Global Health: Science and Practice最新文献

Introduction: In Nigeria, health care services and commodities have increasingly been accessed through private sector entities, including retail pharmacies and drug shops (also called proprietary patent medicine vendors [PPMVs]). However, PPMVs cannot provide long-acting or permanent methods, and concerns have been raised about their quality of services and their need to better comply with government regulations. This article describes how The Challenge Initiative's (TCI) family planning program supported 4 state governments in Nigeria to develop a model to strengthen public-private partnerships between PPMVs and primary health centers (PHCs) to leverage PPMVs to provide adolescents and youth with high-quality contraceptive information, services, and referrals to PHCs.

Program description: The intervention implemented a hub-spoke model by strengthening the linkages between neighboring PPMVs and large PHCs for delivering contraceptive services to adolescents and youth. The steps in the implementation process included: (1) introducing the intervention to state governments, (2) selecting PPMVs as spokes and high-volume PHCs as hubs, (3) conducting whole-site orientations jointly with PPMV and PHC staff, (4) strengthening referral links between PPMVs and PHCs, (5) implementing supportive supervision and coaching, and (6) strengthening client data management. TCI worked with the state and local ministry of health to improve PPMV operators' knowledge, attitudes, and skills to deliver adolescent- and youth-friendly services.

Lessons learned and recommendations: Implementing the PPMV intervention with state governments and PHCs strengthened the public-private partnership. A functional referral system in Plateau State demonstrated significant success, enabling increased contraceptive choice and adherence to regulations for adolescents and youth. We recommend that the government strengthen the working relationship between PPMVs and PHCs, incorporate PPMVs into the routine supportive supervision of the state health system, and incorporate a referral linkage with PHCs into the design and implementation of PPMV programs.

Introduction: Young newly married women and first-time parents (FTPs), particularly those living in slum settlements, have a high unmet need for modern contraceptive methods to limit and space births. We describe an intervention in which adolescents and youth sexual and reproductive health (AYSRH) services tailored to FTPs were incorporated into the government's existing family planning (FP) program in 5 cities of Uttar Pradesh. We examined the effect of this intervention on modern contraceptive use among FTPs aged 15-24 years.

Methods: To assess the effect of this pilot, in 2019, 1 year after the implementation of the program, we analyzed community-based output tracking survey data on 549 married women who are FTPs in the pilot cities. These FTPs were compared with 253 women who were FTPs from other cities where the program was implemented without a specific focus on FTPs. Descriptive statistics and multivariate logistic regression analysis were applied to understand the association between exposure to FP information, either through accredited social health activists or through service delivery points, and use of modern contraceptives.

Results: Use of modern contraceptives was higher among FTPs in the 5 pilot cities than non-pilot cities (39% vs. 32%; P<.05). The interaction effect of city type and exposure to the information showed a positive association between modern contraceptive use and program exposure, greater in pilot cities than non-pilot cities.

Conclusions: Higher uptake of modern contraceptives among young women may be achieved when an FTP-focused intervention is layered on the government's existing FP programs. Future studies with a longer duration of implementation, in a wider geography, and with longitudinal design are recommended to provide more robust measures of high impact intervention/practices in urban areas.

Introduction: The global health community continues to face barriers in scaling up evidence-based interventions for widespread adoption. Although many effective interventions have been developed over the years, expanding their reach to benefit broader populations has happened slowly or not at all.

Overview: The Challenge Initiative (TCI) is a nontraditional development platform that supports local urban governments to rapidly scale up proven family planning (FP) and adolescent and youth sexual and reproductive health (AYSRH) interventions for the urban poor. TCI prioritizes sustainability and local ownership and uses a health systems approach when planning for and managing scale. TCI strengthens urban health systems with seed funding, coaching, and technical assistance (TA), and TCI University houses "how-to" guidance and tools for implementing the interventions. In turn, local governments commit political will and financial and human resources while using TCI coaching to integrate interventions into routine practice and systems to achieve widespread and sustained impact at scale.

Results: As of June 2021, TCI has supported 104 local governments across 11 countries in scaling up effective FP and AYSRH interventions, while also mobilizing about US$28 million from those local governments to facilitate their implementation. TCI has increased capacity and bolstered urban health systems, with 39 local governments "graduating" from TCI support and 2.02 million additional FP clients across 4 regional TA hubs.

Conclusion: TCI aims to change how local governments coordinate, finance, and implement proven interventions to improve access to quality FP information and services. With built-in incentives for local governments, partners, and donors to participate, TCI is generating significant learning on how local governments can realize sustainable scale and demonstrating how organizations like TCI that facilitate governments to scale up effective interventions can accelerate the scale-up of these interventions across multiple geographies.

Introduction: In Benin, the unmet need for family planning services is especially high for adolescent girls and youth aged 15-24 years. The Challenge Initiative (TCI) supported the health system to assess and improve the quality of adolescent and youth sexual reproductive health services and enhance contraceptive uptake in 65 service delivery points (SDPs) of the Zou department.

Program description: Between June 2019 and March 2021, TCI supported the health districts in Zou to train an assessment team to complete 3 cycles of quality assessments (QAs) using a QA checklist adapted to the local context. Based on assessment scores, the SDPs were categorized into poor, moderate, or good to excellent quality. The SDP managers developed remedial action plans after each cycle and for each SDP and followed up with supportive supervision.

Results: The first QA cycle showed that 52% of assessed SDPs achieved a good to excellent classification; by the second QA cycle, this reached 74%. However, the quality of adolescent- and youth-friendly health services regressed during the third QA cycle (during COVID-19 pandemic disruptions), when only 40% of SDPs achieved the good to excellent category. Between the first and second QA cycles, contraceptive uptake for adolescents and youth improved in the SDPs that had good or excellent quality of services, compared to the ones that were of lower quality (established significance level of 5% with a P value of .031).

Conclusion: Further assessments could deepen our understanding of the internal and external factors that can affect service quality. The findings reinforce the importance of investing in quality improvement strategies to maximize the use of sexual and reproductive health services among adolescents and youth. They also underscore the need for a contextual and nuanced approach to ensure enduring results.

Background: Although the unique sexual and reproductive health needs of adolescents and youth (AY) are widely recognized, the challenge remains how to integrate adolescent- and youth-friendly health services (AYFHS) effectively within a systems-based approach that is both feasible and scalable. This article provides preliminary evidence from 4 Nigerian states that sought to overcome this challenge by implementing capacity-strengthening approaches centered around a shortened quality assurance (QA) tool that has become part of the state health system's routine supportive supervision process and follow-up quality improvement (QI) activities.

Methods: A shortened QA tool was administered to assess and track the performance of 130 high-volume health facilities across 5 domains to serve its AY population with quality contraceptive services. Facility-based providers (N=198) received training on adolescent and youth sexual and reproductive health, AYFHS, and long-acting reversible contraceptive methods. To corroborate checklist findings, we conducted exit interviews with 754 clients (aged 15-24 years) who accessed contraceptive services from the facilities that met the World Health Organization's minimum standards for quality AYFHS.

Results: In the 4 states, the QA tool was applied at baseline and 2 rounds, accompanied by QI capacity strengthening after each round. At baseline, only 12% of the 130 facilities in the 4 states scored met the minimum quality standards for AYFHS. After 2 rounds, 88% of the facilities met the minimum standards. AY client volume increased over this same period. All 4 states showed great improvements; however, the achievements varied by state. The exit interview feedback supported client satisfaction with the services provided to AY.

Conclusion: Integrating QA followed by QI within Nigeria's family planning supportive supervision system is not only feasible but also impacts the quality of AYFHS and contraceptive uptake by clients aged 15-24 years.

Background: The Data to Care (D2C) strategy uses multiple sources of complementary data on HIV clients and related services to identify individuals with gaps in HIV treatment. Although D2C has been widely used in the United States, there is no evidence on its use in other settings, such as countries most affected by the epidemic.

Strategy implementation: The D2C strategy was implemented within the context of a project that provided community-based support to children and adolescents living with HIV (C/ALHIV) in Mozambique. A data tracking tool and a standard operating procedure manual for local partner community organizations and health care facilities were developed to support the effort. Project staff met with local project implementing partners to discuss and coordinate the intervention in pilot health facilities.

Strategy piloting: The project initiated a pilot D2C intervention in 2019, working with 14 health facilities across 5 additional districts within 1 province. COVida project data were compared with clinical data from facilities serving C/ALHIV. The D2C intervention identified gaps in HIV treatment for a substantial number of C/ALHIV, and targeted support services were provided to address those gaps. Viral load (VL) monitoring was added in March 2020. Before the intervention, 71% of C/ALHIV reported to be on HIV treatment by their caregivers were documented as on treatment in health facilities. Support interventions targeted those not on treatment, and this proportion increased to 96% within 1 year of implementation. Additionally, 12 months later, the proportion of C/ALHIV with a documented VL test increased from 52% to 72%.

Conclusion: Introducing the D2C pilot intervention was associated with substantial improvements in HIV treatment for C/ALHIV, including increased linkage to and continuity in treatment and increased VL testing. D2C may be a useful approach to improve health outcomes for C/ALHIV in settings outside of the United States.

Background: We describe a 3-tier approach involving a gap analysis, root cause analysis, and pre-exposure prophylaxis (PrEP) collaborative to understand the gap and identify and address the main barriers to oral PrEP uptake and continuity in Uganda.

Methods: We used a mixed methods design with retrospective, cross-sectional, and prospective components. The gap analysis involved descriptive analysis of PrEP uptake and continuity. The RCA identified the main barriers to initiation and continuity on PrEP among 1,334 clients who declined to start PrEP and 1,266 who missed their appointment but were at risk. The PrEP collaborative tested changes mapped onto specific barriers to optimize the PrEP clinical service delivery. A trend analysis of routinely collected data of the PrEP cascade determined significant shifts and trends in PrEP uptake and continuity.

Results: Only 60% of the high-risk population eligible for PrEP were enrolled, while fewer than 30% of the cumulative number of PrEP users were refilled each quarter. Uncertainty and fear of side effects, perceptions about the harmfulness of the medication, perceived inability to adhere to PrEP, and stigma were the main reasons why clients rejected PrEP. Lack of access to the facility, side effects, pill burden, stigma, perceived low-risk exposure to HIV, and preference of staying at work as opposed to picking up refills affected continuity on PrEP. The collaborative registered statistically significant shifts in PrEP enrollment from 64% to 89% and continuity from 51% to 78% between July 21 and November 22 following the collaborative intervention.

Conclusions: We recommend using a 3-tier approach for other similar implementation contexts to strengthen PrEP programming, given the marked statistical shift in PrEP uptake and continuity. This begins with understanding the gap and barriers to use among clients, followed by mapping interventions to specific barriers through a quality improvement collaborative.