An analysis of culture-based methods used for the detection and isolation of Salmonella spp., Escherichia coli, and Enterococcus spp. from surface water: A systematic review.

Identification of methods for the standardized assessment of bacterial pathogens and antimicrobial resistance (AMR) in environmental water can improve the quality of monitoring and data collected, support global surveillance efforts, and enhance the understanding of environmental water sources. We conducted a systematic review to assemble and synthesize available literature that identified methods for assessment of prevalence and abundance of bacterial fecal indicators and pathogens in water for the purposes of monitoring bacterial pathogens and AMR. After screening for quality, 175 unique publications were identified from 15 databases, and data were extracted for analysis. This review identifies the most common and robust methods, and media used to isolate target organisms from surface water sources, summarizes methodological trends, and recognizes knowledge gaps. The information presented in this review will be useful when establishing standardized methods for monitoring bacterial pathogens and AMR in water in the United States and globally.

Differences in Quality of Care of Family Planning Services Received by Age and Contraceptive Continuation Among Young Mothers in India.

PURPOSE: Youth face barriers that affect their use of family planning (FP) services, including low quality of care and provider bias. Although young women have the highest unmet need for FP in India, little is known about the effect of age on quality of care received. Additionally, although youth have higher contraceptive discontinuation than older women, the factors associated with continuation, including the effect of quality of care, are not well known. This study aims to assess differences in quality of care received by young mothers aged 15-24 and mothers aged 25-48, and to examine factors associated with modern contraceptive continuation 6 months after initiation among young mothers. METHODS: Data come from a 12-month longitudinal study of married reversible contraceptive users in India. Multinomial logistic regression was conducted to examine adjusted associations of age and reported receipt of low, medium, or high quality of care. Logistic regression was used to assess factors associated with modern contraceptive continuation after 6 months. RESULTS: Results showed that young mothers were less likely to receive high quality of care than older mothers, and that among young mothers, motivation to prevent pregnancy was significantly associated with continued use after 6 months. DISCUSSION: As India aims to improve quality of care and increase access to services for youth, special attention should be paid to care received by young mothers, as well as options to support them in continuing to use contraceptive methods as long as they desire to prevent pregnancy.

New Client-Centered Discontinuation Measures Using the Demographic and Health Survey Calendar Data.

The main source of method discontinuation data comes from the calendar data of the Demographic and Health Surveys (DHS). DHS considers each episode of use contributed by a woman in the calendar to calculate method discontinuation. This means that episodes from women who contribute only one episode of contraceptive use are combined with episodes from women who contribute multiple episodes of use. This paper explores the DHS calculation of episode-based discontinuation and proposes new indicators that focus specifically on the client and puts her as the unit of analysis. First, we attempt to replicate the DHS calculation by applying weighted averages to episodes from women who contributed only one episode and from women who contributed multiple episodes of use. We then calculate three client-centered discontinuation indicators, using the five-year calendar data of the DHS. The methodology is illustrated by using data collected in Bangladesh, Kenya, and Indonesia. Starting with the very first method used and reported in the calendar and following use over 12 months, we develop a client-centered discontinuation indicator. We build on the calculation of the client-centered discontinuation indicator by: (1) excluding switching to result in all contraceptive discontinuation (complete discontinuation); and (2) limiting discontinuation to women still in need of contraception applying the DHS definitions of in need.

The role of job aids in supporting task sharing family planning services to community pharmacists and patent proprietary medicine vendors in Kaduna and Lagos, Nigeria.

BACKGROUND: CPs and PPMVs are an important source of modern contraceptives in Nigeria, yet many lack the requisite knowledge and skills to capably provide these services. This skills gap might be addressed through targeted family planning (FP) training. This study measures family planning knowledge retention of CPs and PPMVs after receiving training in FP counseling and services in Kaduna and Lagos States, in Nigeria. METHODS: In a quasi-experimental longitudinal design without a comparison group, 559 CPs and PPMVs who were enrolled in the IntegratE project between January and December 2019, completed a self-administered questionnaire to assess their knowledge related to the provision of FP counseling, and injectable and implant contraceptive services at three points in time: 1) before the training; 2) immediately after the training; and 3) 9-months after the training in Kaduna and Lagos states, Nigeria. Adjusted multivariate logistic regression analysis was used to assess the effect of provider characteristics and receipt of job aids on FP knowledge retention 9 months after the training. 95% confidence intervals and p-values were used to assess statistical significance. RESULTS: Majority of study participants were females (60.3%) and between 30 and 49 years old (63.4%). The study revealed the importance of jobs aids as influence on knowledge retention. CPs and PPMVs who reported having the Balanced Counseling Strategy plus (BCS+) counseling cards, were more likely to retain knowledge (AOR: 2.92; 95% CI: 1.01-8.40, p-value = 0.05) at 9 months follow-up. Similarly, in terms of knowledge of injectable contraceptives, CPs and Tier 2 PPMVs who reported receiving the Medical Eligibility Criteria (MEC) Wheel were 2.1 times more likely to retain knowledge of injectable contraceptives 9-months later on (95% CI: 1.14-3.99, p-value = 0.02). CONCLUSION: Community Pharmacists and Proprietary Medicine Vendors had good retention of family planning knowledge, especially when combined with job aids. Training and providing them with job aids on FP will therefore support task shifting and task sharing on family planning services provision in Nigeria.

What Distinguishes Women Who Choose to Self-Inject? A Prospective Cohort Study of Subcutaneous Depot Medroxyprogesterone Acetate Users in Ghana.

Depot medroxyprogesterone acetate administered subcutaneously (DMPA-SC) is an all-in-one injectable contraceptive administered every 3 months, either by a trained health care provider or community health worker or by training a client to self-inject. Using a prospective cohort of family planning (FP) clients in Ghana, this study explores patterns of DMPA-SC use and mode of injection administration over a 6-month period. This study also examines the predictors of self-injection adoption 6 months after initiating DMPA-SC. Our analysis focuses on 378 women who were using DMPA-SC at the 6-month interview. Adjusted odds ratios accounting for clustering show that clients who were new FP users, never married, or attended high school/attained higher education were significantly more likely to self-inject by the third injection. Results of this study suggest that in Ghana, adding DMPA-SC to the method mix may improve access to FP, especially among new users. Results of this study may inform FP projects and programs aiming to improve access to contraceptive methods and increase contraceptive prevalence by introducing or scaling up DMPA-SC self-injection. The findings also provide a sociodemographic profile of FP clients most likely to adopt DMPA-SC self-injection over time, which could serve as an evidence base for social marketing strategies.

Evaluation of 2 Intervention Models to Integrate Family Planning Into Worker Health and Livelihood Programs in Egypt: A Difference-in-Differences Analysis.

Recent increases in fertility rates in Egypt and an increase in desired fertility among unmarried young people highlight the need for renewed attention to awareness of and demand for family planning (FP) among young people. Between 2017 and 2018, the United States Agency for International Development-funded Evidence Project tested 2 intervention models to increase awareness of and demand for FP and reproductive health (RH) services among people aged 18-35 years in Souhag and Port Said governorates, Egypt. In Souhag, FP/RH information was integrated into a 5-day livelihood training program for job seekers. In Port Said, garment factory workers received FP/RH information through trained peer educators, social and behavior change materials, and social media. Workshop participants and factory workers interested in FP services were referred to private project-trained physicians and pharmacists. We present the results of an evaluation of the impact of each intervention on young people's reported exposure to FP messages and their FP knowledge, attitudes, and behaviors. Phone interviews were conducted with participants in intervention and comparison groups before and after the intervention. In Souhag, 1,519 intervention group participants (778 at baseline; 741 at endline) and 1,082 comparison group participants (699 at baseline; 383 at endline) completed the phone interview. In Port Said 1,958 participants from intervention factories (1,145 at baseline; 813 at endline) and 1,047 participants from comparison factories (621 at baseline; 426 at endline) completed the phone interview. A difference-in-differences analysis compared intervention and comparison groups between baseline and endline. Results showed significant differences in knowledge and attitudes over time between the intervention and comparison groups in Souhag but less so in Port Said. FP use did not change among project participants in either governorate. We discuss lessons learned from integrating FP into worker health and livelihood training programs and methodological considerations for evaluating such interventions.

Not All Women Who Experience Side Effects Discontinue Their Contraceptive Method: Insights from a Longitudinal Study in India.

Side effects are a primary reason why women stop using contraception, even though they may still want to avoid a pregnancy. The Demographic and Health Surveys (DHS), the largest source of nationally representative data on contraceptive discontinuation, only asks women who discontinued a method their reasons for discontinuation, for which side effects is an option. Yet, side effects are also experienced by continued users. Using longitudinal data collected from a cohort of contraceptive users in Odisha and Haryana, India, this study explores the effect of side effect severity and frequency on six-month discontinuation. Among women who experienced side effects of their enrollment method, 49.7 percent continued to use it by the six-month interview. Women who experienced moderate/severe side effects infrequently were 67 percent (adjusted odds ratio [AOR]: 0.33; 95 percent confidence interval [CI]: 0.16-0.64) less likely to discontinue the enrollment method compared to women who experienced moderate/severe side effects always. Women who experienced mild side effects were even less likely to discontinue (AOR: 0.15; 95 percent CI: 0.06-0.37). Study results suggest side effect severity and frequency are more important factors than simply the experience of a side effect in understanding contraceptive discontinuation. DHS and other national surveys should expand their exploration of side effects to include questions asked of current users.

The relationship between attitudes towards pregnancy and contraceptive continuation: Results from a longitudinal study of married women in India.

To understand the relationship between pregnancy intentions and contraceptive use, a growing body of research has begun to examine various domains of women's attitudes towards pregnancy, acknowledging that these attitudes may contradict one another, and women may be ambivalent. This study examines pregnancy ambivalence and assesses the relationship between attitudes towards pregnancy and contraceptive continuation after nine months among a sample of women in Odisha and Haryana, India. Data come from a longitudinal study of married women age 15-49 who began using a modern reversible method of contraception at the time of study enrollment. To assess their cognitive attitudes (beliefs/knowledge) towards pregnancy, women were asked "how important is it you to avoid a pregnancy now?" To assess their affective attitudes (feelings/emotions), women were asked about their agreement with the statement: "If I found out I was pregnant in the next several weeks, I would be happy." A joint, 4-category measure combining these cognitive and affective attitudes towards pregnancy was created to measure concordance and ambivalence in attitudes towards pregnancy. Multivariate random-effects logistic regression models were employed to examine the relationship of these two measures with method-specific contraceptive continuation nine months later. Two models were conducted, one with the two attitude variables included independently and the second with the joint, 4-category measure included. Results showed that affective and cognitive attitudes were both significantly associated with continuation, but that there were no significant differences between those that were ambivalent and those whose attitudes were concordantly anti-pregnancy. This study suggests that attitudes towards pregnancy are multifaceted and both cognitive and affective attitudes towards pregnancy may play an important role in contraceptive use in India.

The effect of job aids on knowledge retention among Patent and Proprietary Medicine Vendors trained to administer injectable contraceptives: longitudinal results from implementation science in Nigeria.

BACKGROUND: To increase access to voluntary family planning (FP) services, Nigerian policymakers are debating how to task share injectable contraceptive services to drug shop owners known as Patent and Proprietary Medicine Vendors (PPMVs). Task sharing FP services to drug shops is a promising practice, but information is needed on how to ensure high quality FP services. This analysis assesses the effects of job aids on PPMVs' knowledge of injectable contraceptives 9 months after receiving a standardized training. METHODS: One hundred ninety-four PPMVs were trained on FP counseling and administration of injectable contraceptives in Bauchi, Cross River, Ebonyi and Kaduna states. PPMVs were interviewed before, after, and 9 months after the training. Three variables were used to assess injectable contraceptive knowledge: 1) intramuscular depot-medroxyprogesterone acetate (DMPA-IM) knowledge: a combination of three questions related to device type, injection location, and reinjection frequency; 2) subcutaneous DMPA (DMPA-SC) knowledge: a combination of the same three questions but for DMPA-SC; and 3) knowledge of at least 4 of the 7 common injectable side effects. Three separate adjusted logistic regression models were conducted to determine the factors that influence PPMV knowledge of injectable contraceptives 9 months after the training. RESULTS: Over half of PPMVs (56%) reported using at least two job aids at 9 months. PPMVs' knowledge of DMPA-IM, DMPA-SC and side effects were low before the training but increased immediately after. Nine months later, knowledge remained higher than pre-test levels but generally reduced compared to posttest levels. PPMVs who reported using at least two FP job aids were 2.6 (95% CI: 1.4-5.1) times more likely to have DMPA-IM knowledge 9 months after the training compared to those who used one or no job aids, while adjusting for PPMV characteristics. Similar results were observed for knowledge of DMPA-SC (AOR: 2.5; 95% CI: 1.2-4.6) and side effects (AOR: 2.5; 95% CI: 1.3-4.8). CONCLUSION: PPMVs who used at least two FP job aids were more likely to correctly answer key injectable contraceptive questions 9 months after training. Incorporating proven job aids into routine trainings is a low-cost strategy that can reinforce knowledge and help PPMVs to retain information.

Adding a Question About Method Switching to the Method Information Index Is a Better Predictor of Contraceptive Continuation.

INTRODUCTION: The Method Information Index (MII) is 1 of 18 core indicators used to monitor progress toward achieving Family Planning 2020's goal of 120 million more women using a modern method of family planning by 2020. The 3 questions of the MII are intended to measure informed choice at method initiation. Although routinely used in the Demographic and Health Surveys and the Performance Monitoring and Accountability 2020 project in cross-sectional household surveys, the MII may not adequately reflect all key aspects of quality of care or predict contraceptive continuation. In the current study, a question was added to the MII regarding the possibility of switching to a different contraceptive method if the current method is not suitable. The revised MII is referred to as MIIplus. METHODS: A total of 2,699 married women aged 15-49 who started a new episode of use of intrauterine device, injectable, or oral contraceptive pills between December 2016 and October 2017 were followed for 1 year in India and interviewed at method start and 3, 6, and 12 months later. Of these women, 2,267 were interviewed 3 months later and included in the analysis. Using 3 Cox proportional hazard models, we estimated hazard ratios for risk of discontinuation, based on the MII, MIIplus, and a recategorization of MIIplus into a 3-category variable. RESULTS: The modern method continuation rate 100 days (∼3 months) later was 91% overall. Women who received the information in MIIplus were more likely to continue using a method at 100 days (95%) compared to those who received information covered in the MII (82%) or less than 3 components of the MII (89%) (P<.001). Women who received all components in the MIIplus were 69% (adjusted hazard ratio, 0.31; 95% confidence interval: 0.17 to 0.61) less likely than those who received information in the MII to discontinue using a modern method 100 days later. Discontinuation was not significantly different between women who received information on less than the 3 components of the MII compared to the complete MII. CONCLUSION: We recommend including the question about the possibility of switching to another family planning method in routine measurement because it better predicts contraceptive continuation than the MII alone and ensures that another domain of quality of care is reflected in the measurement. When programs provide information on the possibility of switching, women are better informed about voluntary family planning choice and their options to continue family planning when a method is not suitable.

Validation of Two Quality of Care Measures: Results from a Longitudinal Study of Reversible Contraceptive Users in India.

Bruce's quality of care framework, developed nearly three decades ago, brought needed international attention to family planning services. Various data collection efforts exist to measure the quality of contraceptive services. Our study validates two process quality measures and tests their predictive validity related to contraceptive continuation among 2,699 married women who started to use a reversible contraceptive method in India. We assessed four process quality domains with 22 items, which were reduced to 10 items using exploratory factor analysis. Weighted additive indices were calculated for the 22- and 10-item measures. Scores were trichotomized into high, medium, and low process quality received. The predictive validity of the two measures was assessed related to modern contraceptive continuation three months later. The adjusted odds of continuing a modern contraceptive three months later was nearly three times greater (AOR: 2.78; 95% CI: 1.83-4.03) for women who received high process quality at enrollment compared with low quality with the 22-item measure, and 2.2 times greater (95% CI: 1.46-3.26) with the 10-item measure. Results suggest that the 22- and 10-item measures are valid, and while the larger 22-item measure can be used in special studies, the 10-item measure is more suited for routine data collection and monitoring.

Stigma as a barrier to family planning use among married youth in Ethiopia.

Nearly 33 million female youths have an unmet need for voluntary family planning (FP), meaning they are sexually active and do not want to become pregnant. In Ethiopia, age at marriage remains low: 40% and 14% of young women aged 20-24 were married by the ages of 18 and 15, respectively. Despite increases in FP use by married 15- to 24-year-olds from 5% in 2000 to 37% in 2016, unmet need remains high at 19%. Supply-and-demand factors have been shown to limit FP use, yet little is known about how stigma influences FP use among youth. This study validates an anticipated stigma (expectation of discrimination from others) index and explores its effect on unmet need. A cross-sectional survey was implemented with 15- to 24-year-old female youth in Ethiopia in 2016. The analytic sample included married respondents with a demand (met and unmet need) for FP (n=371). A five-item anticipated stigma index (Cronbach's α=0.66) was developed using principal component factor analysis. These items related to fear, worry and embarrassment when accessing FP. The findings showed that 30% agreed with at least one anticipated stigma question; 44% had an unmet need; 58% were married before age 18; and 100% could name an FP method and knew where to obtain FP. In multivariate regression models, youth who experienced anticipated stigma were significantly more likely to have an unmet need, and those who lived close to a youth-friendly service (YFS) site were significantly less likely to have an unmet need. Interventions should address anticipated stigma while focusing on social norms that restrict married youth from accessing FP; unmet need may be mitigated in the presence of a YFS; and the anticipated stigma index appears valid and reliable but should be tested in other countries and among different adolescent groups.

Condom use at last sex by young men in Ethiopia: the effect of descriptive and injunctive norms.

BACKGROUND: Condoms are an important prevention method in the transmission of HIV and sexually transmitted infections as well as unintended pregnancy. Individual-level factors associated with condom use include family support and connection, strong relationships with teachers and other students, discussions about sexuality with friends and peers, higher perceived economic status, and higher levels of education. Little, however, is known about the influence of social norms on condom use among young men in Ethiopia. This study examines the effect of descriptive and injunctive norms on condoms use at last sex using the theory of normative social behavior. METHODS: A cross-sectional survey was implemented with 15-24 year old male youth in five Ethiopian regions in 2016. The analytic sample was limited to sexually active single young men (n = 260). Descriptive statistics, bivariate and multivariate logistic regressions were conducted. An interaction term was included in the multivariate model to assess whether injunctive norms moderate the relationship between descriptive norms and condom use. RESULTS: The descriptive norm of knowing a friend who had ever used condoms significantly increased respondents' likelihood of using condoms at last sex. The injunctive norm of being worried about what people would think if they learned that the respondent needed condoms significantly decreased their likelihood to use condoms. The injunctive norm did not moderate the relationship between descriptive norms and condom use. Young men who lived closer to a youth friendly service (YFS) site were significantly more likely to have used condoms at last sex compared to those who lived further away from a YFS site. CONCLUSIONS: Social norms play an important role in decision-making to use condoms among single young men in Ethiopia. The interplay between injunctive and descriptive norms is less straightforward and likely varies by individual. Interventions need to focus on shifting community-level norms to be more accepting of sexually active, single young men's use of condoms and need to be a part of a larger effort to delay sexual debut, decrease sexual violence, and increase gender equity in relationships.