Ante La Duda, Pregunta: A Social Marketing Campaign to Improve Contraceptive Access during a Public Health Emergency.

During the 2016-2017 Zika virus outbreak, preventing unintended pregnancy was recognized as a primary strategy to reduce adverse Zika-related pregnancy and birth outcomes. To increase awareness and uptake of contraceptive services provided through the Zika Contraception Access Network (Z-CAN) in Puerto Rico, a multi-strategy campaign called Ante La Duda, Pregunta (ALDP) was developed. The principal aim was to increase awareness of Z-CAN services, which included same-day access to the full range of reversible contraceptives at no cost to women living in Puerto Rico who choose to delay or avoid pregnancy during the 2016-2017 Zika virus outbreak. Using diverse strategies, ALDP increased exposure to and engagement with the campaign in order to raise awareness of Z-CAN services in Puerto Rico. The ALDP social marketing campaign played an important role in the overall Z-CAN effort. Of all the strategies utilized, Facebook appears to have reached the most people. While the importance of a social marketing campaign communicating to raise awareness and create demand has long been known, through the ALDP campaign efforts, it was shown that an effective campaign, built on formative research, can be developed and implemented rapidly in an emergency response situation without compromising on content, quality, or reach.

Access to Contraceptive Services in Puerto Rico: An Analysis of Policy and Practice Change Strategies, 2015-2018.

CONTEXT: During the 2016-2017 Zika virus outbreak in Puerto Rico, preventing unintended pregnancy was a primary strategy to reduce Zika-related adverse birth outcomes. The Zika Contraception Access Network (Z-CAN) was a short-term emergency response intervention that used contraception to prevent unintended pregnancy among women who chose to delay or avoid pregnancy. OBJECTIVE: This analysis reports on the identified policy and practice change strategies to increase access to or provision of contraceptive services in Puerto Rico between 2015 and 2018. METHODS: A policy review was conducted to document federal- and territorial-level programs with contraceptive coverage and payment policies in Puerto Rico and to identify policy and practice change. Semistructured interviews with key stakeholders in Puerto Rico were also conducted to understand perceptions of policy and practice change efforts following the Zika virus outbreak, including emergency response, local, and policy efforts to improve contraception access in Puerto Rico. RESULTS: Publicly available information on federal and territorial programs with policies that facilitate access, delivery, and utilization of contraceptive coverage and family planning services in Puerto Rico to support contraceptive access was documented; however, interview results indicated that the implementation of the policies was often limited by barriers and that policy and practice changes as the result of the Zika virus outbreak were short-term. CONCLUSION: Consideration of long-term policy and practice changes related to contraceptive access is warranted. Similar analyses can be used to identify policies, practices, and perceptions in other settings in which the goal is to increase access to contraception or reduce unintended pregnancy.

Leadership Disparities in State Governmental Public Health Workforce: Examining the Influence of Gender.

OBJECTIVE: To determine the extent to which gender disparities exist in either obtaining a leadership position or pay equity among those with leadership positions in state governmental public health agencies. DESIGN: Utilizing the 2014 Public Health Workforce Interests and Needs Survey, a nationally representative cross-sectional study of state governmental public health agency employees, the characteristics of the state governmental public health agency leadership were described. We estimated the odds of being a manager or an executive leader and the odds of leaders earning greater than $95 000 annually for women compared with men using polytomous multinomial regression and logistic regression models, respectively. SETTING AND PARTICIPANTS: The Public Health Workforce Interests and Needs Survey was conducted via electronic survey at 37 state health departments. This study utilized only those respondents who listed their current position as a supervisory position (n = 3237). MAIN OUTCOME MEASURES: Leadership position and high-earning leadership were the 2 main outcome measures explored. Leadership position was defined as a 3-level ordinal variable: supervisor, manager, or executive leader. High-earning leadership was defined as a member of leadership earning $95 000 or greater. RESULTS: Women accounted for 72.0% of the overall state governmental public health agency workforce and 67.1% of leadership positions. Women experienced lower odds (odds ratio = 0.55, 95% confidence interval: 0.39-0.78) of holding executive leadership positions than men and lower odds (odds ratio = 0.64, 95% confidence interval: 0.50-0.81) of earning an annual salary greater than $95 000. CONCLUSION: While women were represented in similar proportions in the general workforce as in leadership positions, gender disparities still existed within leadership positions. Increased effort is needed to ensure that opportunities exist for women in executive leadership positions and in pay equity. With public health's commitment to social justice and the benefits of diversity to an agency's policies and programs, it is important to ensure that women's voices are equally represented at all levels of leadership.

Contraception as a Medical Countermeasure to Reduce Adverse Outcomes Associated With Zika Virus Infection in Puerto Rico: The Zika Contraception Access Network Program.

The Zika Contraception Access Network established a network of 153 physicians across Puerto Rico as a short-term emergency response during the 2016-2017 Zika virus outbreak to provide client-centered contraceptive counseling and same-day contraception services at no cost for women who chose to prevent pregnancy. Between May 2016 and August 2017, 21 124 women received services. Contraception was used as a medical countermeasure to reduce adverse Zika-related reproductive outcomes during the outbreak and may be considered a key strategy in other emergencies.

Provider Perceptions of Facilitators of and Barriers to Implementation of the Zika Contraception Access Network: A Qualitative Evaluation.

OBJECTIVE: From May 2016 through September 2017, the Zika Contraception Access Network (Z-CAN) program increased access to contraception during the Zika virus outbreak in Puerto Rico by providing no-cost client-centered contraceptive counseling and (same-day) access to the full range of US Food and Drug Administration-approved reversible contraceptives to women desirous of not becoming pregnant. The purpose of this study was to identify areas for programmatic improvement and enhance the sustainability of services from the perspectives of participating Z-CAN physicians and other staff. METHODS: From April through July 2017, 49 in-depth key-informant interviews were conducted with Z-CAN physicians and clinic staff. Twenty-five clinics participating in the Z-CAN program were selected through a cluster randomization process. A semi-structured interview guide was developed to explore the participants' perceptions of the Z-CAN program and examine facilitators of and barriers to said implementation. A thematic analysis of the emerging topics was conducted. RESULTS: Our analysis encountered 4 common overarching themes: facilitators of the Z-CAN program; barriers to Z-CAN implementation; the perceived impact of Z-CAN on providers and communities; and the sustainability of contraception access after the Z-CAN program ended. The key findings were that provider training, mentor support, and communication campaigns facilitated program implementation and that delays in the acquisition and distribution of contraceptives were obstacles. CONCLUSION: Lessons learned from the implementation of Z-CAN from the perspective of physicians and other staff can be used to work towards sustainable contraceptive services in Puerto Rico and inform other contraception-access programs' design and implementation strategies.

Economic evaluation of Zika Contraception Access Network in Puerto Rico during the 2016-17 Zika virus outbreak.

OBJECTIVE: During the 2016-2017 Zika virus (ZIKV) outbreak, the prevention of unintended pregnancies was identified as a primary strategy to prevent birth defects. This study estimated the cost-effectiveness of the Zika Contraception Access Network (Z-CAN), an emergency response intervention that provided women in Puerto Rico with access to the full range of reversible contraception at no cost and compared results with a preimplementation hypothetical cost-effectiveness analysis (CEA). STUDY DESIGN: We evaluated costs and outcomes of Z-CAN from a health sector perspective compared to no intervention using a decision tree model. Number of people served, contraception methods mix, and costs under Z-CAN were from actual program data and other input parameters were from the literature. Health outcome measures included the number of Zika-associated microcephaly (ZAM) cases and unintended pregnancies. The economic benefits of the Z-CAN intervention were ZIKV-associated direct costs avoided, including lifetime medical and supportive costs associated with ZAM cases, costs of monitoring ZIKV-exposed pregnancies and infants born from Zika-virus infected mothers, and the costs of unintended pregnancies prevented during the outbreak as a result of increased contraception use through the Z-CAN intervention. RESULTS: The Z-CAN intervention cost a total of $26.1 million, including costs for the full range of reversible contraceptive methods, contraception related services, and programmatic activities. The program is estimated to have prevented 85% of cases of estimated ZAM cases and unintended pregnancies in the absence of Z-CAN. The intervention cost was projected to have been more than offset by $79.9 million in ZIKV-associated costs avoided, 96% of which were lifetime ZAM-associated costs, as well as $137.0 million from avoided unintended pregnancies, with total net savings in one year of $216.9 million. The results were consistent with the previous CEA study. CONCLUSION: Z-CAN was likely cost-saving in the context of a public health emergency response setting.

Strategies and safeguards to ensure access to long-acting reversible contraception removal after the Zika Contraception Access Network ended: A prospective analysis of patient reported complaints.

OBJECTIVE: The Zika Contraception Access Network (Z-CAN) was a short-term emergency response intervention that used contraception to prevent unintended pregnancy to reduce Zika-related adverse birth outcomes during the 2016 2017 Zika virus outbreak in Puerto Rico. Strategies and safeguards were developed to ensure women who chose long-acting reversible contraception (LARC) had access to no-cost removal, if desired, after Z-CAN ended. STUDY DESIGN: We assessed the number of women who chose LARC at their initial Z-CAN visit who filed complaints regarding challenges with LARC removal within 30-months after the Z-CAN program ended. Complaints and program responses were categorized. RESULTS: Of the 29,221 women who received Z-CAN services, 20,381 chose a LARC method at their initial visit (IUD = 12,276 and implant = 8105). Between September 2017 and February 2020, 63 patient complaints were logged, mostly due to LARC removal charges (76.2%) which were generally (71.4%) determined to be inappropriate charges. All complaints filed were resolved allowing LARC removal within an average of 28 days. CONCLUSION: Safeguards to ensure prompt LARC removal when desired are critical to ensure women s reproductive autonomy. IMPLICATIONS: Strategies and safeguards used by Z-CAN to ensure women have access to LARC removal might be used by other contraception programs to prevent reproductive coercion and promote reproductive autonomy to best meet the reproductive needs of women.

The Role of Public-Private Partnerships to Increase Access to Contraception in an Emergency Response Setting: The Zika Contraception Access Network Program.

The Zika Contraception Access Network (Z-CAN) program was a short-term emergency response intervention that used contraception to prevent unintended pregnancies to reduce Zika-related adverse birth outcomes during the 2016-2017 Zika virus outbreak in Puerto Rico. The Centers for Disease Control and Prevention (CDC) reported that a collaborative and coordinated response was needed from governments and private-sector partners to improve access to contraception during the Zika outbreak in Puerto Rico. In response, the National Foundation for the CDC, with technical assistance from CDC, established the Z-CAN program, a network of 153-trained physicians, that provided client-centered contraceptive counseling and same-day access to the full range of the Food and Drug Administration-approved reversible contraceptive methods at no cost for women who chose to prevent pregnancy. From May 2016 to September 2017, 29,221 women received Z-CAN services. Through Z-CAN, public-private partnerships provided a broad range of opportunities for partners to come together to leverage technical expertise, experience, and resources to remove barriers to access contraception that neither the public nor the private sector could address alone. Public-private partnerships focused on three areas: (1) the coordination of efforts among federal and territorial agencies to align strategies, leverage resources, and address sustainability; (2) the mobilization of private partnerships to secure resources from private corporations, domestic philanthropic organizations, and nonprofit organizations for contraceptive methods, physician reimbursement, training and proctoring resources, infrastructure costs, and a health communications campaign; and (3) the engagement of key stakeholders to understand context and need, and to identify strategies to reach the target population. Public-private partnerships provided expertise, support, and awareness, and could be used to help guide programs to other settings for which access to contraception could improve health outcomes.

Final Program Data and Factors Associated With Long-Acting Reversible Contraception Removal: The Zika Contraception Access Network.

OBJECTIVE: To describe characteristics of the full population of women who participated in the Zika Contraception Access Network program in Puerto Rico during the virus outbreak and to examine factors associated with removal of a long-acting reversible contraception (LARC) method by a Zika Contraception Access Network provider during the program's duration (May 2016-September 2017). METHODS: We conducted an observational cohort study. The Zika Contraception Access Network program was designed to increase access to contraception services in Puerto Rico for women who chose to prevent pregnancy during the Zika virus outbreak as a primary strategy to reduce adverse Zika virus-related pregnancy and birth outcomes. Among program participants, an observational cohort of women served by the Zika Contraception Access Network Program, we describe their demographic and program-specific characteristics, including contraceptive method mix before and after the program. We also report on LARC removals by Zika Contraception Access Network providers during the program. We examined factors associated with LARC removal using multivariable logistic regression. RESULTS: A total of 29,221 women received an initial Zika Contraception Access Network visit during the program. Ninety-six percent (27,985) of women received same-day provision of a contraceptive method and 70% (20,381) chose a LARC method. While the program was active, 719 (4%) women who chose a LARC at the initial visit had it removed. Women with a college degree or higher were more likely to have their LARC removed (adjusted prevalence ratio [aPR] 1.24); breastfeeding women (aPR 0.67) and those using a LARC method before Zika Contraception Access Network (aPR 0.55) were less likely to have their LARC removed. CONCLUSION: The Zika Contraception Access Network program was designed as a short-term response for rapid implementation of contraceptive services in a complex emergency setting in Puerto Rico and served more than 29,000 women. The Zika Contraception Access Network program had high LARC uptake and a low proportion of removals by a Zika Contraception Access Network provider during the program. A removal-inclusive design, with access to removals well beyond the program period, maximizes women's reproductive autonomy to access LARC removal when desired. This model could be replicated in other settings where the goal is to increase contraception access.

Physician and clinic staff attitudes and practices during implementation of the Zika Contraception Access Network.

OBJECTIVE: The Zika Contraception Access Network (Z-CAN) provided women in Puerto Rico access to contraceptive counseling and the full range of reversible contraceptive methods, on the same day and at no cost, during the Zika virus outbreak. Because trained physicians and clinic staff were crucial to the program, we aimed to assess the implementation of and satisfaction with Z-CAN from their perspectives. STUDY DESIGN: Physicians and clinic staff in the Z-CAN program participated in an online survey on program implementation (e.g., on-site and same-day contraceptive provision), program satisfaction, and knowledge consistent with program training (e.g., contraceptive initiation and safety, client-centered contraceptive counseling, intrauterine device [IUD] and implant insertion and removal). RESULTS: Survey respondents included 63 physicians and 53 clinic staff members. A high proportion of physicians (>93%) reported providing IUDs, implants, pills, rings, condoms, and injections and most were very often or always able to provide same-day access to most methods. Over 90% of physicians were satisfied with the Z-CAN program, training, and ongoing support. Staff satisfaction with these program elements was similar but slightly lower. Knowledge about exams and tests needed for initiation and safety of methods varied but was generally consistent with guidelines on which physicians received training. Most physicians (>90%) reported confidence in skills on which they received training as part of the program. CONCLUSIONS: From the perspectives of participating physicians and clinic staff, the program was generally implemented as intended and providers were largely satisfied with program strategies including training and on-going support. IMPLICATIONS: Certain key components of the Z-CAN program, such as training, proctoring, and involvement of clinic staff were likely critical to Z-CAN's implementation and provider satisfaction. Results from this provider survey can inform implementation of similar efforts to increase access to contraception in both emergency and non-emergency settings.

Program Fidelity and Patient Satisfaction among Women Served by the Zika Contraception Access Network Program in Puerto Rico.

BACKGROUND: The Zika Contraception Access Network (Z-CAN) was designed to provide women in Puerto Rico who chose to delay or avoid pregnancy during the 2016-2017 Zika virus outbreak access to high-quality client-centered contraceptive counseling and the full range of reversible contractive methods on the same day and at no cost through a network of trained providers. We evaluated the implementation of Z-CAN from the patient perspective. METHODS: An online survey, administered to a subset of women served by the Z-CAN program approximately 2 weeks after their initial Z-CAN visit, assessed patient satisfaction and receipt of services consistent with select program strategies: receipt of high-quality client-centered contraceptive counseling, same-day access to the contraceptive method they were most interested in after counseling, and no-cost contraception. RESULTS: Of 3,503 respondents, 85.2% reported receiving high-quality client-centered contraceptive counseling. Among women interested in a contraceptive method after counseling (n = 3,470), most reported same-day access to that method (86.8%) and most reported receiving some method of contraception at no cost (87.4%). Women who reported receiving services according to Z-CAN program strategies were more likely than those who did not to be very satisfied with services. Women who received high-quality client-centered contraceptive counseling and same-day access to the method they were most interested in after counseling were also more likely to be very satisfied with the contraceptive method received. CONCLUSIONS: A contraception access program can be rapidly implemented with high fidelity to program strategies in a fast-moving and complex public health emergency setting.