A Field Test of the NORMAL Job Aid With Community Health Workers in Kenya to Address Contraceptive-Induced Menstrual Changes.

INTRODUCTION: Concerns about contraceptive-induced menstrual changes (CIMCs) contribute to nonuse and discontinuation of family planning (FP). Current counseling materials inadequately address these concerns. After obtaining initial feedback, we field-tested an adapted version of the NORMAL job aid that guides community health workers on how to counsel women about CIMCs. The field test aimed to help understand how the job aid was used, the challenges faced in using it, and recommendations to improve the job aid. METHODS: Sixteen community health volunteers (CHVs) from 2 subcounties in Kenya were trained on the 2-page job aid and given copies of the job aid to use with clients. Six to 8 weeks after the training, we interviewed the CHVs about their experiences using the job aid. The interviews were audio-recorded, transcribed, and analyzed to identify qualitative themes. RESULTS: All 16 CHVs reported using the job aid each time they counseled. All liked it and said they used it because it gave them new information and made counseling easier. All reported offering the job aid to most clients and that most clients accepted a copy. CHVs noted clients referred their friends and family to them after counseling using the job aid. CHVs said the job aid reduced clients' and their male partners' concerns about CIMCs and helped clients select or switch FP methods. Most CHVs did not have suggestions for improving the job aid. CONCLUSION: The job aid was highly acceptable to the CHVs who participated in this small assessment. According to the CHVs, it increased counseling effectiveness and may help increase uptake and continued use of FP methods directly through counseling or indirectly through diffusion in the community. Though further research is needed in other settings and to quantify its impact, we recommend this promising job aid be adapted for wider use.

Global research and learning agenda for building evidence on contraceptive-induced menstrual changes for research, product development, policies, and programs.

Background: Contraceptive-induced menstrual changes (CIMCs) can affect family planning (FP) users' lives in both positive and negative ways, resulting in both opportunities and consequences. Despite this, and despite the important links between FP and menstrual health (MH), neither field adequately addresses CIMCs, including in research, product development, policies, and programs globally. Methods: In November 2020, a convening of both MH and FP experts reviewed the existing evidence on CIMCs and identified significant gaps in key areas. Results: These gaps led to the establishment of a CIMC Task Force in April 2021 and the development of the Global Research and Learning Agenda: Building Evidence on Contraceptive-Induced Menstrual Changes in Research, Product Development, Policies, and Programs Globally (the CIMC RLA) , which includes four research agendas for (1) measurement, (2) contraceptive research and development (R&D) and biomedical research, (3) social-behavioral and user preferences research, and (4) programmatic research. Conclusions: Guided by the CIMC RLA, researchers, product developers, health care providers, program implementers, advocates, policymakers, and funders are urged to conduct research and implement strategies to address the beneficial and negative effects of CIMCs and support the integration of FP and MH. CIMCs need to be addressed to improve the health and well-being of women, girls, and other people who menstruate and use contraceptives globally. Disclaimer : The views expressed in this article are those of the authors. Publication in Gates Open Research does not imply endorsement by the Gates Foundation.

Experiences with the levonorgestrel-releasing intrauterine system in Kenya: qualitative interviews with users and their partners.

OBJECTIVES: The levonorgestrel-releasing intrauterine system (LNG-IUS) is an underused contraceptive method in sub-Saharan Africa. A recent market assessment in Kenya found that if a more affordable version of the method were available it may increase demand and uptake of the method. We therefore aimed to examine attitudes and perceptions around the LNG-IUS and experiences of method use, including exploring attributes such as bleeding changes, contraceptive-related amenorrhoea and perceived non-contraceptive benefits. METHODS: Qualitative interviews were conducted among 29 women who were current or recent users of the LNG-IUS, and among a subset (n = 9) of their husbands/partners. RESULTS: Our findings indicate that women's main reason for choosing the LNG-IUS for contraception was their perception that the method had fewer side effects compared with other contraceptive methods. Women had favourable attitudes towards using the LNG-IUS. Husbands were also very positive about their partner's use of the method. CONCLUSION: Understanding the motivations and experiences of early adopters of the LNG-IUS can help inform the development of demand creation and communication strategies to influence uptake and continuation of the LNG-IUS both in Kenya and perhaps more broadly. Communication efforts that emphasise the positive attributes of the LNG-IUS could help promote wider use of the method, especially if new, more affordable product(s) become available.

Expanding Access to a New, More Affordable Levonorgestrel Intrauterine System in Kenya: Service Delivery Costs Compared With Other Contraceptive Methods and Perspectives of Key Opinion Leaders.

BACKGROUND: The levonorgestrel intrauterine system (LNG IUS) is one of the most effective forms of contraception and offers important non-contraceptive health benefits. However, it is not widely available in developing countries, largely due to the high price of existing products. Medicines360 plans to introduce its new, more affordable LNG IUS in Kenya. The public-sector transfer price will vary by volume between US$12 to US$16 per unit; for an order of 100,000 units, the public-sector transfer price will be approximately US$15 per unit. METHODS: We calculated the direct service delivery cost per couple-years of protection (CYP) of various family planning methods. The model includes the costs of contraceptive commodities, consumable supplies, instruments per client visit, and direct labor for counseling, insertion, removal, and resupply, if required. The model does not include costs of demand creation or training. We conducted interviews with key opinion leaders in Kenya to identify considerations for scale-up of a new LNG IUS, including strategies to overcome barriers that have contributed to low uptake of the copper intrauterine device. RESULTS: The direct service delivery cost of Medicines360's LNG IUS per CYP compares favorably with other contraceptive methods commonly procured for public-sector distribution in Kenya. The cost is slightly lower than that of the 3-month contraceptive injectable, which is currently the most popular method in Kenya. Almost all key opinion leaders agreed that introducing a more affordable LNG IUS could increase demand and uptake of the method. They thought that women seeking the product's non-contraceptive health benefits would be a key market segment, and most agreed that the reduced menstrual bleeding associated with the method would likely be viewed as an advantage. The key opinion leaders indicated that myths and misconceptions among providers and clients about IUDs must be addressed, and that demand creation and provider training should be prioritized. CONCLUSION: Introducing a new, more affordable LNG IUS product could help expand choice for women in Kenya and increase use of long-acting reversible contraception. Further evaluation is needed to identify the full costs required for introduction-including the cost of demand creation-as well as research among potential and actual LNG IUS users, their partners, and health care providers to help inform scale-up of the method.

"A cup of tea with our CBD agent ": community provision of injectable contraceptives in Kenya is safe and feasible.

BACKGROUND: In rural areas of Kenya, where the majority of Kenya's population lives, contraceptive use remains low compared with that in urban areas (37% vs. 47%). Inadequate access to family planning services in rural areas is partly due to fewer health facilities and the shortage of health care workers. Community-based access to injectable contraceptives can improve access for rural populations and expand the range of contraceptive methods available. Our pilot project sought to generate local evidence on safety, feasibility, and acceptability of the provision of injectable depot medroxyprogesterone acetate (DMPA) by community health workers (CHWs). DESIGN: We trained 31 CHWs in Tharaka District to provide injectable DMPA in addition to pills and condoms. Data were collected on family planning clients served by CHWs in Tharaka District as well as those who received services from health facilities from August 2009 to September 2010. Service statistics were collected from 3 pilot health facilities in the CHW service catchment area. RESULTS: In the 12-month study period, CHWs reached 1,210 women with family planning services including referrals for long-acting and permanent methods. Family planning use in the pilot sites for all methods increased an estimated fivefold, from 9% in facilities to 46% when facilities and CHWs were combined (32% for CHWs and 14% for facilities). The majority (69%) of clients served by CHWs chose DMPA. No client reported any signs of infection at the injection site nor did any CHW report needlestick injuries or other adverse events. The re-injection rate was 68% at the third visit, which compares favorably with other DMPA continuation studies. Two main reasons given for discontinuing were change of residence and temporary separation from spouse. CONCLUSION: Community-based provision of DMPA along with other contraceptive methods increased the use of family planning and improved method choice during the study period. Injectable contraception provided by trained CHWs is a safe, acceptable, and feasible service delivery option in Kenya.

The promise of affordable implants: is cost recovery possible in Kenya?

BACKGROUND: Contraceptive implants are one of the most effective methods of family planning but remain underutilized due to their relatively high upfront cost. The increasing availability of a low-cost implant may reduce financial barriers and increase uptake of implants. The commodity cost of Sino-implant (II) is approximately 60% less than two other widely available implants, and a direct service delivery cost of approximately US$12 makes it one of the most cost-effective methods available. This study was conducted to assess whether implant clients in Kenya are paying as much or more than the direct service delivery cost of Sino-implant (II). STUDY DESIGN: A study was conducted in 22 facilities throughout Kenya, including public (n=8), private for-profit (n=6) and private not-for-profit facilities (n=8). Interviews were conducted with a convenience sample of 293 current and returning implant clients after at least 6 months of product use. RESULTS: The median price for implant insertion paid by clients in the public, private for-profit and private not-for-profit sectors was US$1.30, US$13.30 and US$20.00, respectively. CONCLUSION: Patient fees in both private sectors allow for 100% recovery of the direct cost of providing Sino-implant (II). Currently in Kenya, all sectors can receive donated commodities free of charge; Sino-implant (II) has the potential to reduce reliance on donor-supplied implants and thereby improve contraceptive security.

Reaching providers is not enough to increase IUD use: a factorial experiment of 'academic detailing' in Kenya.

Although the IUD is an extremely effective and low-cost contraceptive method, its use has declined sharply in Kenya in the past 20 years. A study tested the effectiveness of an outreach intervention to family planning providers and community-based distribution (CBD) agents in promoting use of the IUD in western Kenya. Forty-five public health clinics were randomized to receive the intervention for providers only, for CBD agents only, for both providers and CBD agents, or no detailing at all. The intervention is based on pharmaceutical companies' "detailing" models and included education/motivation visits to providers and CBD programmes, as well as provision of educational and promotional materials. District health supervisors were given updates on contraceptives, including the IUD, and were trained in communication and message development prior to making their detailing visits. Detailing only modestly increased the provision of IUDs, and only when both providers and CBD agents were targeted. The two detailing visits do not appear sufficient to sustain the effect of the intervention or to address poor provider attitudes and lack of technical skills. The cost per 3.5 years of pregnancy protection was US$49.57 for the detailing intervention including the cost of the IUD, compared with US$15.19 for the commodity costs of the current standard of care--provision of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA). The effectiveness of provider-based activities is amplified when concurrent demand creation activities are carried out. However, the cost of the detailing in comparison to the small number of IUDs inserted indicates that this intervention is not cost-effective.

Contraceptive implants in Kenya: current status and future prospects.

BACKGROUND: Since introducing Norplant over 20 years ago in Kenya, demand for contraceptive implants has remained high and implant costs are dropping substantially. METHODS: An assessment of the Kenyan experience with implants was conducted to understand level of demand, capacity to provide services and reproductive health impact of possible increased use. Interviews were conducted with 35 key Kenyan informants. By modeling increases in national implant use (at the expense of oral contraceptives), reductions in the annual number of unintended pregnancies were estimated. RESULTS: Kenya has an unmet need for implants and the current network of trained providers appears ready to increase the volume of services. If 100,000 users of oral contraceptives switch to implants, then an estimated 26,000 unintended pregnancies can be averted over a 5-year period. CONCLUSION: With increased purchases of implants by international donor agencies, Kenya can reduce reliance on short-term hormonal methods and reduce the 45% prevalence rate of unintended pregnancy.