Contraceptive stockouts in Western Kenya: a mixed-methods mystery client study.

BACKGROUND: The prevalence of modern contraception use is higher in Kenya than in most countries in Sub-Saharan Africa. The uptake has however slowed down in recent years, which, among other factors, has been attributed to challenges in the supply chain and increasing stockouts of family planning commodities. Research on the frequency of contraceptive stockouts and its consequences for women in Kenya is still limited and mainly based on facility audits. METHODS: This study employs a set of methods that includes mystery clients, focus group discussions, key informant interviews, and journey mapping workshops. Using this multi-method approach, we aim to quantify the frequency of method denial resulting from contraceptive stockout and describe the impact of stockouts on the lived experiences of women seeking contraception in Western Kenya. RESULTS: Contraceptives were found to be out of stock in 19% of visits made to health facilities by mystery clients, with all contraceptive methods stocked out in 9% of visits. Women experienced stockouts as a sizeable barrier to accessing their preferred method of contraception and a reason for taking up non-preferred methods, which has dire consequences for heath, autonomy, and the ability to prevent unintended pregnancy. Reasons for contraceptive stockouts are many and complex, and often linked to challenges in the supply chain - including inefficient planning, procurement, and distribution of family planning commodities. CONCLUSIONS: Contraceptive stockouts are frequent and negatively impact patients, providers, and communities. Based on the findings of this study, the authors identify areas where funding and sustained action have the potential to ameliorate the frequency and severity of contraceptive stockouts, including more regular deliveries, in-person data collection, and use of data for forecasting, and point to areas where further research is needed.

Provider verbal disrespect in the provision of family planning in public-sector facilities in Western Kenya.

Public-sector healthcare providers in low- and middle-income countries are a primary source of family planning but their disrespectful (i.e., demeaning or insulting) treatment of family planning clients may impede free contraceptive choice. The construct of disrespect and abuse has been widely applied to similar phenomena in maternity care and could help to better understand provider mistreatment of family planning clients. With a focus on public-sector family planning provision in western Kenya, we aim to estimate the prevalence and impact of disrespect and abuse from a variety of perspectives and advance methodological approaches to measuring this construct in the context of family planning provision. We combine and triangulate data from a variety of sources across five counties in western Kenya, including 180 mystery clients, 253 third-party observations, eight focus group discussions, 19 key informant interviews, and two journey mapping workshops. Across both mystery client and third-party observations conducted in public-sector facilities in western Kenya, approximately one out of every ten family planning seekers was treated with disrespect by their provider. Family planning clients were frequently scolded for seeking family planning while unmarried or low parity, but mistreatment was not limited to women with these specific characteristics. Women were also insulted for such characteristics as body size or perceived sexual promiscuity. Qualitative data confirmed both that client disrespect is widespread and leads women to avoid family planning services even when they desire to use a contraceptive method, sometimes leading to unintended pregnancies. Key informants attribute disrespectful provider practices to both low technical skill as well as poor motivation stemming from both intrinsic values as well as extrinsic factors such as low wages and high caseloads. Possible solutions suggested by key informants included changes to recruitment and admission for Kenyan medical/nursing schools, as well as values clarification to shift provider motivations. Interventions to reduce mistreatment must be multi-layered and well-evidenced to ensure that family planning clients receive the person-centered care that enables them to achieve their contraceptive desires and reproductive freedom.

Findings from a mixed-methods journey map study of barriers to family planning in western Kenya.

Our objective was to map and prioritize barriers to high-quality family planning care in western Kenya. We conducted key informant interviews (n = 19); focus group discussions with clients (n = 55); mystery client visits (n = 180); unannounced visitors (n = 120); and direct observation of client-provider interactions (n = 256) at public facilities offering family planning. We synthesized the data into a client and a provider journey map, which we used to facilitate client (n = 9) and provider (n = 12) discussions. For both groups, stockouts were frequent, impactful, and important barriers. Clients also reported male partner resistance, insufficient counseling, and informal fees were priority barriers.

Frequency and impact of long wait times for family planning in public-sector healthcare facilities in Western Kenya.

BACKGROUND: Long wait times for family planning services are a barrier to high quality care and client satisfaction. Existing literature examining family planning wait times has methodological limitations, as most studies use data collected during exit interviews, which are subject to recall, courtesy, and selection bias. OBJECTIVE: We sought to employ a mixed methods approach to capture the prevalence, length, causes, and impacts of wait times for family planning services in Western Kenya. METHODS: We used mystery clients, focus groups, key informant interviews, and journey mapping workshops to measure and describe family planning wait times. Fifteen mystery clients visited 60 public-sector facilities to quantitatively capture wait times. We conducted eight focus group discussions with 55 current or former family planning clients and 19 key informant interviews to understand facility-level barriers to family planning and feasible solutions. Finally, we visualized the process of seeking and providing family planning with journey mapping workshops with nine clients and 12 providers. RESULTS: Mystery clients waited, on average, 74 minutes to be seen for family planning services. In focus group discussions and key informant interviews, three themes emerged: the nature of wait times, the impact of wait times, and how to address wait times. Clients characterized long wait times as a barrier to achieving their reproductive desires. Key informants perceived provider shortages to cause long wait times, which reduced quality of family planning services. Both providers and family planning clients suggested increasing staffing or offering specialization to decrease wait times and increase quality of care. CONCLUSION: Our mixed methods approach revealed that wait times for family planning services were common, could be extensive, and were viewed as a barrier to high quality of care by clients, providers, and key informants. Across the board, participants felt that addressing workforce shortages would enhance service delivery and thus promote reproductive autonomy among women in Kenya.

Contraceptive method denial as downward contraceptive coercion: A mixed-methods mystery client study in Western Kenya.

OBJECTIVE: This study uses mixed methods to quantify the frequency of method denial in Western Kenya and describe how this barrier impacts contraceptive access. STUDY DESIGN: We estimate the frequency of method denial using data from mystery clients deployed to 57 randomly selected public-sector facilities located in Western Kenya. These quantitative data are triangulated with data from 8 focus group discussions, 19 key informant interviews, and 2 journey mapping workshops with contraception clients and providers. RESULTS: In 21% of mystery client visits, the client was denied their preferred contraceptive method. In 13% of visits, mystery clients were unable to procure any method. Method denial was primarily motivated by provider-imposed requirements for HIV or pregnancy testing, or by provider bias against young, unmarried, or nulliparous women. Method denial also occurred because of provider reluctance to offer certain methods. Focus group discussion participants and interviewees confirmed the frequency and reasons for method denial and identified this practice as a substantial barrier to reproductive autonomy. CONCLUSION: Method denial disrupts contraceptive access among women who have already overcome financial and logistical barriers to arrive at a health care facility. Further attention to this barrier is required to promote reproductive autonomy among women in Western Kenya. IMPLICATIONS: Providers may impose unnecessary restrictions on contraceptive access that limit the ability of women to achieve their desired family size. Unwarranted method denial occurs in approximately one out of every 5 visits to public-sector facilities in Western Kenya and presents a major impediment to reproductive autonomy and justice.

Absenteeism among family planning providers: a mixed-methods study in western Kenya.

Public-sector healthcare providers are on the frontline of family planning service delivery in low- and middle-income countries like Kenya, yet research suggests public-sector providers are frequently absent. The current prevalence of absenteeism in Western Kenya, as well as the impact on family planning clients, is unknown. The objective of this paper is to quantify the prevalence of public-sector healthcare provider absenteeism in this region of Kenya, to describe the potential impact on family planning uptake and to source locally grounded solutions to provider absenteeism. We used multiple data collection methods including unannounced visits to a random sample of 60 public-sector healthcare facilities in Western Kenya, focus group discussions with current and former family planning users, key informant interviews (KIIs) with senior staff from healthcare facilities and both governmental and non-governmental organizations and journey mapping activities with current family planning providers and clients. We found healthcare providers were absent in nearly 60% of unannounced visits and, among those present, 19% were not working at the time of the visit. In 20% of unannounced visits, the facility had no providers present. Provider absenteeism took many forms including providers arriving late to work, taking an extended lunch break, not returning from lunch or being absent for the entire day. While 56% of provider absences resulted from sanctioned activities such as planned vacation, sick leave or off-site work responsibilities, nearly half of the absences were unsanctioned, meaning providers were reportedly running personal errands, intending to arrive later or no one at the facility could explain the absence. Key informants and focus group participants reported high provider absence is a substantial barrier to contraceptive use, but solutions for resolving this problem remain elusive. Identification and rigorous evaluation of interventions designed to redress provider absenteeism are needed.

Informal payments for family planning: prevalence and perspectives of women, providers, and health sector key informants in western Kenya.

Informal payments are off-the-record financial transactions made by patients to their healthcare providers. Providers in low- and middle-income countries solicit informal payments from patients to purchase additional supplies, supplement wages, or for other reasons. Informal payments reduce equitable access to healthcare services and undermine efforts to ensure universal health coverage. This study used multiple data collection methods to estimate the prevalence of informal payments, describe the impact, and explore feasible solutions for curbing this practice in western Kenya. Facility-level data were collected in 60 public sector facilities (contributing 142 mystery client visits and, in a subsample of 10 facilities, 253 client-provider observations). We conducted 8 focus groups with current and prior contraceptive users, 19 key informant interviews, and 2 journey mapping workshops. Providers solicited informal payments in 25% of mystery client visits and 13% of client-provider observations; the median amount of money requested from mystery clients was 1 USD. Focus group and journey mapping participants reported informal payments are a financial barrier and contribute to unintended pregnancy; key informants suggested greater community monitoring of facilities is key for reducing this behaviour.

How women and providers perceive male partner resistance to contraceptives in Western Kenya: A qualitative study.

OBJECTIVE: Almost a fifth of Kenyan women who desire to delay or avoid pregnancy are not using modern contraception. The objective of this study is to describe how Kenyan women, healthcare providers, and health policymakers perceive male partner resistance to function as a barrier to women's experiences attempting to obtain contraceptives. METHODS: We used a qualitative description approach to analyze the transcripts from a mixed-methods parent study in Western Kenya. We conducted conventional content analysis on transcripts from 8 focus group discussions with current and former female contraceptive users (n = 55 participants); in-depth interviews with key informants from the healthcare sector (n = 19); a client journey mapping workshop with female current contraceptive users (n = 9 participants); and a provider journey mapping workshop with public sector providers (n = 12 participants). RESULTS: Primary themes concerned the perceived nature, perceived impact, and strategies for addressing male partner resistance to contraceptives. Male partner resistance affected women's experiences of contraceptive care in two ways. First, anticipating male partner resistance, providers modified how they delivered care to female patients to avoid conflicts with male partners. Second, covert utilization, women's primary strategy for obtaining desired contraceptives despite male partner resistance, can make women more vulnerable to facility-level barriers to care. Participants recommended educating men about the benefits of contraception in the clinical encounter and community settings. CONCLUSION: Male partner resistance to contraceptives, whether experienced or anticipated, can influence how women navigate the health system and how contraceptive care is delivered in Kenya.

"When it comes to time of removal, nothing is straightforward": A qualitative study of experiences with barriers to removal of long-acting reversible contraception in Western Kenya.

OBJECTIVE: Barriers to removal of long-acting reversible contraception (LARC) threaten reproductive self-determination, but their influence on contraceptive behaviors is not well understood. We describe perspectives of women in Western Kenya concerning LARC removal barriers. STUDY DESIGN: We used a qualitative descriptive approach with conventional content analysis to analyze transcripts for content and themes from eight focus group discussions (n = 55 participants) and one client journey mapping workshop (n = 9 participants) with women ages 18-49 in Western Kenya who were currently using or had formerly used contraceptives. FINDINGS: Our primary themes concerned women's experience of LARC removal barriers and the impact on their behaviors and attitudes towards contraception. Women described providers being unwilling to remove LARC, regardless of rationale (including expiration, seeking pregnancy, or experiencing intolerable side effects) or demanding unaffordable fees. Women were reluctant to try LARC for fear of having to use the method for its entire lifespan even if they did not like it. Women saw LARC removal barriers as increasing their risk of unintended pregnancy through non-replacement of expired devices and fostering distrust in the health system. CONCLUSION: Barriers to LARC removal may discourage utilization of LARC and contraceptive services generally, which can undermine women's efforts to achieve reproductive self-determination. IMPLICATIONS: Our findings affirm the importance of timely LARC removal to ensure that family planning programs uphold women's reproductive autonomy.