Adapting the definition of multimorbidity - development of a locality-based consensus for selecting included Long Term Conditions.

BACKGROUND: Defining multimorbidity has proved elusive in spite of attempts to standardise definitions. For national studies, a broad definition is required to capture national diversity. For locally based studies, the definition may need to reflect demographic and morbidity patterns. We aimed to define multimorbidity for an inner city, multi-ethnic, deprived, young age community typical of many large cities. METHODS: We used a scoping literature review to identify the international literature, standards and guidelines on Long Term Condition (LTC) definitions for inclusion in our multimorbidity definition. Consensus was categorised into high, medium or low consensus, depending on the number of literature sources citing each LTC. Findings were presented to a workshop consisting of local health service stakeholders who were asked to select LTCs for inclusion in a second stage review. In the second stage, each LTC was tested against seven evaluation domains: prevalence, impact, preventability, treatment burden, progression to multiple LTCs, impact on younger people, data quality. These domains were used to create 12 target criteria. LTC rankings according to consensus group and target criteria scores were presented to a second workshop for a final decision about LTC inclusion. RESULTS: The literature review identified 18 literature sources citing 86 LTCs: 11 were excluded because they were LTC clusters. The remainder were allocated into consensus groupings: 13 LTCs were 'high consensus' (cited by ≥ 11 sources); 15 were 'medium consensus' (cited by 5-10 sources); 47 were 'low consensus' (cited by < 5 sources). The first workshop excluded 31 LTCs. The remaining 44 LTCs consisted of: 13 high consensus LTCs, all with high target score (score 6-12); 15 medium consensus LTCs, 11 with high target scores; 16 low consensus LTCs, 6 with high target scores. The final workshop selected the 12 high consensus conditions, 12 medium consensus LTCs (10 with high target scores) and 8 low consensus LTCs (3 with high target scores), producing a final selection of 32 LTCs. CONCLUSIONS: Redefining multimorbidity for an urban context ensures local relevance but may diminish national generalisability. We describe a detailed LTC selection process which should be generalisable to other contexts, both local and national.

Medical Abortion Provision by Pharmacies and Drug Sellers in Low- and Middle-Income Countries: A Systematic Review.

We undertook a systematic review to assess 1) the level and quality of pharmacy and drug shop provision of medical abortion (MA) in low- and middle-income countries (LMICs) and 2) interventions to improve quality of provision. We used standardized terms to search six databases for peer-reviewed and grey literature. We double-extracted data using a standardized template, and double-graded studies for methodological quality. We identified 22 studies from 16 countries reporting on level and quality of MA provision through pharmacies and drug sellers, and three intervention studies. Despite widespread awareness and provision of MA drugs, even in legally restricted contexts, most studies found that pharmacy workers and drug sellers had poor knowledge of effective regimens. Evidence on interventions to improve pharmacy and drug shop provision of MA was limited and generally low quality, but indicated that training could be effective in improving knowledge. Programmatic attention should focus on the development and rigorous evaluation of innovative interventions to improve women's access to information about MA self-management in low-and middle-income countries.

Efficacy of early induced medical abortion with mifepristone when beginning progestin-only contraception on the same day.

OBJECTIVES: To investigate whether starting progestin-only contraception immediately after mifepristone reduced the efficacy of early medical abortion with a mifepristone-misoprostol regimen. METHODS: A review of patient records from October 1, 2012 to March 31, 2013 from four Marie Stopes Mexico clinics in Mexico City was conducted. Patients were eligible for inclusion if they had undergone a medical abortion with mifepristone-misoprostol at no later than 63days of pregnancy, had a recorded outcome, and had either started progestin-only contraception immediately after mifepristone administration or had not started contraception. The primary outcome-successful induced abortion-was defined as the complete evacuation of uterine contents without the need for further intervention. A secondary outcome was the number of induced abortions completed without the need for manual vacuum aspiration. RESULTS: Records from 2204 patients were included; 448 (20.3%) patients had started progestin-only contraception, and 1756 (79.7%) had not. Patients not taking progestin-only contraception were significantly more likely to be primigravidas and nulliparous. Medical abortion success did not vary between the two groups; 1890 (85.8%) were successful and 2085 (94.6%) were completed without the need for manual vacuum aspiration. Different methods of progestin-only contraception did not affect medical abortion outcomes. CONCLUSION: Beginning progestin-only contraception immediately following mifepristone for early medical abortion was not associated with reduced medical abortion effectiveness.

Development and pilot of a framework to evaluate reproductive health call centre services: experience of Marie Stopes international.

BACKGROUND: Call centres can improve the effectiveness of health services by helping reduce access barriers associated with stigma and geography. This project aimed to develop and pilot a standardised evaluation framework to assess Marie Stopes International reproductive health call centres. METHODS: Consultations were held with staff from the 14 existing international call centres to gauge current monitoring and evaluation processes, identify gaps, and establish evaluation needs. The draft framework was then piloted in the Marie Stopes Mexico call centre using client and provider surveys, mystery callers and a review of call centre records. RESULTS: A flexible framework was developed to allow call centres to measure the effectiveness of services offered. Nineteen indicators were developed to assess access, equity, quality and efficiency. The pilot found pre-defined ranges for indicators of access were not appropriate for a high-functioning call centre that was already achieving nearly 100% compliance. Several indicators could not be measured due to a lack of routine data collection systems. CONCLUSIONS: A standardised evaluation framework will allow comparisons over time and between call centres in different countries. Future assessments could be improved by establishing routine, reliable data collection systems prior to framework implementation. This is one of the first attempts to standardise the evaluation of a reproductive health call centre and establishes a method by which they can be monitored, and thus improved, over time.

SegWeigh: a mixed-method approach to segmenting potential contraceptive user groups and meeting Family Planning 2020 goals.

OBJECTIVE: To evaluate a low-cost mixed-method research tool (SegWeigh) that informs awareness raising and family planning interventions for potential contraceptive users. METHODS: A pilot study of SegWeigh was conducted in Uganda and Vietnam between September 3, 2012, and February 21, 2013. User archetypes were produced in four steps by triangulating Demographic and Health Survey (DHS) data; a secondary literature review; family planning service provision data; and primary qualitative investigation. RESULTS: Triangulation of DHS analysis, secondary literature and service data revealed three potential user profiles: Ugandan women wanting to space pregnancies; Ugandan men wanting to limit pregnancies; and unmarried Vietnamese women having infrequent sex. Archetypes were subsequently created of "Kibuuka," a 52-year-old semi-literate subsistence farmer in rural Uganda, and "Anh," a 20-year-old student in Hanoi, Vietnam. CONCLUSION: SegWeigh rapidly produced data-rich "real life" user profiles that might help to tailor family planning interventions.