptive calendar, reported by a panel of 747 non-contracepting, fecund and sexually active Ugandan women, first interviewed in a 2014 national survey and re-interviewed in 2018. We conducted descriptive, survival and multivariate Cox regression analysis of the influence of women's baseline measures of unmet need, self-reported intention to contracept and their concordance with time to adoption of modern contraception over 36 months. RESULTS: The study found women classified as having unmet need were slower to adopt contraception than those without unmet need, after adjustment for background covariates (aHR = 0.79, 95% CI = 0.57-1.10). Women intending future contraceptive use were significantly faster to adopt (aHR = 1.45, 95% CI = 1.22-1.73) than those not intending. Women with no unmet need but intending to use had the highest rate of adoption compared to those with no need and no intention to use (aHR = 2.78, 95% CI = 1.48-5.25). CONCLUSIONS: The unmet need indicator underperforms in predicting future contraceptive adoption compared to contraceptive intentions, which merits further consideration as a complementary predictor of future use. Non-contracepting women with unmet need but no intention to use contraception in particular warrant programmatic attention. IMPLICATIONS: A non-contracepting woman wanting to limit or space her births is defined as having unmet need, but little is known if she subsequently adopts contraception. By contrasting a woman's unmet need with her expressed intention to use, we offer reasons to further consider self-reported contraceptive intentions as a better predictor of adoption and the underlying latent demand for volitional regulation of fertility.