Global Health: Science & Practice

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    Dr. Jim Shelton's Pearls is an occasional series by USAID’s Global Health Science Advisor that answers commonly asked questions about family planning. 

    Global Health: Science & Practice

    Global Health: Science and Practice 

    Question: I understand USAID is involved in a new online peer reviewed global health journal. Is that right?

    Answer: Yes in collaboration with Johns Hopkins University and George Washington University. It is called Global Health: Science and Practice and is especially oriented toward practical knowledge related to how to implement programs in the field.  At the journal's website you can learn more about the journal and sign up to be a subscriber or peer reviewer.  We are now accepting submissions and project to publish the first issue late 2012 or early 2013. See more description in the image to the right.

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    Global Health: Science and Practice Vol. 3 No. 1

    A provider inserts a Jadelle contraceptive implant into a client's arm at Ilha de Mozambique Health Center in Mozambique. Increasing availability of long-acting reversible contraceptives is important to improving method mix and meeting people’s family planning needs. 2012 Arturo Sanabria, Courtesy of Photoshare.

    Long-acting reversible contraceptives (LARCs) can be delivered successfully in crisis settings even though they require more training and infrastructure support than short-acting methods, shows a new article by Dora Ward Curry and colleagues in the latest issue of Global Health: Science and Practice (GHSP). The program led by CARE reached more than 52,000 new modern method users in just 2.5 years. Of these new users, a remarkably high 61% chose LARCs—either implants or IUDs.

    On a global level, however, short-acting methods predominate. Using national survey data from 123 countries around the world, John Ross and colleagues show that 61% of married/in-union women using contraception rely on oral contraceptive pills, traditional methods, or injectable contraceptives. About 13% of users rely on IUDs and only 1% globally rely on implants.

    In a related editorial, GHSP highlights this difference, explaining that while it may be easier for programs to provide short-acting methods, programs shouldn’t discount the importance of improving access to LARCs, which have much lower failure rates and far better continuation rates than short-acting methods, and thus prevent unintended pregnancy better and increase the health benefits of healthy timing and spacing of pregnancy.

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    The Urban Reproductive Health Initiative, a multicountry family planning project implemented in India (Uttar Pradesh), Kenya, Nigeria, and Senegal, is breaking new ground in family planning communication. An editorial in the latest issue of the Global Health: Science and Practice (GHSP) journal highlights the program’s accomplishments.

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    Nearly all population growth in the future will be in less developed countries, particularly in urban areas of these countries. Expanding access to voluntary family planning can help mitigate rapid population growth as well as provide many other benefits to individuals, families, and societies.

    In the latest issue of the Global Health: Science and Practice (GHSP) journal, Malcolm Potts examines the renewed attention being paid to voluntary family planning and population in recent years and how it might help shape the world that our children and grandchildren inherit. Also in this installment, editor-in-chief James Shelton clears up a common misunderstanding about the relationship between reduced mortality and population growth, explaining that improving child survival does increase the motivation for families to reduce their fertility but that it comes too little and too late to forestall substantial population growth. He argues that couples need effective means to control their fertility, in addition to the motivation to do so. And Associate Editor Victor Barbiero urges the global health community to address the triple health burden that growing populations in urban areas of developing countries are experiencing—the burden of communicable diseases, noncommunicable diseases, and injuries.

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    Ixchen, an NGO providing women's health services, promotes affordable mammography and ultrasound with a banner outside Ixchen's center in the outskirts of Managua, Nicaragua

    Ixchen, an NGO providing women's health services, promotes affordable mammography and ultrasound with a banner outside Ixchen's center in the outskirts of Managua, Nicaragua.

    © 2002 Alfredo L. Fort, Courtesy of Photoshare

    Most if not all health interventions require an element of behavior change. As noted in Dr. Jim Shelton's August 2013 editorial  "The 6 domains of behavior change: the missing health system building block" in the Global Health: Science and Practice Journal, 15 of the top 20 health risk factors in sub-Saharan Africa are predominantly behavioral, and the other five are highly influenced by behavior. (See the table [1] at right for the data.)

    In your own life, think about some of the health-related messages that you hear or see on a daily basis that aim to convince us to change your behavior. For example:

     “Fasten your seat belt.”

    “Don’t litter.”

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    Women attend a free IUD and medical camp at Udani Village in Sindh Province, Pakistan

    Women attend a free IUD and medical camp at Udani Village in Sindh Province, Pakistan.

    © 2009 Population Welfare Department Sindh, Courtesy of Photoshare

    What is the best way to deliver family planning services? Should family planning programs concentrate on improving clinic infrastructure and services? Extend services out to communities through mobile outreach services? Or direct their resources on social marketing approaches?

    The answer, of course, depends on the specific setting and ultimately on the needs and mobility of potential family planning clients, how human and financial resources are organized in a health system, and the expected costs of the service delivery model.    

    In Global Health: Science and Practice (Volume 2, Number 1), an original article by Duvall et al. documents the experiences of Marie Stopes International with scaling up contraceptive implants in sub-Saharan Africa. Between 2008 and 2012, Marie Stopes expanded voluntary access to implants in 15 sub-Saharan African countries, from 80,041 implants in 2008 to 754,329 implants in 2012. This 9-fold increase amounted to more than 1.7 million implants delivered cumulatively over the 5-year period. (Implants were provided as part of a comprehensive method mix.) 

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    Health programs, especially in low- and middle-income countries, have been integrating mHealth interventions at an unprecedented rate. There are now more than 1,000 mHealth products and services around the world, according to the GSMA mHealth Tracker. mHealth provides exciting opportunities for increasing access to health care for underserved populations. Consider that by the end of 2013, there were nearly 7 billion mobile subscriptions worldwide, with most of the growth in the past decade occurring in low- and middle-income countries.  

    One of the key articles in the current issue of Global Health: Science and Practice (GHSP) shows how mHealth interventions can transform the role of community health workers (CHWs) in the health system, from passive recipients of information with little influence to active information agents who seek and provide information to improve health services.

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    A ceiling fan swirled lazily above our heads, doing little to dissipate the intense heat of an afternoon in Western Kenya during the region’s dry season. Ten pairs of eyes watched me expectantly as I waited impatiently for my presentation to load and project onto the concrete block wall. It was the first day of a week-long training that would precede nearly three months of data collection at health care facilities in Kisumu, Kenya. This was my first experience serving as the principal investigator for a study, and I was a bundle of anticipatory nerves. My goal was to charge my data collection team with a sense of urgency and an understanding of the life-saving benefits of family planning for women and their children. The day stretched long as we unpacked the relationship between contraceptive prevalence and maternal, infant, and child health. At the end of the day, I felt encouraged when one member of my team stayed behind to share, “I learned so much today. You’ve given me a language to talk about family planning with women and their partners.”

    A healthcare provider with a client in Kenya

    A healthcare provider with a client in Kenya.

    © 2009 David Mita Aluku, Courtesy of Photoshare

    Many years ago, I worked at my local Planned Parenthood for a program designed to prevent teen pregnancy. Drawing on these early experiences in service delivery, I often wonder if a woman’s decision to use contraception is influenced by her interaction with her health care provider. In many developing countries, we try to understand the relationship between the quality of family planning services and actual contraceptive use by collecting data at health facilities, usually in the form of interviews with family planning providers and their clients. Curious about the accuracy of this self-reported data, I traveled to Kenya in 2012 to implement an unusual study. I worked with a team of undercover data collectors—local women hired to pose at facilities as new family planning clients and then report back to research staff about their experiences.

    Our study findings surprised me. Sometimes my data collectors came back to me with glowing reports of service providers truly devoted to the well-being of their clients. Other times, however, members of my team reported less positive experiences, such as waiting all day at a facility without ever receiving services or witnessing a family planning provider shouting at clients as the clients waited long hours to be served. I was also surprised when a number of my data collectors reported being charged for services that are reportedly provided for free. This often happened behind closed doors and without receipts. A more detailed account of our findings is available in our recently published article in the journal Global Health: Science and Practice.

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    As a researcher, it has been rare for me to interact directly with the women and men whose lives are intended to be impacted by our work. Typically, my interactions go no further than the data collectors I train. However, when my research was based in Latin America and the Caribbean, I could unobtrusively participate in pilot testing of data collection instruments. Not so in sub Saharan Africa (SSA) where I do not resemble the locals, and as a “muzungu” (foreigner) could be disruptive to the data collection process. Nevertheless, it was in Zambia that I experienced the closest, and some of my more memorable, interactions with health care providers and family planning clients.

    Dawn Chin Quee ties the legs of a chicken in Zambia

    Dawn Chin Quee ties the legs of a chicken in Zambia.

    My experiences in Zambia were gained through a pilot study conducted in Mumbwa and Luangwa districts. The study in Zambia is described in detail in a recently published Global Health: Science and Practice online article that reports on the safety, feasibility, acceptability, and cost-effectiveness of community health worker (CHW) provision of Depo Provera as well as its impact on family planning uptake. Our study found very high uptake of injectables when the method was added to the contraceptive method mix provided by CHWs: during the study period, the CHWs provided protection against pregnancy for one year (couple-year of protection) to 2,206 Depo Provera clients compared with 51 condom clients and 391 pill clients. Of the 1,739 clients new to family planning, 85% chose Depo, and continuation rates were high. Collaboration with our partner, ChildFund Zambia, as well as with the Ministry of Health and many other stakeholders were as rewarding as they were integral to the success of the pilot and scale up.

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    This chart shows the methods available at a health center in Holeta, Oromia, Ethiopia

    Providing a range of contraceptive methods is crucial in meeting unmet need for family planning. This chart shows the methods available at a health center in Holeta, Oromia, Ethiopia.

    © 2013 Sarah V. Harlan/CCP, Courtesy of Photoshare

    The theme of last month’s International Conference on Family Planning was Full Access, Full Choice, and there was a strong emphasis on employing a rights-based approach to family planning (FP) provision—one that accounts for unmet need and ensures that all women who want to access contraception are able to do so. But what are some strategies for making this happen?

    First of all, operationalizing the concept of “meeting unmet need” means offering the full range of contraceptive options—including long-acting and permanent methods (LAPMs)—in order to meet different contraceptive needs over the course of a woman’s lifetime. Recognizing that a woman’s reproductive preferences change during different stages of her life is crucial to providing optimal contraceptive care. Young women who want to delay pregnancy will likely have different needs than women who already have children who are looking to space or limit births. Thus, it is important to make a range of options available in every healthcare setting, as there is no “one size fits all” in FP service delivery.