Background
Methods
Study setting
Design of the pilot intervention
Pilot procedures
Ethics & human subjects protection
Data collection
Data analysis
Results
1. Factors that contributed to acceptability of the intervention |
1.a. The intervention improved access to UPT and reproductive healthcare services •Home visits by CHVs eliminate costs and time spent traveling to a clinic for UPT, which is particularly beneficial for women who experience stigma in pregnancy or whose freedom to travel is limited •Early identification of pregnancy supports early initiation of ANC, and negative pregnancy tests support timely initiation of FP •CHVs support links to downstream reproductive care and act as liaisons between women and other healthcare providers |
1.b. The intervention supported more informed choices about pregnancy and reproductive health, but not necessarily for women with unwanted pregnancies interested in abortion •UPT supports women’s and families’ abilities to plan for birth, for example, by saving money •UPT opens up opportunities for women to make major life choices that are affected by pregnancy status, for example, leaving a marriage •Some participants expressed concerns that women would “misuse” the information from UPT to make choices they did not think were acceptable, for example, around abortion •Some CHVs and non-CHV participants thought counselling by CHVs should be directed towards preventing abortion |
1.c. Acceptability of the intervention depends on trust between CHVs and the community •CHV-delivered UPT and counselling was acceptable because CHVs were generally trusted and respected •Concerns about CHVs’ confidentiality, and that CHVs’ biases and conflicts would affect access to UPT, are barriers to acceptability •Post-UPT counselling with a study staff member is an acceptable way to address concerns about confidentiality with a CHV •CHVs themselves described a sense of great value from delivering UPT, a service which provides a diagnosis, and may have enhanced trust in CHV’s skills |
2. Factors that contributed to or detracted from the feasibility of the intervention |
2.a. It is feasible for CHVs to provide UPT, counselling, and referrals if the appropriate supplies are provided •Appropriate supplies included enough test kits, transportation or remuneration of transportation costs for CHVs, and a carrying bag |
2.b. It may not always be feasible for women to access reproductive healthcare services even if a CHV successfully delivers UPT, post-test counselling, and a referral •This intervention does not address downstream barriers to accessing care at distant clinics (costs, distances, mistreatment) •Some men in the community’s negative attitudes toward FP might limit women’s access to FP services |
3. Spanning both acceptability and feasibility: adequate financial, educational, and professional support for CHVs |
3.a. The additional work involved in providing UPT, counselling, and referral exacerbated pre-existing financial strain on CHVs •CHVs live with economic insecurity, and volunteer work infringes on their time for income-generating work •UPT, which was extremely popular, exacerbated the demands on CHVs •Participants thought financial strain on CHVs could be addressed by providing financial support, as a stipend or in-kind |
3.b. CHVs requested additional educational and professional supports •CHVs requested additional training for counselling around unwanted pregnancies, adolescent pregnancies, and infertility •CHVs described fears that they might be blamed for miscarriages, abortions, or breaches of confidentiality |
1. Acceptability
1.a. CHV-delivered UPT and counselling improved access to UPT and reproductive healthcare services
To some women it is difficult to go or reach hospital so it will very helpful to have these CHVs go to them because they are close to them (Woman, Port Victoria, Pre-intervention FGD #2)
Those girls who are under 18, they are ashamed of going to hospital, they can come to us in our homes to know their pregnancy status…I can send her to the health facility and I follow her up to ensure that she attends clinic. (CHV, Port Victoria, Pre-intervention FGD #2)
It’s good because some women are not allowed by their husbands to leave their houses, when the husbands leave for work, [then] the CHVs visit and provide counselling. (Woman, Turbo, Pre-intervention FGD #2)
You know some women’s menses are inconsistent. This can be confusing because she will not know whether she has conceived or not. So, it will be wise for her to go to the hospital and be tested and find out her status. (Woman, Port Victoria, Pre-intervention FGD #1)
[If] she was told to go back on a certain date [for family planning] and she failed to do so, you see she will suspect herself and rush to you for help. She will say that she has missed for around 5 days and she is not sure if she is pregnant but would like to go back to family planning. (CHV, Turbo, Post-intervention FGD #2)
[When] there is misunderstanding between the clients and the healthcare provider…I have to liaise with my CHV because she is the one who referred me to the hospital… it is this same CHV who referred you to the hospital, and escorted you there and maybe counselled on FP side effects and [she] takes you back to the hospital maybe for the 3rd time to be assisted. (Woman, Port Victoria, Post-intervention FGD #1)
1.b. CHV-delivered UPT and counselling supported more informed choices about pregnancy and reproductive health, but not necessarily for women with unwanted pregnancies interested in abortion
Moderator: How will you prepare yourself [after an early positive pregnancy test]?
Respondent: By going to ANC, shopping for your baby, saving some money too. (Woman, Turbo, Pre-intervention FGD #2)
For me also, when I was providing the urine pregnancy tests, there is a mother who came to me and she looked anxious…She felt so happy about the results being negative and when I prompted to know more she told me her husband was a drunkard and she never wanted to have a baby with him...I realized she came to confirm if she was pregnant or not so that she could make her decisions early enough. (CHV, Port Victoria, Post-intervention FGD #2)
Some women are deceitful, they will be testing themselves frequently because maybe they cheat. (Male participant, Turbo, Pre-intervention FGD #2)
It should be made clear to the parents and these women that the kit has not been provided for promoting ill doings like abortion but for better things like early detection of pregnancy for better and early management and treatment. (Woman, Port Victoria, Pre-intervention, FGD #1)
If their only option was to do abortion, then it should be a safe abortion. (CHV, Port Victoria, Post-intervention FGD #2)
I counselled her telling her the effects of abortion and the importance of children and she decided to keep the baby. (CHV, Turbo, Post-intervention FGD #2)
Respondent 1: For the one who the pregnancy test results came positive and she has refused to be counselled, on my side if she is married you can secretly tell her husband that I would want to pay both of you a visit at a certain date… So, when you pay them a visit, you go there like a stranger and provide counselling. So, if the husband is a good man, the wife will eventually agree.
Respondent 2: And if you [try to counsel her] again and she refuses?
Respondent 1: But we have other people like the chief. We have to network. She might not listen to you but she can listen to [other CHV]. (CHV, Port Victoria, Post-intervention FGD #1)
1.c. Acceptability of CHV-delivered UPT depends on trust between CHVs and the community
Moderator: What would be the drawbacks of getting [UPT] from a CHV?
Respondent: …The issue of confidentiality. The CHV tests a client then goes about disclosing the results to people. (Man, Port Victoria, Pre-intervention FGD #1)
Respondent: Some men are different [and] some will argue.Moderator: Why will some argue what comes to their minds?Respondent: They think the kit is used to test for a certain illness [HIV]. (Woman, Turbo, Pre-intervention FGD
Moderator: In your opinion which mode of counselling would you prefer? Phone based or CHV?Respondent: Being counselled and referred by phone, because there are some things I cannot tell the CHV. (Woman, Turbo, Pre-intervention FGD #2)There are those who don’t want you to try to even call them, they don’t want their people to know. (CHV, Turbo, Post-intervention FGD #2)
[CHVs] are also respectful and of good morals and are up to task. They also visit and do follow-up on us and our children, whether we are sick or not. So, I can say they can be of great help to us. (Woman, Port Victoria, Pre-intervention FGD #1)
Whenever I was going, people referred me as a Doctor. They believed that by providing the pregnancy test services to them, then I was a doctor. (CHV, Port Victoria, Post-intervention FGD #1)
We would like to give [UPT] out because they were good in the community and we also got to be educated. (CHV, Turbo, Post-intervention FGD #1)
2. Feasibility
2.a. It is feasible for CHVs to provide UPT, counselling, and referrals to care if the appropriate supplies are provided
2.b. It may not always be feasible for women to access reproductive healthcare services even if a CHV successfully delivers UPT, post-test counselling, and a referral
You can refer a mother but when she goes to the [nearby clinic] she is told to go to Turbo [the further clinic]. She doesn’t have money for transport to go to Turbo. (CHV, Post-intervention FGD #1)
It’s good to use the UPT kit to enable me as the husband to know if my wife is pregnant for purposes of planning. (Man, Turbo, Pre-intervention FGD #2).
In my religion what they detest is the use of contraceptives. (Man, Port Victoria, Pre-intervention FGD #2)
If I can ask, since these [family planning] drugs affect women, can they affect me as well? (Man, Port Victoria, Pre-intervention FGD #2)
There are some husbands that are against family planning…she sometimes has to do it in secret. (Woman, Turbo, Pre-intervention FGD #2)
3. Spanning both acceptability and feasibility: adequate financial, educational, and professional support for CHVs
3.a. The additional work involved in providing UPT, counselling, and referral exacerbated pre-existing financial strain on CHVs
For instance, in our place in XXX Unit we have 1 CHV…villages are densely populated, so you find that there is always a high demand…this is overwhelming if it is just one [CHV] rendering the services. (Woman, Port Victoria, Pre-intervention FGD #1)
You will find that some of these CHVs have their other personal engagements [work] so that sometimes when they are needed it can become difficult due to commitments to earn daily bread. (Man, Port Victoria, Pre-intervention FGD #1)
They call and come to your door, you will even find them at the door waiting for you if you had gone somewhere. (CHV, Turbo, Post-intervention FGD #1)
You keep revisiting that person wanting to know how she is, if she has gone to the clinic. In that revisiting you have no airtime, you have no money to get on a motorcycle. (CHV, Turbo, Post-intervention FGD #2)
If possible allocate to them some stipend to motivate them…at the end of the day they will get some soap at least. (Man, Port Victoria, Pre-intervention FGD #2)
3.b. CHVs requested additional educational and professional supports
Referring this woman was very hard because she didn’t want to, she had not expected to be pregnant. So, it was hard for me, it took a long time because she needed advanced counselling yet you are not a counsellor. (CHV, Turbo, Post-intervention FGD #1)
If her husband sees her with that kit and knows she is using it then maybe she tested positive for pregnancy then he later discovers that she is no longer pregnant, what will be his perception about me [the CHV], and what would follow after that? (CHV, Turbo, Pre-intervention FGD #1)
Some of us we do not know what to do. When a mother is gasping for air when breathing…and the next day the [clinic] is not working. (CHV, Port Victoria, Post-intervention FGD #2)