Promoting long-acting reversible contraception among post-abortion clients with a provider-comparison intervention: a cluster randomized controlled trial in Nepal.

BACKGROUND: Although long-acting reversible contraception (LARC) is more effective and longer lasting than short-acting methods, uptake remains low among post-abortion clients. Using a stepped-wedge, cluster-randomized trial, we evaluate the impact of a provider-level peer-comparison intervention to encourage choice of LARC in Nepal among post-abortion clients. METHODS: The intervention used prominently displayed monthly posters comparing the health clinic's previous month performance on LARC uptake against peer clinics. To understand how the intervention affected behavior, while ensuring voluntarism and informed choice, we used mystery client visits, in-depth provider interviews, and client exit survey data. The trial examined 17,680 post-abortion clients in 36 clinics in Nepal from July 2016 to January 2017. The primary outcome was the proportion of clients receiving LARCs. Statistical analysis used ordinary least squares (OLS) regression with ANCOVA estimation to assess the intervention's impact on LARC uptake while controlling for client- and clinic-level characteristics. RESULTS: The intervention increased LARC use among post-abortion clients by 6.6% points [95% CI: 0.85 to 12.3, p-value < 0.05], a 29.5% increase in LARC use compared to control clinics. This effect persisted after the formal experiment ended. Analysis of provider and client experiences showed that the behavioral intervention generated significant change in providers' counseling practices, motivated the sharing of best practices. Quality of care indicators either remained stable or improved. CONCLUSION: We find that a provider-level behavioral intervention increases LARC uptake among post-abortion clients. This type of intervention represents a low-cost option to contribute to reducing unmet need for contraception through provider behavior change.

Methods of mapping ethnographic data on migration, tourism labor, and health risk in the Dominican Republic.

This paper focuses on a mixed-method approach to quantifying qualitative data from the results of an ongoing NIDA-funded ethnographic study entitled "Migration, Tourism, and the HIV/Drug-Use Syndemic in the Dominican Republic". This project represents the first large-scale mixed method study to identify social, structural, environmental, and demographic factors that may contribute to ecologies of health vulnerability within the Caribbean tourism zones. Our research has identified deportation history as a critical factor contributing to vulnerability to HIV, drugs, mental health problems, and other health conditions. Therefore, understanding the movements of our participants became a vital aspect of this research. This paper describes how we went about translating 37 interviews into visual geographic representations. These methods help develop possible strategies for confronting HIV/AIDS and problematic substance use by examining the ways that these epidemics are shaped by the realities of people's labor migration and the spaces they inhabit. Our methods for mapping this qualitative data contribute to the ongoing, broadening capabilities of using GIS in social science research. A key contribution of this work is its integration of different methodologies from various disciplines to help better understand complex social problems.