archives@tulane.edu / Background: Despite a large body of literature citing the benefits of community-based distribution of family planning (FP) services and high-quality FP services, there is a lack of studies measuring the quality of community-based FP services. Objectives: 1. Evaluate how client perspectives on quality differ from those of health professionals; 2. Identify factors that influence client recall of contraceptive counseling; and 3. Develop a metric for measuring quality and test the association between client satisfaction and quality. Methods: This study employed a convenience sample of 1,179 women ages 15-49 years old who sought contraceptive services from community-based FP distribution events in Kinshasa, DRC. Data were collected using three different instruments: CEIs, COs and provider interviews. Methodology: Paper 1. The 28 variables measured by both the CEI and CO were compared using Gwet’s Agreement Coefficient. Paper 2. The association between recall and provider and client characteristics were tested using multivariate linear regression. Paper 3. Exploratory factor analysis was performed and resulting factor scores were used to test the association between quality and client satisfaction in multivariate linear regression models. Results: Paper 1. According to Gwet’s AC1, COs and CEIs were in agreement for 18 of the 28 items, with most discordant variables falling in the “effective use of the chosen method” domain. Paper 2. Average recall score was 67.6%. Time since the provider’s initial training and quality of the client-provider interaction were associated with higher client recall. Being a first-time user was associated with lower recall. Paper 3. All three domains of quality were significantly associated with client satisfaction after controlling for client characteristics and interactions. Conclusion: This is one of the first studies to measure the quality of individual contraceptive counseling sessions during community-based distribution events. Findings have resulted in several recommendations to improve client recall and satisfaction during these events. / 1 / Rebecca Rosenberg

This dissertation examines the effectiveness of interventions related to family planning and the uptake of HIV-related preventive services among women in low-income settings. Women in low-income settings and living with HIV face many barriers to care, including limited access to services for family planning and HIV-related preventive care. At the same time, national, regional, and global efforts are looking for interventions to help control rapid population growth, create an HIV-free generation, and provide adequate preventive care for those living with HIV. This dissertation cuts across these issues and can help to inform debate and policies to address these issues. This dissertation comprises three discrete papers. Paper 1 (chapter 1) examines the effectiveness of a national scale-up of community-based distribution of family planning services on contraceptive use in Malawi’s rural areas during the period 2005-2016. The national-scale up of the intervention followed the success of a pilot of a similar intervention implemented in the period 1999-2004. As in the pilot, the scaled-up program distributed condoms and oral contraceptives and provided family planning education. Further, because education and income are important determinants of individual contraceptive use, the paper also examines whether the effectiveness of the national scale CBDs varies over these dimensions. The paper uses the Malawi Demographic and Health Surveys. The study finds that the intervention increased contraceptive use by 6.8 percentage points and the effects were greater among uneducated and low-income women. Paper 2 (chapter 2) conducts a cost-effectiveness analysis of a trial of cash incentives aimed at increasing the uptake of services for the prevention of mother-to-child transmission (PMTCT) of HIV. The trial was conducted in the Democratic of the Congo (DRC) as part of an effort to find ways of increasing uptake of PMTCT services in sub-Saharan Africa where uptake of these services remains low. The study is conducted from the societal perspective, relies on multiple sources within and outside of the DRC for cost data, and reports economic costs in 2016 International Dollars (I$). At a threshold of 3*GDP per capita for the DRC (I$2409), the study finds that the intervention is cost-effective. Paper 3 (chapter 3) examines the guideline concordance of the time to follow-up anal cancer screening in women living with HIV at high risk for anal cancer. In the US, the incidence of anal cancer in women living with HIV has increased significantly in the past 2-3 decades. However, early detection of anal cancer, through regular screening, can lead to effective secondary prevention of the disease. While guidelines for anal cancer screening exist, very little is known about the guideline concordance of the time to follow-up anal cancer screening in women at high risk of acquiring anal cancer. Hence this study. The study uses Medicaid Analytic eXtract files which compile claims of individuals enrolled in Medicaid—a public health insurance program largely for eligible low-income adults and the largest single payer for HIV/AIDS in the US. The study finds that time to follow-up screening is not guideline-concordant for most women living with HIV, particularly those with one of the two risk factors for anal cancer: a history of abnormal cervical test results or a history of genital warts.