"When you live in good health with your husband, then your children are in good health ." A qualitative exploration of how households make healthcare decisions in Maradi and Zinder Regions, Niger.

BACKGROUND: Gender dynamics influence household-level decision-making about health behaviors and subsequent outcomes. Health and development programs in Niger are addressing gender norms through social and behavior change (SBC) approaches, yet not enough is known about how health care decisions are made and if gender-sensitive programs influence the decision-making process. METHODS: We qualitatively explored how households make decisions about family planning, child health, and nutrition in the Maradi and Zinder regions, Niger, within the context of a multi-sectoral integrated SBC program. We conducted 40 in-depth interviews with married women (n = 20) and men (n = 20) between 18 and 61 years of age. RESULTS: Male heads of household were central in health decisions, yet women were also involved and expressed the ability to discuss health issues with their husbands. Participants described three health decision-making pathways: (1st pathway) wife informs husband of health issue and husband solely decides on the solution; (2nd pathway) wife informs husband of health issue, proposes the solution, husband decides; and (3rd pathway) wife identifies the health issue and both spouses discuss and jointly identify a solution. Additionally, the role of spouses, family members, and others varied depending on the health topic: family planning was generally discussed between spouses, whereas couples sought advice from others to address common childhood illnesses. Many participants expressed feelings of shame when asked about child malnutrition. Participants said that they discussed health more frequently with their spouses' following participation in health activities, and some men who participated in husbands' schools (a group-based social and behavior change approach) reported that this activity influenced their approach to and involvement with household responsibilities. However, it is unclear if program activities influenced health care decision-making or women's autonomy. CONCLUSIONS: Women are involved to varying degrees in health decision-making. Program activities that focus on improving communication among spouses should be sustained to enhance women role in health decision-making. Male engagement strategies that emphasize spousal communication, provide health information, discuss household labor may enhance couple communication in Niger. Adapting the outreach strategies and messages by healthcare topic, such as couples counseling for family planning versus community-based nutrition messaging, are warranted.

How do changes in motivation to prevent pregnancy influence contraceptive continuation? Results from a longitudinal study with women who receive family planning services from Community Pharmacists and Patent and Proprietary Medicine Vendors in Nigeria.

BACKGROUND: Studies have shown that motivation to avoid pregnancy is associated with contraceptive use and continuation. These motivations can change, however, even within a short period of time. This paper uses longitudinal data to look at women's motivation to avoid pregnancy at two time points, and how changes in motivation influence contraceptive continuation. METHODS: Data for this analysis came from an evaluation of the IntegratE project which seeks to expand access to family planning (FP) in Nigeria through community pharmacies and drug shops. 491 women were interviewed within 10 days after receiving a FP service from these sources and again approximately 9 months later. The dependent variable was contraceptive continuation at the follow-up interview. A categorical independent variable was used to represent changes in motivation to avoid pregnancy from enrollment to the follow-up interview. Univariate and multivariate logistic regression models were used to assess the association between changes in motivation and contraceptive continuation. RESULTS: 89% of women continued using contraception approximately 9 months after the enrollment interview. Women who remained highly motivated to avoid pregnancy were significantly more likely to continue using contraception compared to women who became more motivated (AOR 2.5; 95% CI 1.0-6.0). Women who became less motivated were 64% less likely to continue using contraception compared to who became more motivated (AOR 0.36 95% CI 0.1-0.9). CONCLUSION: FP providers, including private sector pharmacists and drug shop owners, should continuously check-in with women about their motivations around pregnancy to support continuation among those who wish to avoid pregnancy.

Previous research has found women's motivations to avoid pregnancy- how important it is to avoid pregnancy now- is associated with their contraception use. Yet women's motivations to avoid pregnancy often change, even within a short period of time. This paper looks at whether changes in motivation to avoid pregnancy are associated with continued use of contraception in Nigeria.We used data from a larger evaluation of the IntegratE project which seeks to expand access to family planning (FP) in Nigeria through community pharmacies and drug shops. 491 women were interviewed within 10 days after receiving a FP service (counseling, referral or FP method) from these sources and again 9 months later. We then used logistic regression models to assess whether changes in motivation to avoid pregnancy between receiving a FP service to 9 months later is associated with continued use of FP.We found that many women (89%) continued using contraception approximately 9 months after the enrollment interview. Women who remained highly motivated (reported it was very important to avoid pregnancy at both interviews) were more likely to continue using contraception compared to women who became more motivated between the two interviews. Women who became less motivated were 64% less likely to continue using contraception compared to who became more motivated. Our results suggest that FP providers, including private sector pharmacists and drug shop owners, should continuously check in with women about their motivations around pregnancy to support continuation contraceptive use among those who wish to avoid pregnancy.

Reaching women at work with health programming in Bangladesh: results of difference-in-differences analysis among female factory workers.

The rapid growth of Bangladesh's ready-made garment sector has transformed the country's economy while also employing a predominantly female workforce. Companies have begun collaborating with NGOs to provide health messages to and expand health services for workers. This study evaluates the effect of the Health Enables Return (HER) health model's approach of using peer health educators to deliver health messages and increased availability of health products. Using repeated cross-sectional data from female workers in HERhealth and comparison factories between May 2015 and March 2017, baseline (n = 1704) and endline (n = 1503) samples were matched on eight characteristics and then difference-in-differences estimations were used to determine the effect of the HERhealth model on knowledge and behaviours. The average changes over time in knowledge and behaviours were statistically different between the HERhealth and comparison factories. Knowledge of when a woman is at higher risk for pregnancy during her menstrual cycle increased from baseline to endline in both groups but was 12 percentage points greater in the HERhealth factories than in the comparison. An increase in family planning use among ever-married women was observed in the HERhealth factories but decreased in the comparison factories leading to a 12 percentage point difference-in-differences. The greatest effect of the HERhealth model was observed on women's use of sanitary products for menstrual management which significantly increased in both groups, but the increase was 35% greater in the HERhealth factories. The HERhealth model is effective in increasing knowledge and in improving health behaviours when health products are available in factory infirmaries.

The role of unintended pregnancy in internalized stigma among women living with HIV in Kenya.

BACKGROUND: Kenya has successfully expanded HIV treatment, but HIV-related stigma and discrimination, and unintended pregnancy remain issues for many Kenyan women living with HIV. While HIV-related stigma can influence the health seeking behaviors of those living with HIV, less is known about how reproductive health outcomes influence internalized stigma among women living with HIV. METHODS: Baseline data only were used in this analysis and came from an implementation science study conducted in Kenya from 2015 to 2017. The analytic sample was limited to 1116 women who are living with HIV, between 18 to 44 years old, and have ever experienced a pregnancy. The outcome variable was constructed from 7 internalized stigma statements and agreement with at least 3 statements was categorized as medium/high levels of internalized stigma. Unintended pregnancy, categorized as unintended if the last pregnancy was mistimed or unwanted, was the key independent variable. Univariate and multivariate logistic regression models were used to assess the association between unintended pregnancy and internalized stigma. Associations between internalized stigma and HIV-related discrimination and violence/abuse were also explored. RESULTS: About 48% agreed with at least one internalized stigma statement and 19% agreed with at least three. Over half of women reported that their last pregnancy was unintended (59%). Within the year preceding the survey, 52% reported experiencing discrimination and 41% reported experiencing violence or abuse due to their HIV status. Women whose last pregnancy was unintended were 1.6 times (95% CI 1.2-2.3) more likely to have medium/high levels of internalized stigma compared to those whose pregnancy was wanted at the time, adjusting for respondents' characteristics, experiences of discrimination, and experiences of violence and abuse. Women who experienced HIV-related discrimination in the past 12 months were 1.8 times (95% CI 1.3-2.6) more likely to have medium/high levels of internalized stigma compared to those who experienced no discrimination. CONCLUSIONS: Results suggest that unintended pregnancy is associated with internalized stigma. Integrated HIV and FP programs in Kenya should continue to address stigma and discrimination while increasing access to comprehensive voluntary family planning services for women living with HIV.

How do fertility intentions lead to contraceptive continuation among a cohort of family planning users who received services from the private sector in Nigeria.

Background: The Federal Ministry of Health of Nigeria is exploring task sharing family planning (FP) services to Community Pharmacists (CPs) and Patent and Proprietary Medicine Vendors (PPMVs). Yet few studies have explored contraceptive continuation of clients who received FP services from pharmacies and drug shops. This paper uses longitudinal data and looks at women's contraceptive continuation approximately nine months after they received FP services from CPs and PPMVs in Kaduna and Lagos states. Methods: Longitudinal data for this analysis come from an evaluation of the IntegratE project. 491 women were interviewed within 10 days after receiving a FP service from an IntegratE CP or PPMV and approximately nine months later. The dependent variable is contraceptive continuation at the follow-up interview and the independent variable is fertility intentions as reported at enrollment. Multivariate logistic regression models were used to assess the association between fertility intentions and contraceptive continuation. Results: 89% of women continued using contraception approximately 9 months after the enrollment interview. Women who intended to have a child in more than two years were significantly more likely to continue using contraception compared to women who intended to have a child within two-years (AOR 2.6; 95% CI 1.1-6.1). Among women who were asked about the quality of care received, 93% said the CP/PPMV asked whether they wanted to have a/another child in the future and 85% said they were asked when they would like to have that child. Conclusion: The fertility intentions of women who seek FP services from CPs and PPMVs in Nigeria can predict contraceptive continuation. As Nigeria task shares FP services to CPs and PPMVs, training on comprehensive FP counseling will be essential for scale-up. Since many women continued using FP, CPs and PPMVs have the potential to expand access to, and support women's continued use of, FP.

The effect of job aids on knowledge retention among Patent and Proprietary Medicine Vendors trained to administer injectable contraceptives: longitudinal results from implementation science in Nigeria.

BACKGROUND: To increase access to voluntary family planning (FP) services, Nigerian policymakers are debating how to task share injectable contraceptive services to drug shop owners known as Patent and Proprietary Medicine Vendors (PPMVs). Task sharing FP services to drug shops is a promising practice, but information is needed on how to ensure high quality FP services. This analysis assesses the effects of job aids on PPMVs' knowledge of injectable contraceptives 9 months after receiving a standardized training. METHODS: One hundred ninety-four PPMVs were trained on FP counseling and administration of injectable contraceptives in Bauchi, Cross River, Ebonyi and Kaduna states. PPMVs were interviewed before, after, and 9 months after the training. Three variables were used to assess injectable contraceptive knowledge: 1) intramuscular depot-medroxyprogesterone acetate (DMPA-IM) knowledge: a combination of three questions related to device type, injection location, and reinjection frequency; 2) subcutaneous DMPA (DMPA-SC) knowledge: a combination of the same three questions but for DMPA-SC; and 3) knowledge of at least 4 of the 7 common injectable side effects. Three separate adjusted logistic regression models were conducted to determine the factors that influence PPMV knowledge of injectable contraceptives 9 months after the training. RESULTS: Over half of PPMVs (56%) reported using at least two job aids at 9 months. PPMVs' knowledge of DMPA-IM, DMPA-SC and side effects were low before the training but increased immediately after. Nine months later, knowledge remained higher than pre-test levels but generally reduced compared to posttest levels. PPMVs who reported using at least two FP job aids were 2.6 (95% CI: 1.4-5.1) times more likely to have DMPA-IM knowledge 9 months after the training compared to those who used one or no job aids, while adjusting for PPMV characteristics. Similar results were observed for knowledge of DMPA-SC (AOR: 2.5; 95% CI: 1.2-4.6) and side effects (AOR: 2.5; 95% CI: 1.3-4.8). CONCLUSION: PPMVs who used at least two FP job aids were more likely to correctly answer key injectable contraceptive questions 9 months after training. Incorporating proven job aids into routine trainings is a low-cost strategy that can reinforce knowledge and help PPMVs to retain information.

Feasibility of patent and proprietary medicine vendor provision of injectable contraceptives: preliminary results from implementation science research in Oyo and Nasarawa, Nigeria.

BACKGROUND: Nigerian policymakers are debating task-shifting injectable contraceptive services to Patent and Proprietary Medicine Vendors (PPMVs). METHODOLOGY: One hundred fifty-two PPMVs were trained to provide injectable contraceptives in Oyo and Nasarawa states. Data were collected before and 1, 3 and 9 months posttraining. χ2 tests were conducted to assess associations between survey time points. MAIN FINDINGS: Few PPMVs had the necessary knowledge to provide injectables pretraining. A majority demonstrated increased knowledge after the training. Knowledge required for screening and counseling clients was lower than knowledge on administration. CONCLUSION: PPMVs should be trained before providing injectable services. Additional research is needed on the benefits of job aids for screening and counseling.