Design, adaptation, and diffusion of an innovative tool to promote shared contraceptive decision-making: Balanced Counseling Strategy Plus

Contraceptive decision-making is highly complex, and family planning (FP) clients choose methods according to a host of personal, interpersonal, and context-specific considerations. These include concerns about side effects, confidence in their ability to adhere to daily or monthly use, efficacy of methods, partner support, and HIV vulnerability. FP decision support tools can support FP clients and providers to engage in a joint decision-making process to ensure clients make informed choices about contraception. For more than two decades, the Balanced Counseling Strategy (BCS) and Balanced Counseling Strategy Plus (BCS+) decision support tools have been used in lower- and middle-income countries, informed by implementation science research and iterative updates and refinements to reflect new developments in contraceptive technology and HIV prevention strategies. To inform the development and scale-up of future FP decision support tools, as well as share lessons from translating implementation science results to practice, this article describes the development, evaluation, and proliferation of BCS and BCS+.

Testing for sensory threshold in drinking water with added calcium: a first step towards developing a calcium fortified water

Background: Food fortification is an effective strategy that has been recommended for improving population calcium inadequate intakes. Increasing calcium concentration of water has been proposed as a possible strategy to improve calcium intake. The objective of this study was to determine the sensory threshold of different calcium salts added to drinking water using survival analysis. Methods: We performed the triangle test methodology for samples of water with added calcium using three different calcium salts: calcium chloride, calcium gluconate and calcium lactate. For each salt, a panel of 54 consumers tested seven batches of three water samples. Data were adjusted for chance and sensory threshold was estimated using the survival methodology and a discrimination of 50%. Results: The threshold value estimation for calcium gluconate was 587 ± 131 mg/L of water, corresponding to 25% discrimination, for calcium lactate was 676 ± 186 mg/L, corresponding to 50% discrimination, and for calcium chloride was 291 ± 73 mg/L, corresponding to 50% discrimination. Conclusions: These results show that water with calcium added in different salts and up to a concentration of 500 mg of calcium/L of water is feasible. The calcium salt allowing the highest calcium concentration with the lowest perceived changes in taste was calcium gluconate. Future studies need to explore stability and acceptability over longer periods of time.

The National Composite Index for Family Planning (NCIFP): Results and Methodological Issues

Background: The “ FP2020 Global Partnership” signaled a shift to broader, rights-based approaches to family planning programs, and the National Composite Index for Family Planning was developed as part of related measurement efforts. Methods: In each country 10-15 experts on the family planning program completed a 35-item questionnaire, first in 2014 in 89 countries, and in 2017 in 84 countries. Data were entered in Excel, with checks for consistency and data quality. The total score, and scores for each of 5 dimensions of effort are averages across the 35 indicators. Analytic techniques included cross-tabulations, graphical and correlation approaches. Results: The average total score for all countries in 2017 was 64 of the maximum of 100 of effort. Sub-regions differed: Anglophone and Francophone sub-Saharan Africa (SSA) scored highest in the total score and across all 5 dimensions. Next in order came Latin America and the Caribbean, Asia, the Middle East and North Africa, and Eastern Europe and Central Asia. Despite large differences in scores, the sub-regions followed similar profiles across the 35 indicators. The long term rise in the basic family planning effort scores continued, extending the series from surveys approximately every five years beginning in the 1980s. The highest score reached was for the strategy dimension, but the others were close. Their relative levels remained essentially the same as in the 2014 survey. NCIFP scores correlated positively with modern contraceptive use in both the sub-Saharan Africa (SSA) and non-sub-Saharan Africa (non-SSA) countries, but the relationships were stronger for SSA. Access to long-acting and permanent methods (LAPMs) was accompanied by greater LAPM use and modern method use. Conclusion: Repeated surveys in most developing countries show improvements in family planning effort, though unevenly, by 35 indicators and across regions.

Newcastle disease vaccine virus I-2 fails to acquire virulence during repeated passage in vivo

Background This study determined whether the naturally attenuated, thermotolerant Newcastle disease vaccine virus I-2 could acquire virulence after five in vivo passages through SPF chickens. Methods Study design was to international requirements including European Pharmacopoeia, Ph. Eur., v9.0 04/2013:0450, 2013. I-2 Working Seed (WS) was compared with five-times-passaged I-2 WS (5XP WS) in intracerebral pathogenicity index (ICPI), Fo cleavage site sequencing and Safety tests. Results The first passage series used a 50% brain: 50% tracheal tissue challenge homogenate and was unsuccessful as I-2 was not detected after the fourth passage. A second passage series used 10% brain: 90% tracheal tissue homogenates. I-2 was isolated from tracheal tissue in each passage. However harvested titres were below the minimum challenge level (107 EID50) specified for the ICPI and Safety tests, possibly reflecting I-2’s inherently low pathogenicity (interestingly caecal tonsils yielded significant titres). Given this the WS and 5XP WS comparisons proceeded. ICPI values were 0.104 and 0.073 for the WS group and the 5XP WS group respectively confirming that I-2, whether passaged or not, expressed low pathogenicity. F0 amino-acid sequences for both WS and 5XP WS were identified as 112R-K-Q-G-R-↓-L-I-G119 and so compatible with those of avirulent ND viruses. In safety, no abnormal clinical signs were observed in both groups except for two chicks in the 5XP WS group, where one bird was withdrawn due to a vent prolapse, and another bird died with inconclusive necropsy results. Conclusions: These data, the issue of low passage titres with little or no virus isolation from brain tissues and the genomic copy approach suggest a need to amend Ph. Eur. v9.0 04/2013:0450, 2013 for naturally attenuated, low pathogenicity vaccine viruses such as I-2. From an international regulatory perspective, the study provides further definitive data demonstrating that Newcastle disease vaccine virus I-2 is safe for use.

The relationship between shared-decision making in contraceptive counseling and satisfaction in Accra and Kumasi, Ghana

Background: Current use of modern methods of contraception remain low in many parts of sub-Saharan Africa, including Ghana. One way to improve both satisfaction with and continuation of contraceptive usage is to increase the level of shared decision-making around method choice. In this study, we sought to evaluate the extent to which patients in urban Ghana experienced shared decision-making and if this was associated with method chosen, satisfaction, or continuation of the method at three-months post-visit. Methods: We conducted a longitudinal survey. Women were recruited when they were starting a new method of contraception and followed-up with at three-months post-initiation from five family planning clinics in Accra and Kumasi, Ghana. Participants were asked who made the decision about their method choice, the patient herself, the provider, or the patient and provider together. Our outcomes included measures of satisfaction and three months’ continuation. Results: Fifty-eight percent of our participants reported making the decision of which method to use themselves, and eighty percent reported being satisfied to be leaving with their chosen method. At three months, those who reported they engaged in shared decision-making were more likely to report they would choose the same method again (p=.003), a measure of satisfaction. Patients who reported they made the decision of which method to use (p=.002) and those who left with an injection or pill (p=.019) rated their provider less favorably, while participants who had used a method before (p=.024) and those who reported they received their method of choice (p=.000) rated their providers more favorably. Conclusions: Measured in multiple ways, women who made the decision of which method to use were less satisfied. These results show the importance of providers engaging with patients during the contraceptive decision-making process.

Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda

Background: We describe the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) – deaths preventable through health system-delivered evidence-based interventions (EBIs) – in low- and middle-income countries (LMICs). Methods: We reviewed existing IR frameworks to develop a hybrid framework designed to better understand U5M reduction in LMICs from identification of leading causes of amenable U5M, to EBI choice, identification, and testing of strategies, work to achieve sustainability at scale, and key contextual factors. We then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and to extract actionable knowledge for other countries working to reduce U5M. Results: While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda’s actions and success. Building on these frameworks, we combined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing our hybrid framework in Rwanda, we studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country’s success in reducing U5M through the health system EBIs. Using these findings, we identified transferable lessons for other countries working to accelerate reduction in U5M. Conclusions: We found that a hybrid framework building on and adapting existing frameworks was successful in guiding data collection and interpretation of results, emerging new insights into how and why Rwanda achieved equitable introduction and implementation of health system EBIs that contributed to the decline in U5M, and generated lessons for countries working to drop U5M.

The impact of ear growth on identification rates using an ear biometric system in young infants

Background Accurate patient identification is essential for delivering longitudinal care. Our team developed an ear biometric system (SEARCH) to improve patient identification. To address how ear growth affects matching rates longitudinally, we constructed an infant cohort, obtaining ear image sets monthly to map a 9-month span of observations. This analysis had three main objectives: 1) map trajectory of ear growth during the first 9 months of life; 2) determine the impact of ear growth on matching accuracy; and 3) explore computer vision techniques to counter a loss of accuracy. Methodology Infants were enrolled from an urban clinic in Lusaka, Zambia. Roughly half were enrolled at their first vaccination visit and ~half at their last vaccination. Follow-up visits for each patient occurred monthly for 6 months. At each visit, we collected four images of the infant’s ears, and the child’s weight. We analyze ear area versus age and change in ear area versus age. We conduct pair-wise comparisons for all age intervals. Results From 227 enrolled infants we acquired age-specific datasets for 6 days through 9 months. Maximal ear growth occurred between 6 days and 14 weeks. Growth was significant until 6 months of age, after which further growth appeared minimal. Examining look-back performance to the 6-month visit, baseline pair-wise comparisons yielded identification rates that ranged 46.9–75%. Concatenating left and right ears per participant improved identification rates to 61.5–100%. Concatenating images captured on adjacent visits further improved identification rates to 90.3–100%. Lastly, combining these two approaches improved identification to 100%. All matching strategies showed the weakest matching rates during periods of maximal growth (i.e., <6 months). Conclusion By quantifying the effect that ear growth has on performance of the SEARCH platform, we show that ear identification is a feasible solution for patient identification in an infant population 6 months and above.

Practical needs and considerations for refugees and other forcibly displaced persons with neurological disorders: Recommendations using a modified Delphi approach

Background: There are >70 million forcibly displaced people worldwide, including refugees, internally displaced persons, and asylum seekers. While the health needs of forcibly displaced people have been characterized in the literature, more still needs to be done globally to translate this knowledge into effective policies and actions, particularly in neurology. Methods: In 2020, a global network of published experts on neurological disease and refugees was convened. Nine physician experts from nine countries (2 low, 1 lower-middle income, 5 upper-middle, 1 high income) with experience treating displaced people originating from 18 countries participated in three survey and two discussion rounds in accordance with the Delphi method. Results: A consensus list of priority interventions for treating neurological conditions in displaced people was created, agnostic to cost considerations, with the ten highest ranking tests or treatments ranked as: computerized tomography scans, magnetic resonance imaging scans, levetiracetam, acetylsalicylic acid, carbamazepine, paracetamol, sodium valproate, basic blood tests, steroids and anti-tuberculous medication. The most important contextual considerations (100% consensus) were all economic and political, including the economic status of the displaced person’s country of origin, the host country, and the stage in the asylum seeking process. The annual cost to purchase the ten priority neurological interventions for the entire displaced population was estimated to be 220 million USD for medications and 4.2 billion USD for imaging and tests. Conclusions: A need for neuroimaging and anti-seizure medications for forcibly displaced people was emphasized. These recommendations could guide future research and investment in neurological care for forcibly displaced people.

Linking family planning market census data with consumer experiences in three countries: the Consumer’s Market for Family Planning study protocol and data

Background: The Consumer’s Market for Family Planning (CM4FP) project was designed to address limitations of existing family planning (FP) data sources that prevent a full understanding of the total FP market. CM4FP data provide a picture of the complete supply environment and how consumers experience it. Study objectives were to 1) test a ring-fenced census approach consisting of an outlet census in a defined geographical area and a household survey in a smaller inner ring, to comprehensively map the total FP market in a local geography; 2) explore FP supply market dynamism through longitudinal data collection from contraceptive outlets; and 3) test a methodology for directly linking household and outlet data to measure the relationship between contraceptive demand and supply. Methods: Data were collected from study sites in Nigeria, Kenya, and Uganda from 2019 to 2020. Longitudinal outlet census data and repeated cross-sectional household survey data from women ages 18-49 were collected at three quarterly time points. Outlets were located in an outer ring geography to encompass locations likely visited by women sampled from a smaller inner ring. Data from women who received a contraceptive method in the past 12 months were linked to data for the outlet from which they received the method. Results: Datasets include product audits for 22,380 individual FP products, collected from a total of 1,836 outlets across 12 study sites. The datasets also contain data from 11,536 female respondents, of whom 1,975 were successfully matched to the outlet where they most recently obtained their method. Conclusions: CM4FP data are available at www.cm4fp.org. This unique dataset enables in-depth exploration of the family planning supply market in addition to interactions between the market and consumer perspectives and behaviors within each study site. The data can also be used to explore novel methodologies to inform future study designs.

Do differentiated service delivery models for HIV treatment in sub-Saharan Africa save money? Synthesis of evidence from field studies conducted in sub-Saharan Africa in 2017-2019

Introduction: “Differentiated service delivery” (DSD) for antiretroviral therapy (ART) for HIV is rapidly being scaled up throughout sub-Saharan Africa, but only recently have data become available on the costs of DSD models to providers and patients. We synthesized recent studies of DSD model costs in five African countries. Methods: The studies included cluster randomized trials in Lesotho, Malawi, Zambia, and Zimbabwe and observational studies in Uganda and Zambia. For 3-5 models per country, studies collected patient-level data on clinical outcomes and provider costs for 12 months, and some studies surveyed patients about costs they incurred. We compared costs of differentiated models to those of conventional care and identified drivers of cost differences. We also report patient costs of seeking care. Results: The studies described 22 models, including facility-based conventional care. Of these, 13 were facility-based and 9 community-based models; 15 were individual and 7 group models. Average provider cost/patient/year ranged from $100 in Zambia to $187 in Zimbabwe, in both cases for facility-based conventional care. Conventional care was less expensive than any other model in the Zambia observational study, more expensive than any other model in Lesotho, Malawi, and Zimbabwe, and in the middle of the range in the Zambia trial and the observational study in Uganda. Models incorporating 6-month dispensing were consistently less expensive to the provider per patient treated. Savings to patients were substantial for most models, with patients’ costs roughly halved. Conclusion: In five field studies of the costs of DSD models for HIV treatment, most models within each country had relatively similar costs, except for 6-month dispensing models, which were slightly less expensive. Most models provided substantial savings to patients. Research is needed to understand the effect of DSD models on the costs of ART programmes as a whole.