Social accountability for reproductive, maternal, newborn, child and adolescent health: A review of reviews.

Globally, increasing efforts have been made to hold duty-bearers to account for their commitments to improve reproductive, maternal, newborn, child and adolescent health (RMNCAH) over the past two decades, including via social accountability approaches: citizen-led, collective processes for holding duty-bearers to account. There have been many individual studies and several reviews of social accountability approaches but the implications of their findings to inform future accountability efforts are not clear. We addressed this gap by conducting a review of reviews in order to summarise the current evidence on social accountability for RMNCAH, identify factors contributing to intermediary outcomes and health impacts, and identify future research and implementation priorities. The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42019134340). We searched eight databases and systematic review repositories and sought expert recommendations for published and unpublished reviews, with no date or language restrictions. Six reviews were analysed using narrative synthesis: four on accountability or social accountability approaches for RMNCAH, and two specifically examining perinatal mortality audits, from which we extracted information relating to community involvement in audits. Our findings confirmed that there is extensive and growing evidence for social accountability approaches, particularly community monitoring interventions. Few documented social accountability approaches to RMNCAH achieve transformational change by going beyond information-gathering and awareness-raising, and attention to marginalised and vulnerable groups, including adolescents, has not been well documented. Drawing generalisable conclusions about results was difficult, due to inconsistent nomenclature and gaps in reporting, particularly regarding objectives, contexts, and health impacts. Promising approaches for successful social accountability initiatives include careful tailoring to the social and political context, strategic planning, and multi-sectoral/multi-stakeholder approaches. Future primary research could advance the evidence by describing interventions and their results in detail and in their contexts, focusing on factors and processes affecting acceptability, adoption, and effectiveness.

Mixed-methods study on pharmacies as contraception providers to Kenyan young people: who uses them and why?

OBJECTIVES: This study sought to answer two questions: (1) what are the characteristics of young Kenyans aged 18-24 who use contraception obtained at pharmacies, and (2) why are pharmacies appealing sources of contraception? DESIGN AND SETTING: This was a mixed-methods study in one peri-urban part of Kwale County, Kenya. Methods included cross-sectional survey (n=740), six focus group discussions, 18 in-depth interviews and 25 key-informant interviews. Quantitative data analysis identified factors pushing young people to pharmacies for modern contraception versus other sources. Qualitative data analysis identified reasons pharmacies were perceived to be appealing to young clients. PARTICIPANTS: Participants were (1) young people aged 18-24 from the study area, including a subset who had recently purchased contraception from a pharmacy; or (2) pharmacy personnel and pharmacy stakeholders. RESULTS: Among surveyed participants who had ever had sexual intercourse and had used modern contraception at last sexual intercourse, 59% obtained it from a pharmacy. In multivariable analysis, participants who used a condom or emergency contraception as well as those living alone were significantly more likely to get contraception from pharmacies. Pharmacies were valued for their convenience, privacy, non-judgmental and personable staff, service speed, as well as predictable and affordable prices. CONCLUSIONS: Our findings indicate a high percentage of young people in Coastal Kenya use pharmacies for contraception. Our inclusion of emergency contraception users partially explains this. Pharmacies were perceived to be everything that health facilities are not: fast, private and non-limiting. Policy-makers should recognise the role of pharmacies as contraception providers and look for opportunities to link pharmacies to the public health system. This would create a network of accessible and appealing contraception services for young people.

The development of a new accountability measurement framework and tool for global health initiatives.

The Global Strategy for Women's Children's and Adolescents' Health emphasizes accountability as essential to ensure that decision-makers have the information required to meet the health needs of their populations and stresses the importance of tracking resources, results, and rights to see 'what works, what needs improvement and what requires increased attention'. However, results from accountability initiatives are mixed and there is a lack of broadly applicable, validated tools for planning, monitoring and evaluating accountability interventions. This article documents an effort to transform accountability markers-including political will, leadership and the monitor-review-act cycle-into a measurement tool that can be used prospectively or retrospectively to plan, monitor and evaluate accountability initiatives. It describes the development process behind the tool including the literature review, framework development and subsequent building of the measurement tool itself. It also examines feedback on the tool from a panel of global experts and the results of a pilot test conducted in Bauchi and Gombe states in Nigeria. The results demonstrate that the tool is an effective aid for accountability initiatives to reflect on their own progress and provides a useful structure for future planning, monitoring and evaluation. The tool can be applied and adapted to other accountability mechanisms working in global health.

Regulating pharmacists as contraception providers: A qualitative study from Coastal Kenya on injectable contraception provision to youth.

INTRODUCTION: Young people worldwide are often reticent to access family planning services from public health facilities: instead, they choose to get contraception from private, retail pharmacies. In Kenya, certain contraceptives are available in pharmacies: these include injectables, which can be dispensed but not administered, according national guidelines. However, Kenya struggles with enforcement of its pharmacy regulations and addressing illegal activity. Therefore, in this qualitative study, we assessed private pharmacies as an existing source of injectable contraception for young Kenyans (age 18-24), and investigated the perceived quality of service provision. METHODS: This study used: focus group discussions (6) with young community members; in-depth interviews (18) with youth who had purchased contraception from pharmacies; key informant interviews with pharmacy personnel and pharmacy stakeholders (25); and a mystery shopper (visiting 45 pharmacies). RESULTS: The study found that for injectable contraception, private pharmacies had expanded to service provision, and pharmacy personnel's roles had transcended formal or informal training previously received-young people could both purchase and be injected in many pharmacies. Pharmacies were perceived to lack consistent quality or strong regulation, resulting in young clients, pharmacy personnel, and regulators being concerned about illegal activity. Participants' suggestions to improve pharmacy service quality and regulation compliance focused on empowering consumers to demand quality service; strengthening regulatory mechanisms; expanding training opportunities to personnel in private pharmacies; and establishing a quality-based 'brand' for pharmacies. DISCUSSION: Kenya's recent commitments to universal health coverage and interest in revising pharmacy policy provide an opportunity to improve pharmacy quality. Multi-pronged initiatives with both public and private partners are needed to improve pharmacy practice, update and enforce regulations, and educate the public. Additionally, the advent of self-administrable injectables present a new possible role for pharmacies, and could offer young clients a clean, discreet place to self-inject, with pharmacy personnel serving as educators and dispensers.

The feasibility and acceptability of collaborative learning in improving health worker performance on adolescent health: findings from implementation research in Moldova.

BACKGROUND: Collaborative learning has been shown to be effective in improving health worker performance, but relatively little is known about the feasibility or acceptability of collaborative learning in youth-friendly health services (YFHS). This paper describes the characteristics, feasibility and acceptability of a collaborative learning approach implemented in YFHS in Moldova as part of a national scaling up process. METHODS: We gathered and analysed data on the number, location, themes, and participants of sessions, as well as benefits and challenges of collaborative learning, using two information sources: 1) formal reports on collaborative learning sessions, and 2) two questionnaires conducted with participants and moderators. RESULTS: Collaborative learning sessions have been implemented in 30 out of 35 YFHS in Moldova. In 2016, 464 collaborative learning sessions were conducted. Sessions were conducted one to three times per month, had a mean of 15 participants and an average duration of two - three hours. 74.3% of participants (n = 6942) were from rural areas and 55.1% were health professionals. The most common topics in 2016 were adolescent health and YFHS (159 of 464 sessions), sexual and reproductive health (103 sessions), and violence (76 sessions). Reported benefits for participants of collaborative learning fell into three categories: 1) improved knowledge on adolescent health / development and use of evidence-based resources; 2) strengthened teamwork and cooperation; and 3) empowerment to provide high quality, youth-friendly care. Moderators identified benefits for the quality, youth-friendliness, and positioning of YFHS as centres of excellence on adolescent health. Challenges included the time and resources required to start and maintain the program, developing a constructive multi-disciplinary learning culture, and ensuring the involvement of stakeholders from outside YFHS. CONCLUSION: This study confirms that collaborative learning within YFHS is feasible and acceptable, and offers benefits to both participants and YFHS. Collaborative learning may be a valuable strategy to improve the quality and youth-friendliness of services. It may also be relevant to key challenges in scaling up YFHS such as increasing utilisation and achieving long-term sustainability. Further research is required to confirm our results in other settings and to examine the effects of collaborative learning at the outcome and impact level.

Sexual violence as a risk factor for family planning-related outcomes among young Burundian women.

OBJECTIVES: The study aimed to examine associations between experience of sexual violence and family planning-related outcomes. METHODS: A multi-stage cluster survey was conducted among a representative sample of 744 young women aged 15-24 in eight provinces in Burundi. RESULTS: The prevalence of young women who reported having ever been physically forced to have sexual intercourse was 26.1%. Young women who had experienced sexual violence (ever) were 2.5 times more likely not to have used any modern contraceptives in the 12 months preceding the survey. They were also 2.3 times more likely to report that their last pregnancy was unplanned. Higher odds of not being able to negotiate contraceptive use with their partners were only reported by young women having experienced sexual violence in the 12 months prior to the survey when adjusted for confounders. CONCLUSIONS: Sexual violence was found to be significantly associated with contraceptive negotiation and use as well as unplanned pregnancy. Weak perceived ability to negotiate contraceptive use highlights gender inequalities leaving young women vulnerable to unprotected sex and thus unplanned pregnancies.

Strengthening accountability for improved maternal and newborn health: A mapping of studies in Sub-Saharan Africa.

OBJECTIVE: To describe the types of maternal and newborn health program accountability mechanisms implemented and evaluated in recent years in Sub-Saharan Africa, how these have been implemented, their effectiveness, and future prospects to improve governance and MNH outcomes. METHOD: A structured review selected 38 peer-reviewed papers between 2006 and 2016 in Sub-Saharan Africa to include in the analysis. RESULTS: Performance accountability in MNH through maternal and perinatal death surveillance was the most common accountability mechanism used. Political and democratic accountability through advocacy, human rights, and global tracking of progress on indicators achieved greatest results when multiple stakeholders were involved. Financial accountability can be effective but depend on external support. Overall, this review shows that accountability is more effective when clear expectations are backed by social and political advocacy and multistakeholder engagement, and supported by incentives for positive action. CONCLUSION: There are few accountability mechanisms in MNH in Sub-Saharan Africa between decision-makers and those affected by those decisions with both the power and the will to enforce answerability. Increasing accountability depends not only on how mechanisms are enforced but also, on how providers and managers understand accountability.

Using advocacy and data to strengthen political accountability in maternal and newborn health in Africa.

Accountability mechanisms help governments and development partners fulfill the promises and commitments they make to global initiatives such as the Millennium Development Goals and the Global Strategy on Women's and Children's health, and regional or national strategies such as the Campaign for the Accelerated Reduction in Maternal Mortality in Africa (CARMMA). But without directed pressure, comparative data and tools to provide insight into successes, failures, and overall results, accountability fails. The analysis of accountability mechanisms in five countries supported by the Evidence for Action program shows that accountability is most effective when it is connected across global and national levels; civil society has a central and independent role; proactive, immediate and targeted implementation mechanisms are funded from the start; advocacy for accountability is combined with local outreach activities such as blood drives; local and national champions (Presidents, First Ladies, Ministers) help draw public attention to government performance; scorecards are developed to provide insight into performance and highlight necessary improvements; and politicians at subnational level are supported by national leaders to effect change. Under the Sustainable Development Goals, accountability and advocacy supported by global and regional intergovernmental organizations, constantly monitored and with commensurate retribution for nonperformance will remain essential.

Determinants of Elongation of the Labia Minora in Tete Province, Central Mozambique: Findings of a Household Survey.

A WHO-supported provincial-level population-based survey was conducted in 2007 to understand the determinants and implications for health of vaginal practices. A total of 919 women aged 18-60 were selected randomly for enrolment. This is the first population-based study of females in Tete Province, Mozambique. At some time over their lives, 98.8% of women had practiced elongation of their labia minora and a quarter (24.0%) had done so in the past month. Currently practicing women were more likely to have engaged in sex recently, and used contraceptives and condoms at last sex than women who had stopped labial elongation. Younger age, residence in rural areas and having two or more male partners were also determinants of current practice. Women commonly reported they practiced for no specific reason (62.8%). Discomforting itchiness and lower abdominal pain were more frequent in women who had stopped labial elongation than in women who were currently practicing. Although women may not report current vaginal ill health, it is possible that prospective cohort studies could uncover alterations in genital vaginal flora or other indicators of impact on women's health. The findings of this study do not suggest that labial elongation is linked with high-risk behaviors for HIV transmission.

A systematic review of supportive supervision as a strategy to improve primary healthcare services in Sub-Saharan Africa.

BACKGROUND: It may be assumed that supportive supervision effectively builds capacity, improves the quality of care provided by frontline health workers, and positively impacts clinical outcomes. Evidence on the role of supervision in Sub-Saharan Africa has been inconclusive, despite the critical need to maximize the workforce in low-resource settings. OBJECTIVES: To review the published literature from Sub-Saharan Africa on the effects of supportive supervision on quality of care, and health worker motivation and performance. SEARCH STRATEGY: A systematic review of seven databases of both qualitative and quantitative studies published in peer-reviewed journals. SELECTION CRITERIA: Selected studies were based in primary healthcare settings in Sub-Saharan Africa and present primary data concerning supportive supervision. DATA COLLECTION AND ANALYSIS: Thematic synthesis where data from the identified studies were grouped and interpreted according to prominent themes. MAIN RESULTS: Supportive supervision can increase job satisfaction and health worker motivation. Evidence is mixed on whether this translates to increased clinical competence and there is little evidence of the effect on clinical outcomes. CONCLUSIONS: Results highlight the lack of sound evidence on the effects of supportive supervision owing to limitations in research design and the complexity of evaluating such interventions. The approaches required a high level of external inputs, which challenge the sustainability of such models.

Gender Determinants of Vaccination Status in Children: Evidence from a Meta-Ethnographic Systematic Review.

Using meta-ethnographic methods, we conducted a systematic review of qualitative research to understand gender-related reasons at individual, family, community and health facility levels why millions of children in low and middle income countries are still not reached by routine vaccination programmes. A systematic search of Medline, Embase, CINAHL, Cochrane Library, ERIC, Anthropological Lit, CSA databases, IBSS, ISI Web of Knowledge, JSTOR, Soc Index and Sociological Abstracts was conducted. Key words were built around the themes of immunization, vaccines, health services, health behaviour, and developing countries. Only papers, which reported on in-depth qualitative data, were retained. Twenty-five qualitative studies, which investigated barriers to routine immunisation, were included in the review. These studies were conducted between 1982 and 2012; eighteen were published after 2000. The studies represent a wide range of low- to middle income countries including some that have well known coverage challenges. We found that women's low social status manifests on every level as a barrier to accessing vaccinations: access to education, income, as well as autonomous decision-making about time and resource allocation were evident barriers. Indirectly, women's lower status made them vulnerable to blame and shame in case of childhood illness, partly reinforcing access problems, but partly increasing women's motivation to use every means to keep their children healthy. Yet in settings where gender discrimination exists most strongly, increasing availability and information may not be enough to reach the under immunised. Programmes must actively be designed to include mitigation measures to facilitate women's access to immunisation services if we hope to improve immunisation coverage. Gender inequality needs to be addressed on structural, community and household levels if the number of unvaccinated children is to substantially decrease.

Establishing a baseline to measure change in political will and the use of data for decision-making in maternal and newborn health in six African countries.

The Evidence for Action (E4A) program assumes that both resource allocation and quality of care can improve via a strategy that combines evidence and advocacy to stimulate accountability. The present paper explains the methods used to collect baseline monitoring data using two tools developed to inform program design in six focus countries. The first tool is designed to understand the extent to which decision-makers have access to the data they need, when they need it, and in meaningful formats, and then to use the data to prioritize, plan, and allocate resources. The second tool seeks the views of people working in the area of maternal and newborn health (MNH) about political will, including: quality of care, the political and financial priority accorded to MNH, and the extent to which MNH decision-makers are accountable to service users. Findings indicate significant potential to improve access to and use of data for decision-making, particularly at subnational levels. Respondents across all six program countries reported lack of access by ordinary citizens to information on the health and MNH budget, and data on MNH outcomes. In all six countries there was a perceived inequity in the distribution of resources and a perception that politicians do not fully understand the priorities of their constituents.

Using evidence to drive action: a "revolution in accountability" to implement quality care for better maternal and newborn health in Africa.

Introducing evidence-based accountability mechanisms at national and subnational levels into maternal newborn health programs can accelerate reductions in maternal and newborn mortality. Clearly packaged evidence has the potential to catalyze change, if it is communicated not only to the public but also to key policymakers. Evidence for Action (E4A) is a DFID-funded program that contributes to global efforts toward improving accountability in maternal and neonatal health. It uses evidence to drive action and accountability to improve maternal and newborn survival in six African countries: Ethiopia, Ghana, Malawi, Nigeria, Sierra Leone, and Tanzania. This paper introduces the E4A program, the rationale that underpins the program design, and presents initial findings on how information and data currently feed into accountability and implementation across the six E4A countries.

HIV testing and tolerance to gender based violence: a cross-sectional study in Zambia.

This paper explores the effect of social relations and gender-based conflicts on the uptake of HIV testing in the South and Central provinces of Zambia. We conducted a community-based cross-sectional study of 1716 randomly selected individuals. Associations were examined using mixed-effect multivariable logistic regression. A total of 264 men (64%) and 268 women (56%) had never tested for HIV. The strongest determinants for not being tested were disruptive couple relationships (OR = 2.48 95% CI = 1.00-6.19); tolerance to gender-based violence (OR = 2.10 95% CI = 1.05-4.32) and fear of social rejection (OR = 1.48 95% CI = 1.23-1.80). In the Zambian context, unequal power relationships within the couple and the community seem to play a pivotal role in the decision to test which until now have been largely underestimated. Policies, programs and interventions to rapidly increase HIV testing need to urgently address gender-power inequity in relationships and prevent gender-based violence to reduce the negative impact on the lives of couples and families.

Access to HIV/AIDS care: a systematic review of socio-cultural determinants in low and high income countries.

BACKGROUND: The role of socio-cultural factors in influencing access to HIV/AIDS treatment, care and support is increasingly recognized by researchers, international donors and policy makers. Although many of them have been identified through qualitative studies, the evidence gathered by quantitative studies has not been systematically analysed. To fill this knowledge gap, we did a systematic review of quantitative studies comparing surveys done in high and low income countries to assess the extent to which socio-cultural determinants of access, identified through qualitative studies, have been addressed in epidemiological survey studies. METHODS: Ten electronic databases were searched (Cinahl, EMBASE, ISI Web of Science, IBSS, JSTOR, MedLine, Psyinfo, Psyindex and Cochrane). Two independent reviewers selected eligible publications based on the inclusion/exclusion criteria. Meta-analysis was used to synthesize data comparing studies between low and high income countries. RESULTS: Thirty-four studies were included in the final review, 21 (62%) done in high income countries and 13 (38%) in low income countries. In low income settings, epidemiological research on access to HIV/AIDS services focused on socio-economic and health system factors while in high income countries the focus was on medical and psychosocial factors. These differences depict the perceived different barriers in the two regions. Common factors between the two regions were also found to affect HIV testing, including stigma, high risk sexual behaviours such as multiple sexual partners and not using condoms, and alcohol abuse. On the other hand, having experienced previous illness or other health conditions and good family communication was associated with adherence to ART uptake. Due to insufficient consistent data, a meta-analysis was only possible on adherence to treatment. CONCLUSIONS: This review offers evidence of the current challenges for interdisciplinary work in epidemiology and public health. Quantitative studies did not systematically address in their surveys important factors identified in qualitative studies as playing a critical role on the access to HIV/AIDS services. The evidences suggest that the problem lies in the exclusion of the qualitative information during the questionnaire design. With the changing face of the epidemic, we need a new and improved research strategy that integrates the results of qualitative studies into quantitative surveys.

A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa.

BACKGROUND: Despite Sub-Saharan Africa (SSA) being the epicenter of the HIV epidemic, uptake of HIV testing is not optimal. While qualitative studies have been undertaken to investigate factors influencing uptake of HIV testing, systematic reviews to provide a more comprehensive understanding are lacking. METHODS: Using Noblit and Hare's meta-ethnography method, we synthesised published qualitative research to understand factors enabling and deterring uptake of HIV testing in SSA. We identified 5,686 citations out of which 56 were selected for full text review and synthesised 42 papers from 13 countries using Malpass' notion of first-, second-, and third-order constructs. RESULTS: The predominant factors enabling uptake of HIV testing are deterioration of physical health and/or death of sexual partner or child. The roll-out of various HIV testing initiatives such as 'opt-out' provider-initiated HIV testing and mobile HIV testing has improved uptake of HIV testing by being conveniently available and attenuating fear of HIV-related stigma and financial costs. Other enabling factors are availability of treatment and social network influence and support. Major barriers to uptake of HIV testing comprise perceived low risk of HIV infection, perceived health workers' inability to maintain confidentiality and fear of HIV-related stigma. While the increasingly wider availability of life-saving treatment in SSA is an incentive to test, the perceived psychological burden of living with HIV inhibits uptake of HIV testing. Other barriers are direct and indirect financial costs of accessing HIV testing, and gender inequality which undermines women's decision making autonomy about HIV testing. Despite differences across SSA, the findings suggest comparable factors influencing HIV testing. CONCLUSIONS: Improving uptake of HIV testing requires addressing perception of low risk of HIV infection and perceived inability to live with HIV. There is also a need to continue addressing HIV-related stigma, which is intricately linked to individual economic support. Building confidence in the health system through improving delivery of health care and scaling up HIV testing strategies that attenuate social and economic costs of seeking HIV testing could also contribute towards increasing uptake of HIV testing in SSA.

Vaginal practices as women's agency in sub-Saharan Africa: a synthesis of meaning and motivation through meta-ethnography.

This paper reports on a systematic review of qualitative research about vaginal practices in sub-Saharan Africa, which used meta-ethnographic methods to understand their origins, their meanings for the women who use them, and how they have evolved in time and place. We included published documents which were based on qualitative methods of data collection and analysis and contained information on vaginal practices. After screening, 16 texts were included which dated from 1951 to 2008. We found that practices evolve and adapt to present circumstances and that they remain an important source of power for women to negotiate challenges that they face. Recent evidence suggests that some practices may increase a woman's susceptibility to HIV and other sexually transmitted infections. The success of new female-controlled prevention technologies, such as microbicides, might be determined by whether they can and will be used by women in the course of their daily life.

Predictors of vaginal practices for sex and hygiene in KwaZulu-Natal, South Africa: findings of a household survey and qualitative inquiry.

Vaginal practices in sub-Saharan Africa may increase HIV transmission and have important implications for development of microbicides and future HIV prevention technologies. It remains unclear which women undertake vaginal practices and what factors predict prevalence, practice type and choice of products. Using cross-sectional data from mixed research methods, we identify factors associated with vaginal practices among women in KwaZulu-Natal, South Africa. Data were gathered through focus group discussions, in-depth and key-informant interviews, followed by a province-wide, multi-stage cluster household survey, using structured questionnaires in face-to-face interviews with 867 women. This paper details six types of vaginal practices, which--despite their individual distinctiveness and diverse motivations--may be clustered into two broad groups: those undertaken for purposes of 'hygiene' (genital washing, douching and application) and those for 'sexual motivations' (application, insertion, ingestion and incisions). Multivariate analysis found significant associations between 'hygiene' practices and media access, religiosity and transactional sex. 'Sexual' practices were associated with partner concurrency, religiosity and use of injectable hormonal contraceptives. Future interventions relating to vaginal practices as well as microbicides need to reflect this characterisation of practices as sexual- and/or hygiene-related.

Patient-reported barriers and drivers of adherence to antiretrovirals in sub-Saharan Africa: a meta-ethnography.

This meta-ethnography aims at providing a synthesis and an interpretation of the findings of recent social science research on the questions of retention in antiretroviral therapy (ART) programmes in sub-Saharan Africa (SSA). The literature reviewed comprises ethnographic studies of the barriers to adherence to ART in various cultural settings. The results show that the quality of services, treatment-related costs, as well as the need to maintain social support networks - which can be negatively affected by HIV-related stigma - are important barriers to adherence. In addition, they show how African concepts of personhood are incompatible with the way services are conceived and delivered, targeting the individual. In SSA, individuals must balance physical health with social integrity, which is sometimes achieved by referring to traditional medicine. The ability of local concepts of illness to address social relations in addition to health, together with a historically grounded distrust in Western medicine, explains why traditional medicine is still widely used as an alternative to ART.