Pediatric Practice Transformation and Long-Acting Reversible Contraception (LARC) Use in Adolescents.

OBJECTIVE: Long acting reversible contraceptives (LARCs) are recommended as highly effective for adolescents. Although the uptake of LARCs has increased, overall use remains low due to barriers for both providers and patients. We evaluate whether pediatric medical home transformation, including implant placement in pediatrics, may increase LARC use or decrease adolescent pregnancy rates. METHODS: Retrospective interrupted time-series analysis of adolescents ages 11 to 19 years at 2 pediatric practices in academically affiliated community health centers during 2005-2015. The intervention practice underwent medical home transformation including team-based care with family planning and health coaching, youth-friendly policies, and contraceptive implant placement. The control practice continued usual care. Differential changes in population event rates were evaluated using a segmented longitudinal regression model. RESULTS: The study population included 4946 adolescent females at the intervention practice and 1992 at the control practice. Following practice transformation, LARC use increased significantly more at the intervention practice compared to the control (1.73 versus 0.28 events per 1000 patients quarterly P = 0.004). Pregnancy rate declined at both practices without temporal correlation to the LARC intervention. During the medical home transformation period, the intervention practice showed a greater decline in pregnancy rate, though this difference did not reach statistical significance (2.01 versus 0.81 events per 1000 patients quarterly P = 0.090). CONCLUSIONS: Adolescents had higher LARC use where implant placement was offered within the pediatric practice as part of medical home transformation. Although LARC did not impact pregnancy rate, the process of practice transformation may have accelerated its decline through heightened adolescent health focus.

Goal setting and knowledge generation through health policy and systems research in low- and middle-income countries.

The importance of health policy and systems research (HPSR) and its role in aiding health system reforms has been increasingly recognized in recent years within the World Health Organization (WHO). An assessment of the 71 WHO Country Cooperation Strategies (CCS) that are publicly available and were published in English in 2012 was completed to determine the extent to which HPSR goals are incorporated at the global level. A review was then conducted using a Medline database search to determine the number of articles published by countries with HPSR goals. Sixty-six out of the 71 (93%) available CCS describe HPSR as an objective or strategy for achieving health system priorities. However, only 52 out of the 66 countries (79%) have any publications involving HPSR during their most recent CCS cycle. This suggests that although health systems strengthening through HPSR is increasingly emphasized by the WHO and country health ministries, actual HPSR progress may still be lacking. There is a need and an opportunity for the WHO and other global health agencies to focus on providing the necessary tools and building HPSR capacity in low- and middle-income countries.

Use of nutritional and water hygiene packages for diarrhoeal prevention among HIV-exposed infants in Lilongwe, Malawi: an evaluation of a pilot prevention of mother-to-child transmission post-natal care service.

SUMMARY OBJECTIVE: To evaluate a pilot prevention of mother-to-child transmission post-natal programme in Lilongwe, Malawi, through observed retention and infant diarrhoeal rates. METHODS: Free fortified porridge and water hygiene packages were offered to mothers to encourage frequent post-natal visits and to reduce diarrhoeal rates in infants on replacement feeding. Participant retention and infant health outcome were assessed. RESULTS: Of 474 patients enrolled, 357 (75.3%) completed 3-month follow-up visits. Ninety-nine percent of women reported hygiene package use, and only 17.7% (95% CI 13.8-22.0%) of the infants had diarrhoea at least once over the 3-month period. Being 12 months or younger, confirmed HIV positive, access to tap water, and having a mother with diarrhoea were all associated with increased risk of infant diarrhoea. CONCLUSION: The majority of participants adhered to their scheduled visits and retention was favourable, possibly because of the introduction of hygiene and nutrition incentives. The infant diarrhoeal rate was low, suggesting benefits of regular medical care with hygiene package usage and reliable replacement feeding options. Continuation and expansion of the programme would allow further studies and improve the post-natal care of HIV-exposed infants in Malawi and in other resource-constrained countries.