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AbstractThe 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.

AbstractNearly 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'sα=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.

To meet the unique sexual and reproductive health needs of its large adolescent and youth population, Ethiopia's government has expanded and institutionalized youth-friendly services (YFS) at all levels of the health system. To help inform and improve these efforts, the Evidence Project, in collaboration with USAID/Ethiopia and the Ethiopian Federal Ministry of Health, conducted a study on adolescents' and young people's use of and opinions on YFS. Results showed that young people were satisfied overall with the health services they received, regardless of whether it was basic health services or YFS. Awareness and use of YFS was low, but many of the young people who reported using contraception may have been using YFS without knowing it. Importantly, respondents reported low levels of social autonomy and required permission to leave the house from either a parent or spouse, which could present a significant barrier to accessing health services, and especially SRH services. Policymakers and programmers can apply these findings to increase awareness and demand for sexual and reproductive health services among young people, and to ensure that services are targeting and reaching adolescents and young people effectively.

AbstractSide 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.

AbstractBruce'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.

Despite the widely agreed importance of measuring quality of care (QoC), client perspectives are often missing from routine monitoring and studies. The Evidence Project has developed a package of validated, evidence-based tools and training materials to support governments and implementing partners in measuring and monitoring QoC. Measuring QoC from clients' perspectives will help programs celebrate successes, target areas for improvement, and ultimately improve uptake and continuation of voluntary contraceptive use.

Sur la base de l'étude exploratoire menée par le Projet Evidence au Sénégal entre 2015 et 2016, avec un soutien financier supplémentaire de la Fondation William et Flora Hewlett, ce rapport technique documente les résultats d'une étude pilote sur l'offre des services de planification familiale (FP) par les pharmacies privées dans la région de Dakar. Le rapport détaille également les enseignements de valeur tirés de la mise en œuvre de l'étude dans le contexte du Sénégal. Ces résultats contribuent aux discussions politiques en cours au Sénégal concernant l'intégration des pharmacies privées dans la prestation des services de PF. -- Building on the exploratory study conducted by the Evidence Project, with additional funding support from the William and Flora Hewlett Foundation, in Senegal between 2015 and 2016, this technical report documents results from a pilot study that looked at the feasibility of private pharmacies providing family planning (FP) services in the Dakar region. The report also details valuable lessons learned from the study's implementation in the context of Senegal. These results are contributing to ongoing policy discussions in Senegal regarding the integration of private pharmacies in FP service provision.

BACKGROUND: The lifelong responsibility of the autistic children along with the lack of knowledge, lack of treatment, and if treatment is available, it is unaffordable leads to deterioration of quality of life of the parents in several domains. OBJECTIVES: The objective is to study the quality of life of principal caregivers of autistic children and adolescents visiting health facilities in Lucknow city. MATERIALS AND METHODS: The sample included 90 principal caregivers (aged < 60 years) of autistic children and adolescents aged 3–19 years and diagnosed with autism, attending government and private health facilities providing treatment for autism in Lucknow, Uttar Pradesh, India. RESULTS: The quality of life of principal caregivers was found to be influenced most in the physical health domain (with least score). The predictors of quality of life of principal caregivers were type of family and knowledge regarding child's problem. CONCLUSION AND RECOMMENDATIONS: Thus, there is an immense need of increasing awareness through information, education, and communication materials, mass media, and discussions regarding autism.

The Indian National Health Insurance Scheme, Rashtriya Swasthya Bima Yojana (RSBY), was launched by the Ministry of Labour and Employment, Government of India in 2008 to promote equitable access to health services through the private and public sectors. Almost eight years into the program, it was an opportune time to examine usage levels and barriers and facilitators to the program's effectiveness. The Evidence Project conducted a study among the urban poor in Uttar Pradesh to look at awareness and use of the RSBY program and family planning/reproductive health (FP/RH) services, examine concerns of those administering the program and providing services, and provide programmatic recommendations for improvement. This study identified several supply side factors of the insurance scheme that hinder knowledge of and access to services, including FP/RH services, among enrollees and potential enrollees, some of which are highlighted in this study brief.

In 2008, the Government of India launched the National Health Insurance Scheme, Rashtriya Swasthya Bima Yojana (RSBY), to enable families living below the poverty line in both urban and rural areas to access a range of private health services. The available evidence suggests several limitations and barriers that may affect the utilization of RSBY services and warrants a more in-depth examination of the contexts of family planning/reproductive health (FP/RH) services. The Population Council, under the Evidence project, conducted a study among the urban poor to: 1) determine RSBY awareness and barriers to enrollment; 2) identify barriers and facilitating factors to utilizing RSBY for FP/RH services; 3) assess the concerns and limitations of administrators and providers at RSBY-empaneled private hospitals for providing FP/RH services under RSBY; and 4) provide programmatic recommendations to improve the delivery and utilization of RSBY for various FP/RH services. Based on the results of this study, this report suggests a number of programmatic recommendations to improve the supply-side and demand-side barriers of the RSBY program, including for FP/RH services.

IntroductionHIV stigma and discrimination are major issues affecting people living with HIV in their everyday lives. In Thailand, a project was implemented to address HIV stigma and discrimination within communities with four activities: (1) monthly banking days; (2) HIV campaigns; (3) information, education and communication (IEC) materials and (4) "Funfairs." This study evaluates the effect of project interventions on reducing community‐level HIV stigma.MethodsA repeated cross‐sectional design was developed to measure changes in HIV knowledge and HIV‐related stigma domains among community members exposed to the project. Two cross‐sectional surveys were implemented at baseline (respondent n=560) and endline (respondent n=560). T‐tests were employed to assess changes on three stigma domains: fear of HIV infection through daily activity, shame associated with having HIV and blame towards people with HIV. Baseline scales were confirmed at endline, and each scale was regressed on demographic characteristics, HIV knowledge and exposure to intervention activities.ResultsNo differences were observed in respondent characteristics at baseline and endline. Significant changes were observed in HIV transmission knowledge, fear of HIV infection and shame associated with having HIV from baseline to endline. Respondents exposed to three specific activities (monthly campaign, Funfair and IEC materials) were less likely to exhibit stigma along the dimensions of fear (3.8 points lower on average compared to respondents exposed to none or only one intervention; 95% CI: −7.3 to −0.3) and shame (4.1 points lower; 95% CI: −7.7 to −0.6), net of demographic controls and baseline levels of stigma. Personally knowing someone with HIV was associated with low fear and shame, and females were less likely to possess attitudes of shame compared to males.ConclusionsThe multivariate linear models suggest that a combination of three interventions was critical in shifting community‐level stigma – monthly campaign, Funfair and IEC materials. This is especially important given Thailand's new national AIDS strategy to reduce HIV‐related stigma and discrimination by half by 2016. Knowing which interventions to invest in for HIV stigma reduction is crucial for country‐wide expansion and scale‐up of intervention activities.

The International Center for Research on Women, the Muhimbili University College of the Health Sciences, the Population Council, and Family Health International conducted an evaluation of a community-based effort to reduce stigma surrounding HIV infections in a peri-urban community in Tanzania. Results presented a mixed, but hopeful, picture for a way forward in tackling stigma at the community level. Tackling stigma requires that the individuals tasked with doing this undergo personal change. Programs can start by focusing stigma-reduction efforts on a smaller, more manageable geographical area and adding specific anti-stigma components to their portfolio of activities. Engaging community opinion leaders (e.g., political, religious, and youth leaders, and healthcare workers) is a promising way forward for scaling up stigma-reduction at the community level.

AbstractThe adolescent birth rate (ABR) is an important indicator of maternal health, adolescent sexual health, and gender equity; it remains high in sub‐Saharan Africa. While Demographic and Health Surveys (DHS) are the main source of ABR estimates, Health and Demographic Surveillance Systems (HDSS) also produce ABRs. Studies are lacking, however, to assess the ease of access and accuracy of HDSS ABR measures. In this paper, we use birth and exposure data from 10 HDSS in six African countries to compute local ABRs and compare these rates to DHS regional rates where the HDSS sites are located, standardizing by education and place of residence. In rural HDSS sites, the ABR measure is on average 44 percent lower than the DHS measure, after controlling for education and place of residence. Strong temporary migration of childless young women out of rural areas and different capacities in capturing temporarily absent women in the DHS and HDSS could explain this discrepancy. Further comparisons based on more strictly similar populations and measures seem warranted.

IntroductionWithin healthcare settings, HIV‐related stigma is a recognized barrier to access of HIV prevention and treatment services and yet, few efforts have been made to scale‐up stigma reduction programs in service delivery. This is in part due to the lack of a brief, simple, standardized tool for measuring stigma among all levels of health facility staff that works across diverse HIV prevalence, language and healthcare settings. In response, an international consortium led by the Health Policy Project, has developed and field tested a stigma measurement tool for use with health facility staff.MethodsExperts participated in a content‐development workshop to review an item pool of existing measures, identify gaps and prioritize questions. The resulting questionnaire was field tested in six diverse sites (China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis). Respondents included clinical and non‐clinical staff. Questionnaires were self‐ or interviewer‐administered. Analysis of item performance across sites examined both psychometric properties and contextual issues.ResultsThe key outcome of the process was a substantially reduced questionnaire. Eighteen core questions measure three programmatically actionable drivers of stigma within health facilities (worry about HIV transmission, attitudes towards people living with HIV (PLHIV), and health facility environment, including policies), and enacted stigma. The questionnaire also includes one short scale for attitudes towards PLHIV (5‐item scale, α = 0.78).ConclusionsStigma‐reduction programmes in healthcare facilities are urgently needed to improve the quality of care provided, uphold the human right to healthcare, increase access to health services, and maximize investments in HIV prevention and treatment. This brief, standardized tool will facilitate inclusion of stigma measurement in research studies and in routine facility data collection, allowing for the monitoring of stigma within healthcare facilities and evaluation of stigma‐reduction programmes. There is potential for wide use of the tool either as a stand‐alone survey or integrated within other studies of health facility staff.