"That's why they are no longer coming in numbers": A mixed-methods study of outcome sustainability for an HIV and family planning integrated program conducted in Zambian health clinics Pubblico

Abstract

Background: In support of the Zambian government's effort to address the country's high prevalence of HIV and high total fertility rate, the Zambia-Emory HIV Research Program implemented a program in government clinics integrating family planning into their long-standing couples' voluntary HIV counseling and testing (CVCT) services. Implemented from 2013 to 2015, the program trained clinical staff, supported community sensitization, and provided reimbursements or incentives to couples who received counseling. During the program, over 200,000 couples received counseling and over 100,000 women had long-acting reversible contraception (LARC) inserted, for an estimated 20,000+ HIV infections averted and 25,000+ unplanned pregnancies prevented. Six months after program completion, clinics were revisited to assess program sustainability.
Methods: This mixed-methods study abstracted quantitative data from program records and clinic logbooks, and conducted thirteen focus group discussions with service providers. Eighteen of the 55 program clinics were selected for data collection and analysis. Quantitative data on CVCT and LARC uptake from March 2013 through June 2016 were analyzed for overall change, and program endline (October and November 2015) compared to post-program (February and March 2016). Qualitative data from focus group discussion were analyzed to contextualize and more accurately interpret the quantitative data.
Results: Between March 2013 and June 2016, there was a significant change in both the number of couples receiving CVCT (F=25.8, p<.0001) and the number of women receiving LARC (F=52.7, p<.0001). Following the end of the program there was a large drop in uptake of both CVCT and LARC methods. The average two-month decrease per clinic was 197 fewer couples receiving CVCT (95% CI -112, -282; p<.0005) and 224 fewer women receiving LARC insertion (95% CI -154, -295; p<.0005). Focus group discussion participants suggested many possible reasons for the decrease, including the loss of reimbursements/incentives to clients, reduction in service hours, and lack of community sensitization.
Conclusions: The program proved that the intervention could significantly contribute to the national goals of HIV prevention and reduced fertility rate. However, continuation of all program components is necessary for sustained achievement of these goals. Reintroduction of invitation cards, incentives, and an expansion of service hours should be explored.

Table of Contents

Chapter One: Introduction................................................................................................................ 1

Introduction and rationale.................................................................................................................. 1

Problem statement............................................................................................................................ 3

Purpose statement............................................................................................................................ 4

Research questions........................................................................................................................... 4

Significance statement...................................................................................................................... 4

Definition of terms............................................................................................................................ 5

Chapter Two: Literature Review........................................................................................................ 7

Couples' voluntary counseling and testing (CVCT) for HIV......................................................................... 7

Demand creation for CVCT.................................................................................................................. 8

Family planning and Long Acting Reversible Contraception (LARC)............................................................. 8

Demand creation for LARC................................................................................................................ 10

Integration of CVCT and family planning.............................................................................................. 11

The role of men in couples' sexual and reproductive health..................................................................... 12

Methods for increasing male involvement in reproductive health services.................................................. 13

Health system service provision......................................................................................................... 14

Material incentives for health care providers........................................................................................ 15

Nudging......................................................................................................................................... 15

Staff trainings................................................................................................................................. 15

The role of traditional practices in the Zambian health system................................................................. 16

Genital practices among women......................................................................................................... 17

Conclusion...................................................................................................................................... 18

Chapter Three: Manuscript.............................................................................................................. 20

Contribution of the Student................................................................................................................ 20

Title Page for Manuscript................................................................................................................... 21

Abstract......................................................................................................................................... 22

Introduction.................................................................................................................................... 23

Methods......................................................................................................................................... 25

Ethical Considerations....................................................................................................................... 25

Integrated program.......................................................................................................................... 25

Clinic selection................................................................................................................................ 26

Study design................................................................................................................................... 26

Data abstraction.............................................................................................................................. 26

Focus group discussions.................................................................................................................... 27

Data analysis.................................................................................................................................. 28

Results.......................................................................................................................................... 29

Changes in service uptake................................................................................................................. 29

Changes in service provision.............................................................................................................. 30

System functionality......................................................................................................................... 32

Discussion...................................................................................................................................... 34

Limitations..................................................................................................................................... 35

Conclusions.................................................................................................................................... 36

Figures.......................................................................................................................................... 38

Chapter Four: Conclusions and Recommendations............................................................................... 41

Conclusions.................................................................................................................................... 41

Implications/Recommendations.......................................................................................................... 42

Summary....................................................................................................................................... 43

References................................................................................................................................... 44

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Parola chiave	HIV Incentives Family planning CVCT Service integration LARC Mixed-methods Zambia Contraception
Committee Chair / Thesis Advisor	Allen, Susan A, Emory University
Committee Members	Ordonez, Claudia, KZN HIV Drug Resistance Surveillance Program Wall, Kristin, Emory University
Partnering Agencies	Non-US governmental agency (e.g., Minister of Health in Haiti) International Non-governmental organization (e.g., CARE, Inc.)

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