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BackgroundMethod mix – the percent distribution of contraceptive use by method among contraceptive users – reflects both client choice of method and method availability. In a country where clients have access to a wide range of methods at an affordable price, method mix is a strong proxy for method choice. In contrast, where access is limited by numerous factors – method availability, cost, or provider attitudes – method mix may not capture method choice well. Given that method mix can be measured reliably from population-based surveys, it is useful in exploring method choice. While the method mix for all women of reproductive age (15–49 years) has been described previously, the method mix for adolescents and young women aged 15–24 remains unexplored despite this population's high risk for unintended pregnancy.ObjectivesThis study investigates the contraceptive method mix for women aged 15–24 in low- and middle-income countries (LMICs) with national survey data and describes how the method mix differs by age group, geographic region, and marital status for women.MethodsUsing data from the Demographic and Health (DHS) Surveys, the contraceptive method mix among women aged 15–24 across 64 LMICs is analyzed by age, marital status, and region, with measures of skew and average deviation. Three case studies are presented in which the trend over time in the method mix is examined.ResultsThere are large variations in method mixes across regions, which reflect their differences in various supply and demand constraints. However, there is consistently high usage of short-acting methods among both age groups, 15–19 and 20–24, compared to the full population of all women of reproductive age. Male condoms overwhelmingly predominate as the method used by women 15–24 in all regions.ConclusionThe marked differences found by marital status, region, and age show the need for programs to be tailored to local circumstances. Additionally, the large unmet need for contraception signals the ongoing urgency for strengthened programmatic efforts, and for a wider offering of methods to enlarge the choices available to young women. Unmarried women in particular deserve attention, as well as young married women who wish to postpone a pregnancy.

Background The use of implants has steadily increased in Kinshasa since 2013 but clinic-based access to this family planning method is limited due to distance and costs barriers. The objective of this study was to examine the feasibility and acceptability of providing Implanon NXT at the community level using medical and nursing students (M/N) as distributors, as part of a strategy to improve contraceptive uptake in the Democratic Republic of Congo. Methods A cohort of 531 women who chose to receive Implanon NXT from a M/N student during community-based campaign days participated in three rounds of a quantitative survey administered at the time of insertion of the method, and at 6 and 12 months later. We conducted descriptive analysis to assess the feasibility and acceptability of providing the method through M/N students in terms of method choice, user profiles, contraceptive history, experience with insertion and side effects, continuation / discontinuation of the method, and overall satisfaction with FP services as well as students’ preparedness and capacity to safely offer the method, and their satisfaction with the experience.. Results The study demonstrated the feasibility of training students for community-based provision of Implanon NXT and 95% of them were satisfied with their experience. Acceptability of both the method and the service delivery strategy was high among participants, including among young and first-time contraceptive users. Out of the 441 women with a known outcome at 12 months, 92% still had Implanon NXT inserted, despite some of them reporting experiencing side effects. The vast majority (79%) would “strongly recommend” obtaining NXT from a M/N student if a friend wanted to avoid pregnancies. Conclusions The provision of Implanon NXT at the community-level is a promising solution to address some of the barriers to accessing this method for women living in Kinshasa. However, strengthening pre-insertion counseling, particularly on expected side-effects and the possibility of early removal, is necessary to increase informed choice for the women and potentially limit method discontinuation.

Injection drug use is a known risk factor for HIV transmission, but research suggests non-injection drug use also heightens HIV risk. This study measures HIV prevalence and examines sexual behavior among drug users in Guatemala City. The multiplier method and respondent-driven sampling (RDS) were used to estimate the size of the population, generating a representative sample of 299 drug users 18+ years old living in Guatemala City. The study found that drug users tended to be males with low education and income; 6% were HIV positive. Most drug users reported sexual behaviors that heightened the risk of HIV transmission like multiple sexual partners, buying or selling sex, low rates of consistent condom use, and exchanging sex for drugs. HIV prevalence is low in Guatemala, but non-injection drug use likely increases behaviors that heighten risk of HIV transmission.

Traditional contraceptive methods are used by 55 million women in developing countries. This study analysed over 80 national surveys to compare traditional with modern method users, by type, region, socio-demographic characteristics, strength of family planning programmes and discontinuation rates. The advance of modern methods has greatly reduced the share held by traditional methods, but the actual prevalence of their use has declined little. Young, sexually active unmarried women use traditional contraception much more than their married counterparts. Discontinuation rates are somewhat lower for traditional methods than for the resupply methods of the pill, injectable and condom; among users of all of these methods, more than a quarter stop use in the first year to switch to alternative methods. Traditional method use is firmly entrenched in many countries, as the initial method tried, a bridge method to modern contraception and even the primary method where other methods are not easily available.

In Kinshasa, Democratic Republic of the Congo (DRC), modern contraceptive prevalence is low by international standards: 29.6% as of 2020. A 2015 pilot study demonstrated the feasibility and acceptability of using medical and nursing students to administer DMPA-SC (the subcutaneous injection) among other methods at the community level. The more far-reaching discovery was the potential of clinically trained students to increase access to low-cost contraception in the short-run, while improving the quality of service delivery for future generations of healthcare providers. Scale-up involved integrating the family planning curriculum into the training of nursing students, including classroom instruction in contraceptive technology and service delivery, coupled with a year-long field practicum in which students offered a range of contraceptive methods during intermittent outreach events, door-to-door distribution or sales from their homes. Starting in 2015, a multi-agency team consisting of an international non-governmental organizations (NGO), several Ministry of Health directorates and a local NGO used the ExpandNet/WHO framework to guide this scale-up. This article details the nine steps in the scale-up process. It presents results on increases in contraceptive uptake, feedback from participating nursing school personnel and the employment experience of the graduates from this programme. Between 2015 and 2019, the family planning curriculum was incorporated into 30.8% of the 477 nursing schools in 7 of the 26 provinces in the DRC. Students delivered 461 769 couple-years of protection (the key output indicator for family planning programmes). Nursing school personnel were strongly favourable to the approach, although they needed continued support to adequately implement a set of additional interventions related to the service delivery components of the new training approach. Post-graduation, only 40.1% of graduates had paid employment (reflecting the staggering unemployment in the DRC); among those, over 90% used their family planning training in their work. We describe the multiple challenges faced during the scale-up process and in planning for expansion to additional schools.

Introduction The objective of this study is to assess change over time in the modern contraceptive prevalence rate (MCPR) and related variables among married women of reproductive age (15–49 years) in the military population in Kinshasa, Democratic Republic of Congo, compared to women in the non-military population, based on cross-sectional surveys in 2016 and 2019. Methods Data among women living in military camps were collected as a special study of contraceptive knowledge, use, and exposure to FP messaging, for comparison to women in the non-military population from the annual PMA2020 survey. Both used a two-stage cluster sampling design to randomly select participants. This analysis is limited to women married or in union. Bivariate and multivariate analysis was used to compare the military and non-military populations. Results The socio-demographic profile of women in the military camps differed between 2016 and 2019, which may reflect the more mobile nature of this population. In both populations, knowledge of modern contraceptive methods increased significantly. Similarly, use of a modern contraceptive method also increased significantly in both, though by 2019 women in the military camps were less likely to use modern contraception (24.9%) than their non-military counterparts (29.7%). Multivariate analysis showed no significant difference in the amount of increase in MCPR for the two populations. Among contraceptive users in both populations, the implant was the leading method. Potential effects of FP programming were evident in the military population: exposure to FP messaging increased (in comparison to a decrease among the non-military population). Moreover, women who had lived in the camps for 4+ years had a higher MCPR than those living in the camps for less than four years. Conclusions This study demonstrates the feasibility and importance of collecting data in military camps for better understanding contraceptive dynamics among this specialized population.

Background Clients must recall information from contraceptive counseling sessions to properly use their chosen method. Client recall in community-based settings is challenging given the public nature of these events and the presence of many potential distractions. Understanding the factors that influence client recall during community-based distribution events can guide future training of providers to improve proper use of contraceptive methods and client satisfaction. Methods This cross-sectional study employed a convenience sample of 957 women ages 15–49 old who sought contraceptive services from community-based contraceptive distribution events in Kinshasa, Democratic Republic of the Congo, known as Lelo PF. Recall scores were developed by matching direct observations with client exit interviews. The association between recall and client characteristics, provider characteristics and an index for the quality of the provider-client interaction were tested using multivariate linear regression. Results The average recall score was 67.6%. Recall scores were higher among clients who accepted methods with simpler administration procedures, such as CycleBeads (81.3%), compared to methods requiring more medically advanced administration procedures, such as DMPA-SC (56.6%) and Implanon-NXT (62.1%). This relationship held even after controlling for amount of information each client received. Status as a first-time user was associated with a 5.8 percentage point decrease in recall score (p = 0.002). Time since the provider’s initial family planning training and clients’ perception of the provider-client interaction were associated with higher client recall scores. Conclusion Results of this study suggest that to improve client recall at Lelo PF events, future provider training should focus on how to deliver clear, specific information to clients, making sure clients feel at ease during the counseling session, and treating clients with respect. First-time family planning users and clients who select methods with more medically advanced administration procedures may require extra attention during the consultation to ensure they are able understand and remember the information. Results suggest that providers who have been offering services longer may be more effective in conveying information in a way that clients can remember. Program managers should consider requesting input from experienced providers to improve training sessions.

Trends in contraceptive method mix show that dominance of 1 method in the mix remains very common, though countries and regions throughout the world are diverse as to which method is dominant. Our analysis argues for continued concerted efforts of programs to increase contraceptive method choice., Key Messages Contraceptive method mix reflects both supply and demand.Recent trends include a progression in hormonal methods toward implants in sub-Saharan Africa, and where HIV is common, more condom use in some countries.However, dominance of 1 method in the mix remains very common, though countries and regions throughout the world are diverse as to which method is dominant.Our analysis argues for continued concerted efforts of programs to increase contraceptive method choice.There is no ideal method mix; client preferences are key., Context: Improving contraceptive method choice is a goal of international family planning. Method mix—the percentage distribution of total contraceptive use across various methods—reflects both supply (availability of affordable methods) and demand (client preferences). We analyze changes in method mix, regional contrasts, and the relationship of the mix to contraceptive prevalence. Methods: We use 789 national surveys from the 1960s through 2019, from 113 developing countries with at least 1 million people and with data on use of 8 contraceptive methods. Two measures assess the “evenness” of the mix: method skew (more than 50% use is by 1 method), and the average deviation (AD) of the 8 methods’ shares from their mean value. Population weighted and unweighted results are compared because they can differ substantially. Results: Use of traditional methods has declined but still represents 11% of all use (population weighted) or 17% (unweighted country average). Vasectomy’s share was historically low with the exception of a few countries but is now even lower. The previous trend toward greater overall evenness in the mix has slowed recently. Sub-Saharan Africa shows a hormonal method progression from oral contraceptives to injectables to implants in a substantial number of countries. In some countries with high HIV prevalence, the condom share has increased. The leading method’s share differs by region: female sterilization in Asia (39%) and in Latin America (31%), the pill in the Middle East/North Africa (32%), and the injectable in sub-Saharan Africa (36%). Method skew persists in 30% of countries. “Evenness” of mix is not related to contraceptive prevalence. Conclusion: The marked diversity in predominant methods underscores the conclusion that no single method mix is ideal or appropriate everywhere. But that diversity across countries, coupled with the persisting high degree of extreme skewness in many of them, argues for continued concerted efforts for programs to increase method choice.

Background: Spatial access has a direct effect on health service utilization in many settings. While, all elements of access are usually affected by service delivery points and client characteristics. Distance to facility has proven to affect family planning service use in many Sub-Saharan countries. Studies show that women who reside closer to facilities offering family planning services are more likely to use modern contraceptives. However, researchers often test the theory of distance decay to observe any association between an increased distance of health facilities and health service utilization. This study to analyze the significance of proximity to family planning (FP) services, as well as service availability and quality of family planning services in Kinshasa. Methods: We used a pool of four rounds of facility- and population-based survey data in Kinshasa. We tested if women who live closer to service delivery points with higher level of availability and quality are more likely to use modern contraceptives or less likely to have unmet need for contraceptive services. Results: Our findings show that living closer to an SDP is not a determinant of modern contraceptive use or having unmet need for FP services. Discussion: Lack of cognitive access, economic barriers, bypassing the closest facility, and sociocultural norms are among the strong barriers for women in Kinshasa not to use modern contraceptives. Our analysis shows that proximity to quality services does not necessarily result in increased FP use among women of reproductive age living in Kinshasa, thus suggesting that a bypass phenomenon may occur when obtaining modern contraceptive services. Conclusion: This study indicates that proximity to facilities does not necessarily equate proximity to methods, nor does it necessarily enable current users or women with an unmet need (potential contraceptive users) to easily obtain services for their method of choice. This study notes that other barriers to access may be substantial determinants of contraceptive use or unmet need. More research should be conducted that directly measures multidimensional components of access in order to interpret women’s contraceptive seeking behaviors in urban areas of Sub-Saharan Africa.

In a context where distance, user fees, and health staff shortages constitute significant barriers to accessing facility-based family planning services, the use of community-based distributors (CBDs) as counseling and contraceptive providers has been tested in several resource-constrained environments to increase family planning uptake. In the capital city of the Democratic Republic of the Congo (DRC), Kinshasa, a massive CBD program (AcQual) has been implemented since 2014, with lackluster results measured in terms of the low volume of contraceptives provided. A process evaluation conducted in 2017 assessed the fidelity of implementation of the program compared with the original AcQual design and analyzed gaps in provider training and motivation, contraceptive supplies, and reporting and monitoring processes. Its objective was to identify both theory and implementation failures in order to propose midcourse corrections for the program. The mixed-method data collection focused on the CBDs as a pivotal component of the AcQual program with 700 active CBDs interviewed. In addition, 10 in-depth interviews were conducted with clinical personnel, local health program managers, and project partners to identify gaps in the AcQual implementation environment. Issues with CBDs' performance, knowledge retention, and commitment to program activities, as well as gaps in contraceptive supply chains and insufficient monitoring and supervision processes, were the main implementation failures identified. Inappropriate method mix offered by the CBDs (condoms, pills, and CycleBeads only) and chronic overburdening of health care staff at the local level compounded these issues and explained the low volume of contraceptives provided through AcQual. Midcourse corrections included a more structured schedule of activities, stronger integration of CBDs with clinical providers and health zone managers, expansion of the mix of contraceptives offered to include subcutaneous injectables and emergency contraceptive pills, and clarifying reporting and monitoring responsibilities among all partners. Findings from this process evaluation contribute to the limited knowledge base regarding "unwelcome results" by examining all the intervention components and their relationships to highlight areas of potential failures, both in design and implementation, for similar CBD programs.

Formidable challenges: uncertain political situation, cultural norms favoring high fertility, a thin patchwork of service delivery institutions, logistical issues in a vast country with weak infrastructure, and low capacity of the population to pay for contraceptive services. Encouraging progress: increasing government and donor support, openness to progressive service delivery policies, innovative programming including robust social marketing and initiatives with nursing schools and the military, strong collaboration among stakeholders, high unmet need suggesting strong latent demand for family planning, and an increasingly balanced method mix including long-acting methods., Momentum for family planning in the Democratic Republic of the Congo (DRC) is evident in multiple ways: strong political will, increasing donor support, a growing number of implementing organizations, innovative family planning programming, and a cohesive family planning stakeholder group. Between 2013 and 2017, the modern contraceptive prevalence rate (mCPR) in the capital city of Kinshasa increased from 18.5% to 26.7% among married women, but as of 2013–14, it was only 7.8% at the national level. The National Multisectoral Strategic Plan for Family Planning: 2014–2020 calls for achieving an mCPR of 19.0% by 2020, an ambitious goal in light of formidable challenges to family planning in the DRC. Of the 16,465 health facilities reporting to the national health information system in 2017, only 40% offer family planning services. Key challenges include uncertainty over the political situation, difficulties of ensuring access to family planning services in a vast country with a weak transportation infrastructure, funding shortfalls for procuring adequate quantities of contraceptives, weak contraceptive logistics and supply chain management, strong cultural norms that favor large families, and low capacity of the population to pay for contraceptive services. This article describes promising initiatives designed to address these barriers, consistent with the World Health Organization's framework for health systems strengthening. For example, the national family planning coordinating mechanism is being replicated at the provincial level to oversee the expansion of family planning service delivery. Promising initiatives are being implemented to improve the supply and quality of services and generate demand for family planning, including social marketing of subsidized contraceptives at both traditional and non-traditional channels and strengthening of services in military health facilities. To expand contraceptive access, family planning is being institutionalized in nursing schools, allowing students to operate as community-based distributors. While major challenges remain, significant progress in family planning has been made in the DRC, which should be judged not in comparison with sub-Saharan African countries with high mCPR and mature programs, but rather with those starting from much further behind.

Recent research in the Democratic Republic of Congo (DRC) has shown that over a quarter of women have an unmet need for family planning and that modern contraceptive use is three times higher among urban than rural women. This study focuses on the reasons behind the choices of married men and women to use contraception or not. What are the barriers that have led to low levels of modern contraceptive use among women and men in DRC rural areas? The research team conducted 24 focus groups among women (non-users of any method, users of traditional methods and users of modern methods) and husbands (of non-users or users of traditional methods) in six health zones of three geographically dispersed provinces. The key barriers that emerged were poor spousal communication, sociocultural norms (especially the husband's role as primary decision-maker and the desire for a large family), fear of side-effects and a lack of knowledge. Despite these barriers, many women in the study indicated that they were open to adopting a modern family planning method in the future. These findings imply that programming must address mutual comprehension and decision-making among rural men and women alike in order to trigger positive changes in behaviour and perceptions relating to contraceptive use.

Background Kinshasa is Africa's third largest city and one of the continent’s most rapidly growing urban areas. PMA2020 data showed that Kinshasa has a modern contraceptive prevalence of 26.5% among married women in 2018. In Kinshasa’s method mix, the contraceptive implant recently became the dominant method among contraceptive users married and in union. This study provides insight into patterns of implant use in a high-fertility setting by evaluating the 24-month continuation rate for Implanon NXT and identifying the characteristics associated with discontinuation. Methodology This community-based, prospective cohort study followed 531 Implanon users aged 18–49 years at 6, 12 and 24 months. The following information was collected: socio-demographic characteristics, Method Information Index (MII) and contraceptive history. The main outcome variable for this study was implant discontinuation. The incidence rate of discontinuation is presented as events per 1000 person/months (p-m), from the date of enrolment. The Cox proportional hazards modelling was used to measure predictors of discontinuation. Results A total of 9158.13 p-m were available for analysis, with an overall incidence rate of 9.06 (95% CI: 9.04–9.08) removals per 1000 p-m. Of nine possible co-variates tested, the likelihood of discontinuation was higher among women who lived in military camps, had less than three children, never used injectables or implants in the past, had experienced heavy/prolonged bleeding, and whose MII score was less than 3. Conclusion In addition to four client characteristics that predicted discontinuation, we identified one programmatic factor: quality of counseling as measured by the Method Information Index. Community providers in similar contexts should pay more attention to clients having less than three children, new adopters, and to clients living military camps as underserved population, where clients have less access to health facilities. More targeted counselling and follow-up is needed, especially on bleeding patterns.

Background: Current facility conditions, obstetric and neonatal care practices, and availability of emergency obstetric and neonatal care (EmONC) were assessed in the Kwango and Kwilu provinces of the Democratic Republic of the Congo (DRC). Methods: This is an analysis of the baseline survey data from an ongoing clinical mentoring program among 72 rural health facilities in the DRC. Data collectors visited each of the facilities and collected data through a pre-programmed smartphone. Frequencies of selected indicators were calculated by province and facility type—general referral hospital (GRH) and primary health centers (HC). Results: Facility conditions varied across province and facility type. Maternity wards and delivery rooms were available in the highest frequency of rooms assessed (>95% of all facilities). Drinking water was available in 25.0% of all facilities; electricity was available in 49.2% of labor rooms and 67.6% of delivery rooms in all facilities. Antenatal, delivery, and postnatal care services were available but varied across facilities. While the proportion of blood pressure measured during antenatal care was high (94.9%), the antenatal screening rate for proteinuria was low (14.7%). The use of uterotonics immediately after birth was observed in high numbers across both provinces (94.4% in Kwango and 75.6% in Kwilu) and facility type (91.3% in GRH and 81.4% in HC). The provision of immediate postnatal care to mothers every 15 minutes was provided in less than 50% of all facilities. GRH facilities generally had higher frequencies of available equipment and more services available than HC. GRH facilities provided an average of 6 EmONC signal functions (range: 2-9). Conclusions: Despite poor facility conditions and a lack of supplies, GRH and HC facilities were able to provide EmONC care in rural DRC. These findings could guide the provision of essential needs to the health facilities for better delivery of maternal and neonatal care.

The current limited focus on management in global health activities is highly problematic given the amounts of financial and human resources that are pouring into health system strengthening interventions and the complexity of clinical operations across settings. By ensuring that public health and healthcare practitioners in domestic and international settings receive management training in their educational programs and that we build management capacity among individuals already in the health workforce, we can begin to prepare for more effective health systems strengthening efforts. Rigorous evaluation of health systems strengthening and the impact of management capacity building is crucial to building evidence for the field.

Objectives The objective of this research is to assess the acceptability of the provision of subcutaneously administered depo medroxyprogesterone acetate (DMPA-SC) by nonclinically trained community health workers (CHWs) among acceptors in the rural province of Lualaba in the Democratic Republic of the Congo (DRC). Study design In 2017, 34 CHWs received training in provision of DMPA-SC. Among other methods, DMPA-SC by CHWs was offered during household visits and at community outreach events. The initial survey included questions on acceptors' demographic characteristics, contraceptive use history and experience with provision of DMPA-SC by a CHW. The follow-up included questions about side effects experienced and continuation of DMPA-SC by a CHW. Results Seventy-four percent of initial acceptors of DMPA-SC (N=252) were first-time contraception users. Almost all (96.0%) felt very comfortable with a CHW performing the injection rather than a physician or nurse, and 97.6% perceived that the CHW was very comfortable performing the injection. A total of 239 women were interviewed at follow-up. Most expressed satisfaction with the method despite some side effects experienced. Almost all acceptors (97.9%) were satisfied with the information provided by CHWs, and 93.8% were satisfied with the overall service. Most (96.4%) would choose to continue receiving DMPA-SC by a CHW rather than in a health clinic, and 95.2% would recommend DMPA-SC by a CHW to a friend. Conclusions Overall, administration of DMPA-SC by CHWs is acceptable to users in Lualaba. DMPA-SC can be safely provided within the community after proper training. Implications This study validates the use of CHWs (without clinical training) to provide DMPA-SC in a rural sub-Saharan African setting. It also represents an important step in obtaining official MOH authorization for the scale-up of this mechanism of distribution to other underserved regions in the DRC.

Behavioral health integration (BHI) is a proven, effective practice for addressing the joint behavioral health and medical health needs of vulnerable populations. As part of the New Orleans Charitable Health Fund (NOCHF) program, this study addressed a gap in literature to better understand factors that impact the implementation of BHI by analyzing perceptions and practices among staff at integrating organizations. Using a mixed-method design, quantitative results from the Levels of Integration Measure (LIM), a survey tool for assessing staff perceptions of BHI in primary care settings (n=86), were analyzed alongside qualitative results from in-depth interviews with staff (n=27). Findings highlighted the roles of strong leadership, training, and process changes on staff collaboration, relationships, and commitment to BHI. This study demonstrates the usefulness of the LIM in conjunction with in-depth interviews as an assessment tool for understanding perceptions and organizational readiness for BHI implementation.

Context Method mix-the percentage distribution of contraceptive users in a given country, by method-is one measure that reflects the availability of a range of contraceptive methods. A skewed method mix-one in which 50% or more of contraceptive users rely on a single method-could be cause for concern as a sign of insufficiency of alternative methods or provider bias. Shifts in method mix are important to individual countries, donors and scholars studying contraceptive dynamics. Methods To determine current patterns and recent changes in method mix, we examined 109 low- and middle-income countries. A variety of statistical methods were used to test four factors as correlates of skewed method mix: geographic region, family planning program effort index, modern contraceptive prevalence rate and human development index. An assessment of changes in reliance on female and male sterilization, the IUD, the implant and the injectable was conducted for countries with available data. Results Of the 109 countries included in this analysis, 30% had a skewed method mix-a modest decrease from 35% in a 2006 analysis. Only geographic region showed any correlation with method skew, but it was only marginally significant. The proportion of users relying on female sterilization, male sterilization or the IUD decreased in far more countries than it increased; the pattern was reversed for the injectable. Conclusion Method mix skew is not a definitive indicator of lack of contraceptive choice or provider bias; it may instead reflect cultural preferences. In countries with a skewed method mix, investigation is warranted to identify the cause.

The DRC’s National Program for Reproductive Health—the government office charged with coordinating and overseeing family planning—has lacked the human and financial resources to effectively carry out its role. As of 2011, at least 10 local and international nongovernmental organizations (NGOs) were providing some type of family planning service delivery in Kinshasa; however, each tended to work in isolation. Although these groups have worked diligently to attain their own project objectives, there was no coordinated effort to collectively increase contraceptive prevalence in Kinshasa. This special report presents a case study of a promising model for increasing contraceptive availability in Kinshasa, which could be replicated in other large cities in the DRC and elsewhere in the region.

This article details how the New Orleans Musicians' Clinic (founded 1998) has evolved to sustain New Orleans' musicians in mind, body and spirit by developing a unique access point to primary care, preventative health and social services and occupational outreach. Today, the clinic engages many partners, providers and funders at the federal, state and local levels to serve the increasing demand of their more than 2,400 patients.

Objective: The study aims to assess Pu’er rural drinking water quality and to investigate the reasons why microbial indexes exceed the national rural drinking water standard. Methods: The study uses existing data obtained from Pu’er rural drinking water monitoring Network. Simultaneously, a series of semi-constructed in-depth interviews were conducted with key informants. Results: The water samples taken from Pu’er which met the national rural drinking water standard only accounted for 17.5%, while 82.5% of samples did not meet this standard. The P-value of x2 test of total colony and total coliform number with chemical and physical treatment was .195 and .000, treated water and tap water was .175 and .340, dry season and rainy season was .003 and .000. Discussion: The results present that the percentage of water in Pu’er Municipality which meets the national rural drinking water standard is very low.

This qualitative study explored the relationship between drug use and risk for HIV transmission among middle-class young people in Guatemala City. It used the PEER methodology, whereby the interviewers were themselves drug users, and each recruited three friends as informants. The 21 peer interviewers recruited a total of 62 informants who participated in three interviews each. The informants viewed drug use favorably: as the social lubricant that facilitates interactions with friends and provides new, pleasurable experiences, free from the conventions of a conservative society. Drug use was limited almost exclusively to noninjection drugs: cocaine, marijuana, ecstasy, lysergic acid diethylamide, and mushrooms. Informants feared pregnancy, detection of their drug use, overdosing, and becoming addicted but did not perceive any risk of HIV. With the recent escalation of drug trafficking in Guatemala, it is important to build the evidence base on drug use in this population and its potential implications for HIV transmission.

This study evaluates the 2008–2009 “Lose your Excuse” public service advertising (PSA) campaign on energy efficiency targeting 8- to 12-year-olds, intended to increase knowledge, foster proactive attitudes, and change energy usage behaviors. Baseline and two follow-up surveys were conducted with online samples representative of the national population of households with kids with online access. Almost half (47%) of the tweens recognized at least one ad from the campaign. Ad recognition was positively associated with knowledge, proactive attitudes, and energy-saving behavior. Propensity score analysis confirmed a small but measurable and statistically significant effect on energy-saving behavior. The discussion section compares these results to public health campaigns in terms of ghost awareness, reach, and effect size.

This article reviews 44 operations research projects aiming to improve reproductive health services in Guatemala, conducted by the Population Council from 1988 to 2001. It documents the experience of the research programme, traces the extent to which research results are identifiable in existing programmes, and analyses factors influencing utilization. Utilization of research results occurs as a gradual process of information sharing, where researchers influence decision-makers through a continual stream of information rather than a single set of findings. Utilization depends on leadership, collaborative planning and implementation, close monitoring, and feasible research designs, among other factors. To influence policy formulation, organizations should form enduring links among institutions and develop critical research skills among personnel who collaborate with or manage service programmes. To understand how operations research affects policy and programme change, one must consider not just individual projects, but rather the synergistic impact of multiple projects on a broad range of themes over time.

A series of facility-based surveys that mapped all sites providing family planning services and that assessed readiness to provide services, using mobile phones, was feasible in a low-resource setting, contributing to mobilization of partners and increased donor support. Between 2012 and 2013, readiness to provide services increased from 44% of sites to 63%. Three factors most associated with productivity: type of facility (clinics more than hospitals or health centers), more years in operation, and number of methods available., Background: Modern contraceptive prevalence was 14.1% in 2007 in Kinshasa, the capital city of the Democratic Republic of the Congo (DRC). Yet virtually nothing was known about the family planning supply environment. Methods: Three surveys of health facilities were conducted in 2012, 2013, and 2014 to determine the number, spatial distribution, and attributes of sites providing family planning services. The 2012 and 2013 surveys aimed to identify the universe of family planning facilities while obtaining a limited set of data on “readiness” to provide family planning services (defined as having at least 3 modern methods, at least 1 person training in family planning in the last 3 years, and an information system to track distribution of products to clients) and output (measured by couple-years of protection, or CYP). In contrast, the 2014 survey, conducted under the umbrella of the Performance Monitoring and Accountability 2020 (PMA2020) project, was based on 2-stage cluster sampling. This article provides detailed analysis of the 2012 and 2013 surveys, including bivariate and multivariate analysis of correlates of readiness to provide services and of output. Results: We identified 184 health facilities that reported providing at least 1 contraceptive method in 2012 and 395 facilities in 2013. The percentage of sites defined as “ready” to provide services increased from 44.1% in 2012 to 63.3% in 2013. For the 3-month period between January and March 2013, facilities distributed between 0 and 879.2 CYP (mean, 39.7). Nearly half (49%) of the CYP was attributable to implants, followed by IUDs (24%), CycleBeads (11%), and injectables (8%). In 2013, facilities supported by PEPFAR (n = 121) were more likely than other facilities to be rated as ready to provide services (P

The Democratic Republic of the Congo (DRC)—with a population estimated at 67.5 million1—is the third most populous country in sub-Saharan Africa and the most populous francophone country. Since its independence from Belgium in 1960, the country has had a tumultuous history. During the dictatorship of President Mobutu Sese Seko (1965–1997), when the country was named Zaire, the repressive government provided periods of relative stability but at great cost to the country and to its citizens. In 1991, Mobutu lost control over the population; political turmoil and social unrest, known as the pillage (plundering), created a highly volatile environment that caused foreign investors and international donor agencies to withdraw completely or reduce support to the country, plunging the country further into poverty. The First Congo War (1996–1997) resulted in Mobutu being overthrown by the Rwandan-backed rebel leader Laurent-Desire Kabila.2 The Second Congo War (that involved 9 neighboring countries) occurred primarily in the eastern part of the country between 1998 and 2002, resulting in further economic devastation. By the early 2000s, life in the capital city of Kinshasa and some other provinces began returning to normalcy, although the threat of war continued to simmer in the eastern provinces bordering Rwanda and Uganda.3 Because of the ravages of war, political uncertainty, external exploitation, inadequate investment in human capital, and widespread poverty, the DRC—one of the richest countries in the world in minerals—ties for last place among 187 nations on the Human Development Index.4 The DRC is typical of African countries that are just beginning the demographic transition, with a total fertility rate of 6.6 as of 2013,5 a doubling in population size every 23 years, and a very young population (46% are under the age of 15). Almost three-quarters (71.3%) of the population live below the poverty line, and 45.9% live in severe poverty.5 With its high maternal mortality rate of 846 per 100,000 live births5 and large population base, the DRC is among the 5 countries that contribute the greatest number of maternal deaths to the global total.6 Although the country established a national family planning program (Projet National des Naissances Desirables, or PSND) in the early 1980s, it became inactive in the early 1990s in the wake of the pillage. In the mid2000s, external donors and technical organizations tentatively began to resume operations in the DRC. With a myriad of challenges facing the government from every sector, family planning was low on the priority list; the government had more important problems to address. Although the government established the National Program of Reproductive Health (Programme National de Sante de la Reproduction, or PNSR) in 2001 to address maternal mortality, family planning, and related issues, it drew little attention or support from higher levels of government. While maternal mortality did register as a national priority, family planning did not during the first decade of the millennium. The Growth and Poverty Reduction Strategy failed to mention family planning, although it did touch on leprosy, onchocercosis, and tuberculosis7; family planning was mentioned in the second edition released in 2010. For decades, there was little evidence of government interest in family planning. Some have questioned if the Roman Catholic Church has been an obstacle to family planning in the DRC. The Ministry of Health estimates that 40% of health facilities in the DRC are managed by the Church.8 In some cases, these facilities refuse to offer modern contraceptive methods; in others, they turn a blind eye. To the extent that the Roman Catholic Church in the DRC has attempted to exercise its influence in terms of family planning, it has been to promote natural methods over “artificial contraception.” In contrast to selected countries in Latin America and to the Philippines (where the Church has tried to block government or NGO family planning programs), it does not constitute a source of organized opposition to family planning programming in the DRC. Beginning in 2012, the DRC government took a number of actions that demonstrated its commitment to family planning, which has taken the international family planning community and many local observers by surprise. The purpose of this article is to document the evolution of the family planning policy environment in the DRC, analyze events that led to positive change, and identify factors that could influence the durability of this change.

Intimate partner violence (IPV) has been found to be negatively associated with contraceptive use in developing countries, but evidence from Africa is mixed. This study examines whether the above association differs in conflict settings, which have the potential for both higher levels of violence and more limited access to family planning. We use nationally representative data from the Democratic Republic of the Congo to examine the relationship between individual- and community-level IPV and modern contraceptive use, and to explore whether conflict modifies the relationship between IPV and contraceptive use. Nationally, only 6% of women reported current modern contraceptive use, while 53% reported experiencing physical IPV and 32% reported experiencing sexual IPV. In multivariate models, we found that individual-level sexual IPV was positively associated with current using modern contraceptive use, but that a combined measure of physical and sexual IPV did not demonstrate a similar association. Community-level IPV was not associated with individual-level contraceptive use. Conflict exposure was neither an independent predictor nor modifier of contraceptive use. Results suggest improved access to family planning should be a priority for programming in DRC, and efforts should ensure that sufficient resources are allocated towards the reproductive health needs of women in both conflict and non-conflict regions.

Communication is at the heart of behavior change programs in developing countries. It is hard to imagine a program designed to bring about some type of change in behavior or health status that does not utilize at least some type of directed communication. How effective are these interventions however in bringing about the desired change? And at what cost? This special issue of the Journal of Health Communication examines the state of the art for addressing the familiar question "What is the bang for the buck?" We expect this issue to be of interest to two main audiences: (1) health communication specialists interested in designing the most effective programs on limited budgets and (2) researchers/evaluators interested in applying state-of-the-art methods for conducting cost-effectiveness analysis of communication programs for behavior change. Health communication programs aim to bring about change in individual behaviors and social norms using some combination of (1) mass media (2) community-level interventions (e.g. community mobilization) and (3) interpersonal communication/ counseling. Programs today tend to incorporate the highly effective elements of entertainment education. Earlier evaluations often measured the effects of a program consisting of a few or even a single communication channel in a limited geographical area. Todays communication programs however often use a more comprehensive approach consisting of multiple mutually reinforcing media. (excerpt)

Contraceptive prevalence has been central to family planning research over the past few decades, but researchers have given surprisingly little consideration to method mix, a proxy for method availability or choice. There is no ‘ideal’ method mix recognized by the international community; however, there may be reason for concern when one or two methods predominate in a given country. In this article method skew is operationally defined as a single method constituting 50% or more of contraceptive use in a given country. Of 96 countries examined in this analysis, 34 have this type of skewed method mix. These 34 countries cluster in three groups: (1) sixteen countries in which traditional methods dominate, most of which are in sub-Saharan Africa; (2) four countries in which female sterilization predominates (India, Brazil, Dominican Republic and Panama); and (3) fourteen countries that rely on a single reversible method (the pill in Algeria, Kuwait, Liberia, Morocco, Sudan and Zimbabwe; the IUD in Cuba, Egypt, Kazakhstan, Kyrgyz Republic, Moldova, Turkmenistan and Uzbekistan; and the injectable in Malawi). A review of available literature on method choice in these countries provides substantial insight into the different patterns of method skew. Method skew in some countries reflects cultural preferences or social norms. Yet it becomes problematic if it stems from restrictive population policies, lack of access to a broad range of methods, or provider bias.

This study explores the role of access versus traditional beliefs in the decision to seek obstetric care from health professionals. Eighteen purposively sampled homogenous groups in Kassena-Nankana District of northern Ghana participated in focus-group discussions about traditional beliefs, barriers to the use of health professionals, and ways to improve obstetric care. All the groups were knowledgeable about the life-threatening signs and symptoms of complications of pregnancy and labor. Decisions about place of delivery generally were made after the onset of labor. Accessibility factors (cost, distance, transport, availability of health facilities, and nurses' attitudes) were major barriers, whereas traditional beliefs were reported as less significant. Informants made pertinent recommendations on how to improve obstetric services in the district. These findings demonstrate that even in this district, where African traditional religion is practiced by a third of the population, compared with a national average of 4 percent, lack of access was perceived as the main barrier to seeking professional obstetric care.

Guatemala has the second lowest level of contraceptive use of any country in Latin America despite an active private family planning program for over 30 years. Previous analyses identify correlates of contraceptive use but fail to address the fundamental question: Why does Guatemala differ so markedly from the rest of Spanish-speaking Latin America in the acceptance of family planning? This case study explores political and historical factors at the macrolevel that have shaped the evolution of family planning in Guatemala. These include the anti-imperialistic leftist movements of the 1960s and 1970s; the large percentage of the population that is indigenous; the civil unrest that peaked in the 1980s and paralyzed social programs especially in the western highlands; and the powerful alliance between the government and the Catholic Church. Although none of these factors is unique to Guatemala the convergence of the four in a single country explains why Guatemala lags far behind its Latin American neighbors in the acceptance of family planning. However recent events give reason for guarded optimism that Guatemala is advancing toward greater acceptance of family planning. (authors)

Background: Voluntary medical male circumcision (VMMC) service delivery is complex and resource-intensive. In Kenya’s context there is still paucity of information on resource use vis-a -vis outputs as programs scale up. Knowledge of technical efficiency productivity and potential sources of constraints is desirable to improve decision-making. Objective: To evaluate technical efficiency and productivity of VMMC service delivery in Nyanza in 2011/2012 using data envelopment analysis. Design: Comparative process evaluation of facilities providing VMMC in Nyanza in 2011/2012 using output orientated data envelopment analysis. Results: Twenty one facilities were evaluated. Only 1 of 7 variables considered (total elapsed operation time) significantly improved from 32.8 minutes (SD 8.8) in 2011 to 30 minutes (SD 6.6) in 2012 (95%CI = 0.0350–5.2488; p = 0.047). Mean scale technical efficiency significantly improved from 91% (SD 19.8) in 2011 to 99% (SD 4.0) in 2012 particularly among outreach compared to fixed service delivery facilities (CI -31.47959–4.698508; p = 0.005). Increase in mean VRS technical efficiency from 84% (SD 25.3) in 2011 and 89% (SD 25.1) in 2012 was not statistically significant. Benchmark facilities were #119 and #125 in 2011 and #103 in 2012. Malmquist Productivity Index (MPI) at fixed facilities declined by 2.5% but gained by 4.9% at outreach ones by 2012. Total factor productivity improved by 83% (p = 0.032) in 2012 largely due to progress in technological efficiency by 79% (p = 0.008). Conclusions: Significant improvement in scale technical efficiency among outreach facilities in 2012 was attributable to accelerated activities. However ongoing pure technical inefficiency requires concerted attention. Technological progress was the key driver of service productivity growth in Nyanza. Incorporating service-quality dimensions and using stepwise-multiple criteria in performance evaluation enhances comprehensiveness and validity. These findings highlight site-level resource use and sources of variations in VMMC service productivity which are important for program planning.

Previous studies have demonstrated consistently that the Mayan women of Guatemala have a far lower level of contraceptive use than their ladino counterparts (e.g. 50% versus 13% in the 1998 Demographic and Health Survey - DHS). Most researchers and practitioners have attributed this to social, economic and cultural differences between the two groups that result in Mayans having a far lower demand for family planning than ladinos. This paper tests an alternative hypothesis: that the contraceptive supply environment may be more limited for Mayans than ladinos. This analysis uses an innovative approach of linking household level data from the 1995/6 Guatemala DHS and with facility-level data from the 1997 Providers Census for four highland departments in which the latter was conducted. On average, married women of reproductive age in the four departments lived 2 km from a facility that provided some type of contraception. Mayans and ladinos did not differ significantly in terms of (1) mean distance to the closest facility offering family planning services, or (2) mean distance to a facility providing each specific method (except injectables). Mayans were more likely to live closer to an APROFAM clinic, whereas ladinos were closer to a facility that offered access to injectables. Otherwise, the family planning supply environment differed little for the two groups. However, access may not be the determining factor in contraceptive use, given that less than 8% of users got their (last) contraceptive from the nearest facility. Moreover, APROFAM - which was the nearest facility for only 7% of the respondents in this study - was the source of supply for 48% of users. Although this study does not directly measure quality, the characteristics that differentiate APROFAM from other service providers point to quality as more important than physical access or cost in source of contraception among this group of users.

Francophone sub-Saharan African countries have among the highest fertility rates and lowest modern contraceptive prevalence rates worldwide. This analysis is intended to identify the factors driving contraceptive prevalence in this population. In addition to testing the usual correlates, we have included three other variables potentially related to lower contraceptive use in the Francophone African context: being Muslim, being in a polygynous union, and participation in crucial decision-making processes. We obtained descriptive statistics for 11 Francophone African countries with DHS data collected since 2000 for relevant variables. As expected, education, place of residence, age and number of children were significant for most countries in predicting modern contraceptive use. The final three factors yielded inconclusive results. The conventional correlates were by far the most predictive of MCPR, although women’s participation deserves further analysis. These results dispel anecdotal evidence that being Muslim and in a polygynous union explain low CPR in this region.