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The relative roles of ANC and EPI in the continuous distribution of LLINs: a qualitative study in four countries.
Health Policy and Planning. 2017 May 1; 32(4):467-475.Background: The continuous distribution of long-lasting insecticidal nets (LLINs) for malaria prevention, through the antenatal care (ANC) and the Expanded Programme on Immunizations (EPI), is recommended by the WHO to improve and maintain LLIN coverage. Despite these recommendations, little is known about the relative strengths and weaknesses of the ANC and EPI-based LLIN distribution. This study aimed to explore and compare the roles of the ANC and EPI for LLIN distribution in four African countries. Methods: In a qualitative evaluation of continuous distribution through the ANC and EPI, semi-structured, individual and group interviews were conducted in Kenya, Malawi, Mali, and Rwanda. Respondents included national, sub-national, and facility-level health staff, and were selected to capture a range of roles related to malaria, ANC and EPI programmes. Policies, guidelines, and data collection tools were reviewed as a means of triangulation to assess the structure of LLIN distribution, and the methods of data collection and reporting for malaria, ANC and EPI programmes. Results: In the four countries visited, distribution of LLINs was more effectively integrated through ANC than through EPI because of a) stronger linkages and involvement between malaria and reproductive health programmes, as compared to malaria and EPI, and b) more complete programme monitoring for ANC-based distribution, compared to EPI-based distribution. Conclusions: Opportunities for improving the distribution of LLINs through these channels exist, especially in the case of EPI. For both ANC and EPI, integrated distribution of LLINs has the potential to act as an incentive, improving the already strong coverage of both these essential services. The collection and reporting of data on LLINs distributed through the ANC and EPI can provide insight into the performance of LLIN distribution within these programmes. Greater attention to data collection and use, by both the global malaria community, and the integrated programmes, can improve this distribution channel strength and effectiveness.
Assessing the availability of LLINs for continuous distribution through routine antenatal care and the Expanded Programme on Immunizations in sub-Saharan Africa.
Malaria Journal. 2016 May 04; 15(1):255.BACKGROUND: In addition to mass distribution campaigns, the World Health Organization (WHO) recommends the continuous distribution of long-lasting insecticidal nets (LLINs) to all pregnant women attending antenatal care (ANC) and all infants attending the Expanded Programme on Immunization (EPI) services in countries implementing mosquito nets for malaria control. Countries report LLIN distribution data to the WHO annually. For this analysis, these data were used to assess policy and practice in implementing these recommendations and to compare the numbers of LLINs available through ANC and EPI services with the numbers of women and children attending these services. METHODS: For each reporting country in sub-Saharan Africa, the presence of a reported policy for LLIN distribution through ANC and EPI was reviewed. Prior to inclusion in the analysis the completeness of data was assessed in terms of the numbers of LLINs distributed through all channels (campaigns, EPI, ANC, other). For each country with adequate data, the numbers of LLINs reportedly distributed by national programmes to ANC was compared to the number of women reportedly attending ANC at least once; the ratio between these two numbers was used as an indicator of LLIN availability at ANC services. The same calculations were repeated for LLINs distributed through EPI to produce the corresponding LLIN availability through this distribution channel. RESULTS: Among 48 malaria-endemic countries in Africa, 33 malaria programmes reported adopting policies of ANC-based continuous distribution of LLINs, and 25 reported adopting policies of EPI-based distribution. Over a 3-year period through 2012, distribution through ANC accounted for 9 % of LLINs distributed, and LLINs distributed through EPI accounted for 4 %. The LLIN availability ratios achieved were 55 % through ANC and 34 % through EPI. For 38 country programmes reporting on LLIN distribution, data to calculate LLIN availability through ANC and EPI was available for 17 and 16, respectively. CONCLUSIONS: These continuous LLIN distribution channels appear to be under-utilized, especially EPI-based distribution. However, quality data from more countries are needed for consistent and reliable programme performance monitoring. A greater focus on routine data collection, monitoring and reporting on LLINs distributed through both ANC and EPI can provide insight into both strengths and weaknesses of continuous distribution, and improve the effectiveness of these delivery channels.
Comparative effectiveness of congregation- versus clinic-based approach to prevention of mother-to-child HIV transmission: Study protocol for a cluster randomized controlled trial.
Implementation Science. 2013 Jun 8; 8(62):p.Background: A total of 22 priority countries have been identified by the WHO that account for 90% of pregnant women living with HIV. Nigeria is one of only 4 countries among the 22 with an HIV testing rate for pregnant women of less than 20%. Currently, most pregnant women must access a healthcare facility (HF) to be screened and receive available prevention of mother-to-child HIV transmission (PMTCT) interventions. Finding new approaches to increase HIV testing among pregnant women is necessary to realize the WHO/ President's Emergency Plan for AIDS Relief (PEPFAR) goal of eliminating new pediatric infections by 2015. Methods: This cluster randomized trial tests the comparative effectiveness of a congregation-based Healthy Beginning Initiative (HBI) versus a clinic-based approach on the rates of HIV testing and PMTCT completion among a cohort of church attending pregnant women. Recruitment occurs at the level of the churches and participants (in that order), while randomization occurs only at the church level. The trial is unblinded, and the churches are informed of their randomization group. Eligible participants, pregnant women attending study churches, are recruited during prayer sessions. HBI is delivered by trained community health nurses and church-based health advisors and provides free, integrated on-site laboratory tests (HIV plus hemoglobin, malaria, hepatitis B, sickle cell gene, syphilis) during a church-organized 'baby shower.' The baby shower includes refreshments, gifts exchange, and an educational game show testing participants' knowledge of healthy pregnancy habits in addition to HIV acquisition modes, and effective PMTCT interventions. Baby receptions provide a contact point for follow-up after delivery. This approach was designed to reduce barriers to screening including knowledge, access, cost and stigma. The primary aim is to evaluate the effect of HBI on the HIV testing rate among pregnant women. The secondary aims are to evaluate the effect of HBI on the rate of HIV testing among male partners of pregnant women and the rate of PMTCT completion among HIV-infected pregnant women. Discussion: Results of this study will provide further understanding of the most effective strategies for increasing HIV testing among pregnant women in hard-to-reach communities.
WHO / USAID / FHI Technical Consultation: Expanding Access to Injectable Contraception, 15-17 June 2009, Room M405, WHO, Geneva.
[Unpublished] 2009. 5 p.The agenda for the consultation is presented. The objectives of the consultation were: To review systematically the evidence and programmatic experience on interventions designed to expand access to / provision of contraceptive injectables, focusing on non clinic-based services and programs; To reach conclusions on issues: (a) for which evidence is consistent and strong; (b) for which evidence is mixed; and (c) for which evidence is marginal or entirely lacking and, thus requires additional research; To document discussions and conclusions of the Consultation, including policy and program implications, and to disseminate these widely.
Findings Infobriefs. 2007 May; (136): p.The specific objectives of this project - financed through an IDA credit of $28.7 million (2002-05) - were to : (i) provide resources that would enable the government to implement a balanced, diversified multi-sector response, engaging all relevant government sectors, non-governmental organizations (NGOs) and grassroots initiatives; (ii) to expand contributions made by the Ministry of Health ( MOH ) engage civil society in the fight against AIDS; and (iii) finance eligible activities conducted by civil society organizations, including NGOs, community-based organizations (CBOs), faith-based organizations (FBOs), trade and professional associations, associations of people living with HIV/AIDS (PLWHAs), districts, and line ministries to ensure a rapid multisector scaling-up of HIV prevention and care activities in all regions and at all administrative levels. (excerpt)
Research Triangle Park, North Carolina, FHI, 2002.  p. (FHI Research Brief No. 6; RB-02-06E)Community-based workers worldwide use checklists to determine whether women are medically eligible to use combined oral contraceptives (COCs) or depot-medroxyprogesterone acetate (DMPA). However, problems may arise when outdated and inaccurate checklists are used. With input from dozens of experts, Family Health International developed new checklists that are easily understandable and consistent with the World Health Organization's (WHO) medical eligibility requirements. (author's)
BMJ. British Medical Journal. 2006 Aug 19; 333(7564):367.The world's richest nations are failing to ensure that people living with HIV/AIDS in the developing world have universal access to antiretroviral drugs, delegates at the 16th international AIDS conference in Toronto were told this week. In an opening address, Microsoft founder Bill Gates said that he was making AIDS the top priority of his foundation, at which resources doubled last month to $62bn (£33bn; €49bn), after a donation by US investor Warren Buffett. Bill Gates, who with his wife Melinda pledged $500m to the Global Fund to Fight AIDS, Tuberculosis, and Malaria last week, emphasised the importance of seeking more funds, creating cheaper drugs with fewer side effects, and achieving more widespread treatment for the world's most vulnerable people with HIV/AIDS. (excerpt)
Geneva, Switzerland, Joint United Nations Programme on HIV / AIDS [UNAIDS], 2000 Nov. 49 p. (UNAIDS Best Practice Collection Key Material; UNAIDS/00.37E)Condom Social Marketing: Selected Case Studies presents six applications of different social marketing techniques drawn from among on-going projects in developing countries in the field of reproductive health and prevention of HIV/AIDS and STDs. Individually they illustrate different, real- life approaches to condom promotion through social marketing in response to particular challenges and needs. All describe activities from which significant lessons may be learned. In addition, they demonstrate the flexibility of social marketing and how the technique can be adapted to deal with differing situations and constraints. The booklet is intended mainly for distribution to individuals and organizations, from both the public and private sectors, who are interested in learning more about social marketing, and how its concepts and techniques can be applied in response to the spread of HIV/AIDS and STDs, particularly in developing countries. It is also intended to provide basic information, as an aid to training, programme planning and related activities. (excerpt)
Annals of Tropical Medicine and Parasitology. 2002; 96 Suppl 1:S15-S28.The main strategy of APOC, of community-directed treatment with ivermectin (CDTI), has enabled the programme to reach, empower and bring relief to remote and under-served, onchocerciasis-endemic communities. With CDTI, geographical and therapeutic coverages have increased substantially, in most areas, to the levels required to eliminate onchocerciasis as a public-health problem. Over 20 million people received treatment in 2000. APOC has also made effective use of the combination of the rapid epidemiological mapping of onchocerciasis (REMO) and geographical information systems (GIS), to provide information on the geographical distribution and prevalence of the disease. This has led to improvements in the identification of CDTI-priority areas, and in the estimates of the numbers of people to be treated. A unique public–private-sector partnership has been at the heart of APOC’s relative success. Through efficient capacity-building, the programme’s operations have positively influenced and strengthened the health services of participating countries. These laudable achievements notwithstanding, APOC faces many challenges during the second phase of its operations, when the full impact of the programme is expected to be felt. Notable among these challenges are the sustainability of CDTI, the strategy’s effective integration into the healthcare system, and the full exploitation of its potential as an entry point for other health programmes. The channels created for CDTI, could, for example, help efforts to eliminate lymphatic filariasis (which will feature on the agenda of many participating countries during APOC’s Phase 2). However, these other programmes need to be executed without compromising the onchocerciasis-control programme itself. Success in meeting these challenges will depend on the continued, wholehearted commitment of all the partners involved, particularly that of the governments of the participating countries. (excerpt)
Annals of Tropical Medicine and Parasitology. 2002; 96 Suppl 1:S5-S14.This article describes the evolution of the partnership, between various health and developmental agencies, that has sustained the campaign against river blindness in Africa. The international community was oblivious to the devastating public-health and socio–economic consequences of onchocerciasis until towards the end of the 1960s and the beginning of the 1970s. Then a ‘Mission to West Africa’, supported by the United Nations Development Programme, and a visit to the sub-region by the president of the World Bank culminated, in 1974, in the inauguration of the Onchocerciasis Control Programme in West Africa (OCP). OCP was a landmark event for the World Bank as it represented its first ever direct investment in a public-health initiative. The resounding success of the OCP is a testimony to the power of the partnership which, with the advent of the Mectizan Donation Programme, was emboldened to extend the scope of its activities to encompass the remaining endemic regions of Africa outside the OCP area. The progress that has been made in consolidating the partnership is discussed in this article. The prospects of adapting the various strategies of the African Programme for Onchocerciasis Control, to entrench an integrated approach that couples strong regional co-ordination with empowerment of local communities and thereby address many other health problems, are also explored. (excerpt)
Annals of Tropical Medicine and Parasitology. 2002; 96 Suppl 1:S3-S4.The African Programme for Onchocerciasis Control (APOC) was launched in December 1995 on the tidal wave of the resounding success of the 21-year-old Onchocerciasis Control Programme in West Africa (OCP). Six years later and now at the mid-point of its pre-determined existence, it is time to take stock and plan for the second half. This special Supplement contains a set of articles that focus on some key areas of the activities of APOC in the first phase. Each article makes a critical appraisal of the major achievements and shortcomings of the programme, from the start of operations in 1996, and identifies the main challenges for Phase 2. A succinct account of the state of affairs at the birth of APOC would help to put the achievements and the challenges in better perspective. The ultimate goal of APOC is 'to eliminate onchocerciasis as a disease of public-health importance and an important constraint to socio-economic development throughout Africa'. The prescribed strategy by which this goal is to be attained is 'the establishment of a self-sustainable ivermectin treatment programme' in the high-risk zones of all the endemic countries outside the OCP area. Where feasible, control would also be effected by local vector eradication. (excerpt)
Lancet. 2003 Jul 19; 362(9379):249.These positive results from the new community-based therapeutic care (CTC) model of intervention call for a change in the way that we classify acute malnutrition. The WHO classification consists of moderate and severe categories, defined according to anthropometry and the presence of bilateral pitting oedema. This classification was appropriate and operationally relevant when the modes of treatment involved inpatient therapeutic feeding centres for severe acute malnutrition, and outpatient supplementary feeding for moderate acute malnutrition. This new era of community-based care, however, has three treatment modes. To be operationally relevant, a new system of classification must, therefore, include complicated malnutrition as well as severe and moderate malnutrition. (excerpt)
Prediction of community prevalence of human onchocerciasis in the Amazonian onchocerciasis focus: Bayesian approach. [Prévisions portant sur la prévalence communautaire de l'onchocercose humaine au niveau du foyer amazonien de l'onchocercose : approche bayésienne]
Bulletin of the World Health Organization. 2003 Jul; 81(7):482-490.Objective: To develop a Bayesian hierarchical model for human onchocerciasis with which to explore the factors that influence prevalence of microfilariae in the Amazonian focus of onchocerciasis and predict the probability of any community being at least mesoendemic (>20% prevalence of microfilariae), and thus in need of priority ivermectin treatment. Methods: Models were developed with data from 732 individuals aged515 years who lived in 29 Yanomami communities along four rivers of the south Venezuelan Orinoco basin. The models’ abilities to predict prevalences of microfilariae in communities were compared. The deviance information criterion, Bayesian P-values, and residual values were used to select the best model with an approximate cross-validation procedure. Findings: A three-level model that acknowledged clustering of infection within communities performed best, with host age and sex included at the individual level, a river-dependent altitude effect at the community level, and additional clustering of communities along rivers. This model correctly classified 25/29 (86%) villages with respect to their need for priority ivermectin treatment. Conclusion: Bayesian methods are a flexible and useful approach for public health research and control planning. Our model acknowledges the clustering of infection within communities, allows investigation of links between individual- or community-specific characteristics and infection, incorporates additional uncertainty due to missing covariate data, and informs policy decisions by predicting the probability that a new community is at least mesoendemic. (author's)
Bulletin of the World Health Organization. 2003 Jul; 81(7):473.Rigorous science is the basis of our credibility and of our capacity to get results. In recent months, the fight against SARS has confirmed WHO’s scientific leadership in the global struggle against disease. Yet solid science only the beginning. Scientifically excellent public health guidelines and other reliable information sit inert in journals and databases unless there political commitment — on the part of governments, communities and individuals—to turning knowledge into action that will get results on the ground. In this WHO’s political role of leadership and partnership-building is essential. (excerpt)
Final report of an operations research project: "A Study to Increase the Availability and Price of Oral Contraceptives in Three Program Settings", Contract CI90.59A.
[Unpublished] 1991 Oct 10. , 32,  p. (PER-19; USAID Contract No. DPE-3030-Z-00-9019-00)In an effort to reach more clients while increasing self-sufficiency, a group of private and public agencies in Peru collaborated in 2 operations research (OR) studies. This OR project, which cost US $62,040, was affected by the action of the newly elected government which ended price controls and subsidies in August 1990 and resulted in changes in the spending habits of most Peruvian families. Sales of all oral contraceptives (OCs) fell from an average of 141,400 to 73,400 cycles/month, and sales of Microgynon in pharmacies fell from 76,400 to 38,000 cycles/month. The first OR study tested the use of community-based distributors (CBDs), Ministry of Health (MOH) facilities, and private midwives as contraceptive social marketing (CSM) outlets by adding the OC Microgynon (sold at pharmacy prices) to CBD programs and raising the price of the donated OC, Lo-Femenal, over time. Specific objectives were to determine 1) if total CBD sales increased with the method mix, 2) whether CBD from homes of small businesses was more effective, 3) if the new distribution of Microgynon would increase sales of the OC as a whole, and 4) the impact of Lo-Feminal price increases on sales and user characteristics. The study was carried out in 44 experimental and 44 control groups in Lima and 20 experimental and 21 control groups in Ica. Baseline data were obtained for December 1989-April 1990, and monthly sales were monitored during the 12 months from May 1990 to April 1991. Data were also obtained from surveys of dropouts and new Microgynon acceptors. It was found that the August 1990 price increase effectively destroyed the significant market penetration exhibited by Microgynon in the first 4 months of the study. Adding an affordable CSM brand to CBD programs will, however, increase sales and self-sufficiency, although the sale of donated OCs for around $0.30/cycle will reduce sales of the new brand by 20-40%. It was also found that most clients who dropped out because of side effects were less likely to be contracepting than those who dropped out because of cost, indicating a need for improved distributor counseling. The second study tested the price elasticity of demand for OCs in CBD programs by measuring the demand for Microgynon. Specific objectives were to determine 1) the level of Microgynon sales in MOH facilities, 2) the level of sales by nurse-midwives, 3) the number of Microgynon users who formerly used Lo-femenal from the MOH, and 4) the number of Microgynon users in MOH and nurse-midwife facilities who formerly obtained the OC from pharmacies. A demonstration project was carried out in the rural departments of Ayacucho and Huancavelica, the poorest areas of Peru. 4 MOH hospitals in 4 cities and 17 nurse-midwives participated. The hope was that the CSM products would mitigate the effect of stock-outs in the hospitals. It was found that no Microgynon was sold because of a reluctance to recommend it and other unfavorable study conditions (the necessity for separate accounting, the lack of stock-outs, the reluctance of the midwives to sell a contraceptive, and the decline in client purchasing power). Cost recovery in the MOH would be better served by charging a modest amount for donated contraceptives.
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (PHI-01)In 1975, a USAID-Commission on Population (POPCOM) planning team reported that the key problem facing the National Family Planning (FP) Program in the Philippines was extending the program beyond its existing network of municipal-based clinics to the surrounding barrios. At that time, the number of new FP acceptors was declining, and there was a shift to less effective methods among current users. Because most clinics were urban-based, rural acceptors could not easily access FP services. The report recommended that supply depots be established in barrios and that motivators be used to distribute contraceptives and hygiene information and materials. An operations research project, which cost US $77,313, was developed to test the feasibility and cost-effectiveness of delivering FP/hygiene materials directly to households in rural areas. The Barrio Supply Point (BSP) operators were to visit and make available to every household free FP and hygiene materials. After the initial visit, BSP operators were to continue to serve as resupply agents. Although contraceptives were resupplied free, a nominal charge was required for hygiene materials. A quasi-experimental study design was employed. Pilot tests were conducted to determine what materials might be effectively distributed in addition to contraceptives. Project support was terminated in December 1978, before the project was fully implemented, because of the evolution of a national outreach program. Results of the pilot test showed that over 90% of households offered free condoms and oral contraceptives, or free contraceptives and bars of soap, accepted them. No data on use of these items were collected.
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (EGY-01)Egypt's family planning (FP) program, active since 1966, has been facilitated by the country's population density, flat terrain, and extensive health infrastructure. Nevertheless, by the early 1970s, a substantial proportion of couples were still not using contraception because of minimal clinic outreach; high dropout rates for oral contraceptive (OC) users; lack of knowledge about side effects among clinic staff and clients; disruptions in clinical supplies; and unavailability of other methods, such as the IUD, especially in rural areas. In 1971, USAID supported the American University in Cairo's (AUC) FP research activities in rural Egypt, in which household fertility survey data, a follow-up of women attending FP clinics, the cultural context of FP, communication and education, and the implementation of services were studied. In 1974, AUC initiated a demonstration project (which cost US $224,000) of a low-cost way to provide FP services to all married women in a treatment population through a household contraceptive distribution system. The interventions were implemented in the Shanawan (rural) and Sayeda Zeinab (city of Cairo) communities of Menoufia Governorate. During an initial canvas in November 1974, married women 15-49 years of age, who were living with their husbands and were not pregnant or less than 3 months postpartum and breast feeding, were offered 4 cycles of OCs or a supply of condoms. During a second canvas in February 1975, acceptors were provided with an additional 4 cycles of OCs and referred to a local depot for resupply. Each distribution area was mapped, and each housing unit numbered. Data collected through canvassing consisted primarily of eligibility screening items and provided numbers of acceptors, refusals, ineligibles, not at homes, etc. To increase coverage, 2 attempts were made to reach women not at home. Of the 2,493 women canvassed in Sayeda Zeinab, 1713 (69%) were eligible to receive contraceptives. Of these, 58% accepted 4 to 6 cycles of OCs. At the time of initial household distribution, 45% of eligible women were already using OCs. As a result of the canvass, an additional 5% of the women became acceptors. The AUC did not expand the household distribution of contraceptives to other urban areas of Cairo, because women there evidently already had adequate access to FP information and supplies. In the 6,915 households canvassed in Shanawan, 1156 of the 1820 women (64%) were eligible to receive contraceptives. Of these, 45% accepted 4 to 6 cycles of OCs. 21% of eligible women were already using OCs at the time of initial household distribution. Although condoms were offered, few were accepted, apparently because it was not culturally acceptable for women to either distribute or accept condoms. One year after the initial household distribution, contraceptive use among married women of reproductive age had increased 69% from 18.4 to 31% among all age and parity groups and at all educational and occupational levels, and the incidence of pregnancy declined from 19.3 to 14.9%.
Incorporating IEC activities for AIDS into a contraceptive community-based distribution (CBD) project in Kinshasa.
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (ZAI-11)AIDS represents a major public health problem in Zaire; 6 to 8% of the adult population of Kinshasa is estimated to be sero-positive. This study, which cost US $135,000, assesses the feasibility of incorporating AIDS education activities into community-based contraceptive distribution (CBD). The project encompassed 5 administrative zones in Kinshasa. In 3 zones, CBD posts were installed, and community meetings on AIDS were held; 2 zones served as a comparison. As part of this study, a knowledge, attitudes, and practice (KAP) survey was conducted city-wide to determine the extent to which the adult population of Kinshasa is aware of AIDS and its modes of transmission, and to what extent they practice behaviors which increase or decrease their risk of contacting AIDS. The survey represents one of the first attempts to collect data on AIDS KAP from a large, probabilistic sample of adults in an African setting and also served to update the 1982-84 Demographic and Health survey conducted by Westinghouse in Kinshasa. The original study, a controlled field experiment, was to include a pre/post AIDS KAP survey. However, because the baseline survey was expanded to cover all 24 administrative zones of Kinshasa, there was not sufficient time to conduct the planned follow-up survey. With concurrence from AID/W and USAID/Zaire, the study was reoriented toward a diagnostic analysis of the extent of AIDS knowledge and practices among Kinshasa adults. Service statistics on condom sales were collected and analyzed. The baseline KAP survey established: 99% of men and women have heard of AIDS; 85% know 4 main modes of transmission. 60% of males know that condoms block transmission of HIV; 40% of men and 21% of women believe that AIDS is curable; 33% of men and women believe an AIDS vaccine exists. Service statistics on the sale of condoms are being analyzed.
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (ZAI-10)This project grew out of the need to monitor the quality of care in the various community-based contraception distribution (CBD) projects which were subprojects of the Tulane Family Planning Operations Research Project. The objectives of this activity were to: 1) assure that women who use the services of CBD workers were properly screened for use of oral contraceptives (if that was the method they chose), that they received correct information about the methods and their use, and that they were referred to other levels in the health system when appropriate; 2) to strengthen the position of existing CBD programs if they were to come under attack in the future over the issue of quality of service; and 3) to develop a methodology that could be used in other CBD programs, including those outside of Zaire. The project consisted of a series of activities designed to improve the quality of care in CBD programs, including conducting workshops among project personnel and standardizing medical norms and program procedures. A system for evaluating distributor performance, based on a knowledge test, observation of interactions with clients, and a client survey, was developed and tested in the field. A guide for implementing contraceptive CBD programs and a manual for training CBD distributors were produced to standardize many of the procedures used in the CBD programs and to provide certain norms for service delivery. A methodology was subsequently developed for evaluating distributor performance which included: a knowledge test for distributors to assure that they were able to answer basic questions about the contraceptives and other medications they sold (correct use, side effects, contraindications); an observation guide consisting of a list of points which a distributor should cover during visits to a potential (new) client as well as to a continuing user; and a subjective measurement of rapport between distributor and client. A short questionnaire was prepared for clients to determine whether they knew the correct use of the method chosen and whether they were satisfied with the services of the distributor. This 3-pronged approach to the evaluation of distributor performance was tested at 2 sites: Kisangani and Matadi. The knowledge test was also administered in Mbuyi Mayi and Miabi. While the knowledge test proved to be a quick way to determine whether distributors were informed on key points, the full evaluation approach proved too labor-intensive to be practical as a tool for continuously monitoring distributor performance. Based on experience with the full model, a supervisory form was developed which included some of the same elements but was more practical for routine use in the field.
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (ZAI-03)This project, which cost US $97,000, is an extension of the original Tulane Family Planning (FP) Operations Research Project in Bas Zaire (known locally as PRODEF). PRODEF was initiated to increase the availability and acceptability of modern contraceptives in both an urban area (Matadi) and a rural area (Nsona Mpangu). The urban program is vertical (FP only), whereas in the rural program, FP is integrated with 3 interventions for children under 5 years of age: anti-malarial drugs, anti-helminthic drugs, and rehydration salts. The Matadi project was designed to: 1) increase knowledge and use of modern contraceptive methods in the target population; 2) test the cultural acceptability of community-based distribution (CBD) workers in an urban setting; 3) determine the preference for type of provider when services are available through both dispensaries and CBD posts; and 4) measure the cost per couple years of protection (CYP) over time. In treatment area A, dispensaries began distributing contraceptives in 1982; 3 rounds of household distribution were conducted in 1982-83. In area B, dispensaries distributed contraceptives, but there was no household distribution. The residential zone of Kananga served as a comparison. By 1984, prevalence had increased from 4-5% to 19% (in area A) and to 16% (in area B). While this represented a significant increase over the baseline rate, the difference between the 2 zones was not statistically significant. Thus, household distribution was discontinued in area A, and the 2 treatment areas became one. From 1986 to 1989, the project consisted of training CBD workers to sell contraceptives from their homes in Matadi. 40 women were recruited and trained; due to attrition, there have been approximately 25 active distributors in the project. Prevalence surveys were conducted in 1982 and 1984 under the original Matadi project; the third round of survey data were collected under this cooperative agreement in 1988. Service statistics on contraceptive sales and cost data were collected and analyzed to yield data on the cost per CYP in the Matadi project on an annual basis. An AIDS knowledge, attitude, and practice (KAP) module was included in the follow-up survey. Preliminary findings of the 1989 KAP follow-up survey show prevalence to be 23% in areas A and B, the highest in any city in Zaire. Kananga has achieved positive results based on strong clinic services and social marketing, even without community-based distribution. Analysis of choice of service provider is in progress.
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (ZAI-02)This project, which cost US $97,000, is an extension of the original Tulane Family Planning (FP) Operations Research Project in Bas Zaire (known locally as PRODEF). PRODEF was initiated to increase the availability and acceptability of modern contraceptives in an urban area (Matadi) and a rural area (Nsona Mpangu). The urban program is vertical (FP only), whereas in the rural program FP is integrated with 3 interventions for children under 5 years of age: anti-malarial drugs, anti-helminthic drugs, and rehydration salts. The Nsona Mpangu project is designed to: 1) increase knowledge and use of modern contraceptive methods among the target population; 2) assess whether villages having attained 10% prevalence tend to plateau once the "predisposed" are already reached; and 3) determine the effect of time on prevalence: do villages that enter the program later "catch up"? In treatment areas A and B, health posts began distributing contraceptives and drugs for children under 5 years of age in 1982; community-based distribution (CBD) was provided in villages without posts. In area A, 3 rounds of household distribution were conducted in 1982-83. At the close of the original project (1984), prevalence was 13% in area A and 10% in area B. The difference between A and B was not statistically significant, thus household distribution (which proved costly in the earlier project) was discontinued and treatment areas A and B became identical under this cooperative agreement. A third treatment area (C) was added in 1986 to determine the effect of time on prevalence: do villages that enter the program later "catch up"? Area D served as the comparison. The study employed a quasi-experimental design, with 3 treatment areas and a comparison area. A pre/post-intervention survey was conducted in all 4 areas to measure changes in contraceptive prevalence, service statistics were monitored to determine trends in contraceptive purchases, and the cost in the program as a whole per couple month of protection (CYP) was analyzed. An AIDS knowledge, attitude, and practice module was included in the follow-up survey. Preliminary findings from the follow-up survey indicate that 26.5% of women had ever used a modern method and 80% of women had ever used a traditional method. Among married women of reproductive age, current use of any method (traditional or modern) was 58.3%. Analysis of service statistics and cost per CYP is still in progress. CYP decreased from a 1985-87 annual average of 1,500 to 278 in 1988 due to the appointment of a regional medical officer who was not favorable towards CBD.
Increasing the availability and acceptability of contraceptives through community-based outreach in Bas Zaire Programme d'Education Familiale (PRODEF). Original.
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (ZAI-01)The Tulane Family Planning (FP) Operations Research (OR) Project in Bas Zaire (known locally as PRODEF) aims to increase the availability and acceptability of modern contraceptives in an urban and a rural area. The urban program offers FP only, whereas the rural program integrates FP with 3 interventions for children under 5 years of age: anti-malarial drugs, anti-helminthic drugs, and rehydration salts. The objectives of this project, which cost US $623,504, were to: increase knowledge and use of modern contraceptives; improve attitudes toward FP; decrease "ideal" family size; and increase appropriate treatment for children under 5 years of age who have malaria, intestinal helminths, and dehydration due to malaria. The project tests 2 alternative strategies for the delivery of FP services. In treatment area A, dispensaries distribute contraceptives (and the rural children's drugs) and outreach activities are conducted. In area B, dispensaries distribute contraceptives (and the rural children's drugs), but there are no outreach activities. In the rural villages that do not have a dispensary, a matrone selected by the villagers is trained by PRODEF to serve as a distributor. Pre/post-intervention surveys were conducted in all project areas to measure changes in FP knowledge and practice and the relative effectiveness of the 2 approaches. Service statistics were used to monitor project activity, and cost/couple month of protection (CMP) was compared. The promotion of modern contraceptives was found to be culturally acceptable. Offering FP services only was acceptable in the urban area. The number of ever-married women who had ever used a modern contraceptive rose from 10 to 48% among women in area A and to 44% among women in area B. The child health interventions greatly enhanced the value of the program for the rural communities. Ever use of modern contraceptives increased from 8 to 34% in area A and from 7 to 27% in area B. The matrones were an efficient and culturally acceptable distribution channel. Simply making the contraceptives available increased contraceptive prevalence. However, the level of contraceptive prevalence was greater in area A, which also received outreach. Current use of modern methods in the urban area increased from 4 to 19% in area A and from 5 to 16% in area B. In the rural area, modern method use increased from 5 to 14% in area A, and from 2 to 10% in area B. The number of women using a traditional method decreased from 60 to 48% in area A and from 65 to 53% in area B; however, traditional methods are still used more than modern methods by a factor of 2:1 in the urban area and by over 3:1 in the rural area. The baseline survey showed that 95% of all women know at least one traditional fertility control method and about 80% had heard of at least one modern method. At follow-up, almost all urban respondents knew at least one modern and one traditional method. In the rural area, 90% knew at least one modern method. In the urban region, cost per CMP was US $7.11 in area A and $6.18 in area B; in the rural region the respective costs were US $11.22 and $7.95.
Family Life Association of Swaziland [FLAS] community-based distribution (CBD) pilot project evaluation.
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (SWA-01)The Family Life Association of Swaziland (FLAS), an associate member of the International Planned Parenthood Federation, provides family planning (FP) services through a network of 3 clinics and through industry- and community-based distributors (CBDs). FLAS is the second largest provider of FP services in Swaziland, supplying approximately 30% of all services available. In 1986, FLAS initiated a 2-year CBD pilot project to demonstrate the effectiveness of an alternative service delivery approach to increase contraceptive availability and use in rural areas. If effective, the model was to be recommended for replication on a larger scale in similar rural settings. FLAS conducted an internal assessment of its activities in 1987. The evaluation found that the project's immediate objectives had been met and the project had community support. However, the future of the pilot project was not adequately addressed in the internal evaluation. Ministry of Health officials determined there was a need for additional information in order to decide the pilot program's future. The Population Council conducted the first external evaluation of the FLAS' CBD project. The pilot CBD project successfully demonstrated that CBD of FP services can increase contraceptive availability and accessibility in underserved rural areas. Success in terms of service use was influenced by the level and quality of supervision, the appropriate selection of agents and areas, and adequate training. An area of need in the expanded program is to broaden the choice of methods given to clients in order to increase service coverage. Several research topics related to improved delivery and sustainability of CBD services were identified.
Community-based distribution (CBD) of low cost family planning and maternal and child health services in rural Nigeria (expansion).
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (NGA-02)A community-based distribution (CBD) project has been in operation since 1980 in Oyo State, Nigeria. As a result of word-of-mouth communication among health professionals, television coverage of graduation ceremonies, and positive political feedback from the pilot area, the state government requested assistance in expanding the program. In collaboration with the State Health Council, the Pathfinder Fund, University College Hospital, and the Center for Population and Family Health of Columbia University, the program was expanded in 1982 at a cost of US $237,517. In each of the 4 health zones of the expansion area, a Primary Health Center (PHC) became the training and supervisory center. The expanded program was modified in light of experience in the pilot area. Monthly stipends to CBD workers were eliminated and, because of government policy, no fees were to be charged for services. (This policy was later reversed.) Also, a full-time CBD supervisor was assigned to each zone, rather than relying on individual maternity staff members for supervision. Each zone was limited to 100 CBD workers. Data collection included baseline and post-intervention knowledge, attitudes, and practice surveys and a village documentation survey to estimate the service population. The project also carried out in-depth CBD worker interviews, structured observations of training, mini-surveys, analyses of supervision records and service statistics, and a case study of the impact of the CBD program in which villagers were interviewed about the educational and clinical roles of the CBD workers. Although initial family planning (FP) acceptance was low, ever use of a modern method has increased from 2 to 25% in the pilot area. About half of the married women of reproductive ages in the project area are not sexually active at any one time because of postpartum abstinence. Most of the acceptance of modern contraceptives replaces use of traditional abstinence. Male promoters have proved to be an asset to male acceptance of FP services. Individual monetary incentives are not required to motivate CBD workers; however, once incentives are given, difficulties are created if they are stopped, as they were in the pilot area. The CBD approach has changed the concept of health care from that of providing services to clients who come to a fixed site to reaching out to provide services to all people living within a particular catchment area. The expanded project was subsequently extended into additional areas of Oyo State by the State Health Council. In addition, a conference to discuss the project, held in January 1985, was attended by health program managers and policymakers from all parts of Nigeria. The conference stimulated planning by State and Federal Ministries of Health to undertake CBD as a major strategy for primary health care in rural areas.
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (KEN-13)For the past 20 years, Chogoria Hospital has run a steadily expanding clinic and community-based health service program in Meru District. This hospital, with its 32 satellite clinics and its catchment area, has been renowned for its high contraceptive prevalence and low fertility rate compared to the Kenyan national average and that of many sub-Saharan countries. Several factors have contributed to this success, including community-based distribution by family health educators (FHEs) and community health workers (CHWs). Through these community-based distributors, family planning (FP), child welfare, and antenatal clients who fail to turn up for appointments within a month after the default date are followed-up and encouraged to visit a clinic. Financial support for this default tracking system has been ensured through donor funds. Lately, however, the longterm sustainability and usefulness of the tracking system have been questioned. In response to this concern, the management at Chogoria Hospital asked The Population Council to evaluate the default tracking system. This study, which cost US $15,080, determined the extent to which the default tracking system is effective in identifying, tracking, and bringing defaulters back to the program. In addition, the cost of tracking down and bringing back a client was determined. A third component involved assessing the attitude of clients towards this activity and their consequent behavior when they visit Chogoria or other clinics. Data were collected from interviews with 654 defaulting clients using a general questionnaire and 3 other ones specific to FP, child welfare, and antenatal issues. 4 teams composed of local school teachers, with heads of schools acting as supervisors, identified and interviewed the defaulters over a period of 13 days. The teams, who had substantial previous experience in interviewing and data collection, received a week-long training session which included 2 days of fieldwork. A different questionnaire was used to collect information from CHWs. These data were supplemented by information received from field team observations. True defaulters were few, and the impact of CHWs and FHEs in bringing back these clients was low (11-17%). The benefits derived from bringing back a defaulter were negligible compared to the high cost of deploying the CHWs and FHEs. As a result, it was recommended that the default tracking system be discontinued. In addition, it was suggested that the CHWs and FHEs be supervised more effectively and that they concentrate their efforts on other community health activities such as primary health care counseling.