Self-sampling for human papilloma virus DNA as a strategy to increase access to cervical cancer screening: patients' and providers' perspectives on facilitators and barriers to scale.

Self-sampling represents a high accuracy approach to human papilloma virus DNA (HPV-DNA) testing that allows for privacy and autonomy. As part of a larger study to evaluate cervical cancer screening in Mozambique, we explored user-driven facilitators and barriers to, and provider perspectives on, self-sampling. Our study was conducted in 4 public health facilities in 2 districts in Mozambique. Women aged 30-49 were prospectively enrolled for HPV screening and were offered provider or self-collected sampling. We used enrolment data from 9014 participants to examine characteristics of women choosing self-sampling and conducted in depth interviews with 104 women and 15 providers to understand facilitators and barriers to self-sampling. 97.5% of participants chose self-sampling over provider sampling. Participant-reported barriers included fear about technique, discomfort and inadequate training. Facilitators to self-sampling included increased privacy and having been exposed to a peer who previously self-sampled. Providers expressed concern about their limited role in the screening process with a self-sampling technique. Self-sampling for HPV is an acceptable approach to cervical cancer screening but barriers such as fear of sampling incorrectly and discomfort with their bodies remain.

L'auto-échantillonnage représente une approche de haute précision pour les tests d'ADN du virus du papillome humain (ADN-HPV) qui permet la confidentialité et l'autonomie. Dans le cadre d'une étude plus vaste visant à évaluer le dépistage du cancer du col de l'utérus au Mozambique, nous avons exploré les facilitateurs et les obstacles imposés par les utilisateurs, ainsi que les points de vue des prestataires sur l'auto-échantillonnage. Notre étude a été menée dans 4 établissements de santé publics dans 2 districts du Mozambique. Les femmes âgées de 30 à 49 ans ont été inscrites de manière prospective pour le dépistage du VPH et se sont vu proposer un prélèvement par un prestataire ou un prélèvement auto-collecté. Nous avons utilisé les données d'inscription de 9 014 participantes pour examiner les caractéristiques des femmes choisissant l'auto-échantillonnage et mené des entretiens approfondis avec 104 femmes et 15 prestataires pour comprendre les facilitateurs et les obstacles à l'auto-échantillonnage. 97,5 % des participants ont choisi l'auto-échantillonnage plutôt que l'échantillonnage par un prestataire. Les obstacles signalés par les participants comprenaient la peur concernant la technique, l'inconfort et une formation inadéquate. Les facilitateurs de l'auto-échantillonnage comprenaient une plus grande intimité et le fait d'avoir été exposé à un pair qui avait déjà effectué un auto-échantillonnage. Les prestataires ont exprimé leur inquiétude quant à leur rôle limité dans le processus de dépistage avec une technique d'auto-échantillonnage. L'auto-prélèvement pour le VPH est une approche acceptable pour le dépistage du cancer du col de l'utérus, mais des obstacles tels que la peur d'un prélèvement incorrect et l'inconfort avec leur corps demeurent.

Lessons Learned in Improving the Quality of a Free Reproductive Health Hotline in Benin.

INTRODUCTION: Since 2006, the Ligne Verte project-a toll-free national hotline that provides counseling and provider linkages to family planning, HIV, and sexually transmitted infection services-has been implemented by the Association Béninoise pour le Marketing Social et la Communication pour la Santé (ABMS) in Benin. Annual evaluations have been conducted to monitor client satisfaction, with feedback mechanisms to learn from callers and staff, aiming to continually improve the program. We document lessons learned from these evaluations, outline the adaptation process to improve the quality of the hotline, present results from Ligne Verte caller and counselor studies, and describe how the studies fed client-driven changes to the project. METHODS: Annual rounds of semistructured phone interviews with Ligne Verte callers and call center advisors were conducted. The sample of clients interviewed included consenting men and women aged 18 years and older who had used Ligne Verte services in the 3 months preceding the evaluation. All advisors working on the helpline were also eligible for inclusion in qualitative interviews. RESULTS: From 2013 to 2020, most callers were satisfied with the Ligne Verte project. Users reported appreciating the accurate, timely, and confidential support they received from the helpline but noted the need to expand the service to other local languages and improve call quality. Call center advisors requested mental health support. In employing a systematic approach to program improvement, ABMS was able to add extended language services, upgrade their telecommunication hardware, and provide a psychologist for call center advisors. These program adaptations have increased caller satisfaction by 20 percentage points, and in 2020, 95% of callers reported being satisfied with their Ligne Verte experience. CONCLUSION: Taking a consumer-centered approach, listening to user feedback, and making evidence-based recommendations to improve the Ligne Verte project has led to an overall increase in caller satisfaction.

Determinants of COVID-19 vaccine acceptance in Mozambique: The role of institutional trust.

BACKGROUND: Vaccination plays an imperative role in protecting public health and preventing avoidable mortality. Yet, the reasons for vaccine hesitancy in African countries are not well understood. This study investigates the factors associated with the acceptance of COVID-19 vaccine in Mozambique, with a focus on the role of institutional trust. METHODS: The data came from the three waves of the COVID-19 Knowledge, Attitudes and Practices (KAP) survey which followed a cohort of 1,371 adults in Mozambique over six months (N = 3809). We examined vaccine acceptance based on three measurements: willingness to take vaccine, perceived vaccine efficacy, and perceived vaccine safety. We conducted multilevel regression analysis to investigate the trajectories of, and the association between institutional trust and vaccine acceptance. RESULTS: One third of the survey participants (37%) would definitely take the vaccine. Meanwhile, 31% believed the vaccine would prevent the COVID-19 infection, and 27% believed the vaccine would be safe. There was a significant decrease in COVID-19 vaccine acceptance between waves 1 and 3 of the survey. Institutional trust was consistently and strongly correlated with different measures of vaccine acceptance. There was a greater decline in vaccine acceptance in people with lower institutional trust. The positive correlation between institutional trust and vaccine acceptance was stronger in younger than older adults. Vaccine acceptance also varied by gender and marital status. CONCLUSIONS: Vaccine acceptance can be volatile even over short periods of time. Institutional trust is a central driver of vaccine acceptance and contributes to the resilience of the health system. Our study highlights the importance of health communication and building a trustful relationship between the general public and the institutions in the context of a global pandemic.

Bias in product availability estimates from contraceptive outlet surveys: Evidence from the Consumer's Market for Family Planning (CM4FP) study.

Area-based sampling approaches designed to capture pharmacies, drug shops, and other non-facility service delivery outlets are critical for accurately measuring the contraceptive service environment in contexts of increasing de-medicalization of contraceptive commodities and services. Evidence from other disciplines has demonstrated area-based estimates may be biased if there is spatial heterogeneity in product distribution, but this bias has not yet been assessed in the context of contraceptive supply estimates. The Consumer's Marker for Family Planning (CM4FP) study conducted censuses and product audits of contraceptive outlets across 12 study sites and 2-3 rounds of quarterly data collection in Kenya, Nigeria, and Uganda. We assessed bias in estimates of contraceptive product availability by comparing estimates from simulations of area-based sampling approaches with census counts among all audited facilities for each study site and round of data collection. We found evidence of bias in estimates of contraceptive availability generated from simulated area-based sampling. Within specific study sites and rounds, we observed biased sampling estimates for several but not all contraceptive method types, with bias more likely to occur in sites with heterogeneity in both spatial distribution of outlets and product availability within outlets. In simulations varying size of enumeration areas (EA) and number of outlets sampled per EA, we demonstrated that the likelihood of substantial bias decreases as EA size decreases and as the number of outlets sampled per EA increases. Straightforward approaches such as increasing sample size per EA or applying statistical weights may be used to reduce area-based sampling bias, indicating a pragmatic way forward to improve estimates where design-based sampling is infeasible. Such approaches should be considered in development of improved methods for area-based estimates of contraceptive supply-side environments.

Comparing modelled with self-reported travel time and the used versus the nearest facility: modelling geographic accessibility to family planning outlets in Kenya.

INTRODUCTION: Geographic access to family planning (FP) services has been characterised through a variety of proximity metrics. However, there is little evidence on the validity of women's self-reported compared with modelled travel time to an FP outlet, or between different distance measures. METHODS: We used data from four urban sites in Kenya. A longitudinal FP outlet census was directly linked with data from cross-sectional FP user surveys. We combined characteristics of outlet visited to obtain FP, transport mode, self-reported travel time and location of households and outlets with data on road networks, elevation, land use and travel barriers within a cost-distance algorithm to compute modelled travel time, route and Euclidean distance between households and outlets. We compared modelled and self-reported travel times, Euclidean and route distances and the use of visited versus nearest facility. RESULTS: 931 contraceptive users were directly linked to their FP source. Self-reported travel times were consistently and significantly higher than modelled times, with greater differences for those using vehicles rather than walking. Modelled and Euclidean distances were similar in the four geographies. 20% of women used their nearest FP outlet while 52% went to their nearest outlet when conditional on it offering their most recently used FP method. CONCLUSION: In urban areas with high facility density and good road connectivity, over half of FP users visited their nearest outlet with their chosen method available. In these settings, Euclidean distances were sufficient to characterise geographic proximity; however, reported and modelled travel times differed across all sites.

Motivation to test, treat, and report malaria cases: a quantitative assessment among private sector providers in the Greater Mekong Subregion.

BACKGROUND: Accurately testing, treating, and tracking all malaria cases is critical to achieving elimination. Ensuring health providers are able and motivated to test, treat, and report cases is a necessary component of elimination programmes, and particularly challenging in low endemic settings where providers may not encounter a large volume of cases. This study aimed to understand provider motivations to test, treat, and report malaria cases to better optimize programme design, adjust incentive schemes, and ultimately improve reporting rates while growing the evidence base around private providers in the Greater Mekong Subregion (GMS). METHODS: With funding from the Bill & Melinda Gates Foundation, this study aimed to identify and validate distinctive subtypes of motivation among private sector providers enrolled in the Greater Mekong Subregion Elimination of Malaria through Surveillance (GEMS) programme, implemented by Population Services International. Quantitative questionnaires were administered electronically in person by trained enumerators to various provider groups in Myanmar, Lao PDR, and Vietnam. A three-stage confirmatory factor analysis was then conducted in STATA. RESULTS: Following this analysis, a two-factor solution that describes motivation in this population of providers was identified, and providers were scored on the two dimensions of motivation. The correlation between the two rotated factors was 0.3889, and the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.93, indicating an excellent level of suitability. These providers, who are often assumed to only be financially motivated, engaged in malaria elimination activities because of both internal and external motivational factors that are independent of remuneration or financial gain. For all three countries' data, significant covariances between the two latent variables for internal and external motivation were found. The models were found to be of adequate to good fit for the data across all three countries. It was determined that private sector providers, who were previously believed to be primarily financially motivated, were also motivated by personal factors. Motivation was also associated with key outcomes of importance to malaria elimination, such as reporting and stocking of tests and treatments. CONCLUSION: Maintaining or increasing provider motivation to test and treat is essential in the fight to eliminate malaria from the GMS, as it helps to ensure that providers continue to pursue this goal, even in a low incidence environment where cases may be rare and in which providers face financial pressure to focus on areas of health service provision. Establishing mechanisms to better motivate providers through intrinsic factors is likely to have a substantive impact on the sustainability of malaria case management activities.

A New Contraceptive Diaphragm in Niamey, Niger: A Mixed Methods Study on Acceptability, Use, and Programmatic Considerations.

INTRODUCTION: Diaphragms have never been widely available in West Africa, a region with very low contraceptive use due in part to health system constraints and low demand for other modern methods of contraception. Research has demonstrated the single-size Caya contoured diaphragm to be a safe and effective barrier method of nonhormonal, self-care contraception, offering features that improve upon the design of traditional diaphragms. No studies have measured continuation of Caya. In Niamey, Niger, this pilot introduction study explored Caya acceptability, use, and programmatic considerations. METHODS: Women in Niger participated in surveys (n=150) and in-depth interviews (n=25) 6 months after adopting Caya. In-depth interviews were also conducted with men in the community (n=15) and family planning providers (n=15). We conducted descriptive analysis of the percentage of adopters who continued to use the method at 6 months and women's reasons for discontinuation among women who completed the 6-month follow-up survey. We used deductive thematic analysis of in-depth interview data from women, men, and providers to understand program elements and other factors associated with acceptability. RESULTS: Six months after initiation, 76.7% (95% confidence interval=0.70, 0.83) of 150 survey respondents reported continued use of Caya. Top reasons for use included: Caya causes no side effects for most users, works on demand, and is reusable for up to 2 years. Roughly one-quarter of women interviewed reported inconsistent use. Some men supported their partner's use; in other cases, women used Caya without informing or involving their partners. Providers described Caya as compatible with the needs of many women and credited pelvic models with enabling effective counseling. DISCUSSION: The Caya diaphragm has the potential to be a valuable addition to the range of contraceptive options, especially in settings with high levels of opposition to other modern methods.