Community-based Distribution Program Research Articles

Community-based distribution program's response to increased contraceptive demand in the Democratic Republic of Congo during COVID-19.

In the Democratic Republic of Congo (DRC), the United States Agency for International Development (USAID) Integrated Health Program supports the Ministry of Health to strengthen family planning (FP) services through a Community-Based Distribution (CBD) program. As a part of this project, we investigated whether the CBD program responded to the increased need for contraceptives in nine provinces of the DRC during COVID-19 pandemic. Analysis compared distribution rates of contraception methods, uptake by new users, and renewal rates among women before and during the pandemic. Data sourced from women of childbearing age using modern contraceptives through CBD across 179 health zones were analyzed using chi-square tests in MedCalc software to examine proportion differences pre-COVID-19 versus during COVID-19. The CBD program distributed about 348,958 contraceptives during the pandemic, with 18.3% being new users, significantly higher than pre-pandemic levels (14.5%; P < 0.0001). Renewal rates were higher pre-pandemic overall (26.3% vs. 24.6%; P < 0.0001), but urban areas saw increased renewals during COVID-19 compared to before (34.8% vs. 24.1%; P < 0.0001). Despite pandemic-induced healthcare challenges, the CBD program effectively met escalated contraceptive demands. These findings underscore CBD's efficacy in crisis response, offering insights for governments on optimizing CBD services during health emergencies

Evaluation of Strategies to Enhance Community-Based Naloxone Distribution Supported by an Opioid Settlement

Many US states are substantially increasing community-based naloxone distribution, supported in part through settlements from opioid manufacturers and distributors. To evaluate the potential impact of increased naloxone availability on opioid overdose deaths (OODs) and explore strategies to enhance this impact by integrating interventions to address solitary drug use. This decision analytical modeling study used PROFOUND (Prevention and Rescue of Fentanyl and Other Opioid Overdoses Using Optimized Naloxone Distribution Strategies), a previously published simulation model, to forecast annual OODs between January 2023 and December 2025. The simulated study population included individuals from Rhode Island who misused opioids and stimulants and were at risk for opioid overdose. The study modeled expanded naloxone distribution supported by the state's opioid settlement (50 000 naloxone nasal spray kits each year). Two approaches to expanding naloxone distribution were evaluated: one based on historical spatial patterns of naloxone distribution (supply-based approach) and one based on the spatial distribution of individuals at risk (demand-based approach). In addition, hypothetical interventions to enhance the likelihood of witnessed overdoses in private or semiprivate settings were considered. Annual number of OODs and ratio of fatal to nonfatal opioid overdoses. Modeling results indicated that distributing more naloxone supported by the state's opioid settlement could reduce OODs by 6.3% (95% simulation interval [SI], 0.3%-13.7%) and 8.8% (95% SI, 1.8%-17.5%) in 2025 with the supply-based and demand-based approaches, respectively. However, increasing witnessed overdoses by 20% to 60% demonstrated greater potential for reducing OODs, ranging from 8.5% (95% SI, 0.0%-20.3%) to 24.1% (95% SI, 8.6%-39.3%). Notably, synergistic associations were observed when combining both interventions: increased naloxone distribution with the 2 approaches and a 60% increase in witnessed overdoses could reduce OODs in 2025 by 33.5% (95% SI, 17.1%-50.4%) and 37.4% (95% SI, 19.6%-56.3%), respectively. These findings suggest that interventions to address solitary drug use are needed to maximize the impact of continued efforts to increase community-based naloxone distribution, which may be particularly important for jurisdictions that have strong community-based naloxone distribution programs.

Best practices for community-based overdose education and naloxone distribution programs: results from using the Delphi approach

BackgroundOpioid-related overdose deaths have surged in the USA over the last two decades. Overdose fatalities are preventable with the timely administration of naloxone. Syringe service programs (SSP) have pioneered community-based naloxone distribution through overdose prevention and naloxone distribution (OEND) programs. There is a dearth of information with regards to best practices for community-based OEND.MethodsWe utilized a modified Delphi approach to develop a set of best practices for OEND delivery. Starting with an initial list of best practices, we engaged 27 experts, in the field of OEND programming who reviewed, made recommendations for changes, and assigned a priority to each best practice.ResultsTwo rounds of input resulted in a final list of 20 best practices organized into four categories. The mean priority scores ranged from 1.17 to 2.17 (range 1 to 3). The top 5 ranked best practices were ensuring that SSP participants have low barrier, consistent, needs-based access to naloxone and that there is ample naloxone available within communities. While the remaining fifteen best practices were deemed important, they had more to do with organizational culture and implementation climate.ConclusionsIncreasing community-based OEND delivery is essential to reduce opioid overdose deaths; however, it will be insufficient to add programs without an eye toward quality of implementation and fidelity to the model upon which the evidence is based. This list of best practices summarizes the consensus among OEND experts and can serve as a tool for SSPs providing OEND programming to improve services.

Adaptive capacity in emergency food distribution: Pandemic pivots and possibilities for resilient communities in Colorado

The unprecedented circumstances of the COVID-19 pandemic have revealed weaknesses in our emergency food distribution programs and also highlighted the importance of the adaptive capacity that is actively fostered within such programs. Community-based food distribution programs have faced an increased reliance on their services due to record-breaking food insecurity since March 2020. Concurrently, these emergency food distribution programs have had to deal with the logistical chal­lenges of operating their programs during a pan­demic. How are they adapting, and which existing organizational assets have they been able to draw from and/or strengthen? Based on in-depth quali­tative research with emergency food distribution programs in Boulder and Denver, Colorado, this paper analyzes how their operational responses to the COVID-19 crisis both demonstrate and rein­force adaptive capacities. By drawing from collec­tive resources, leveraging the efficiency of their flexible and decentralized structures, and network­ing across organizations, the programs in our study took advantage of existing organizational assets. At the same time, we argue that by overcoming logisti­cal and practical barriers to address emerging food insecurity needs, they simultaneously deepened their adaptive capacities to respond to ongoing and future crises.

Factors associated with take-home naloxone kit usage in British Columbia: an analysis of administrative data

BackgroundThe British Columbia (BC) Take-Home Naloxone (THN) program provides naloxone to people at risk of experiencing or witnessing an opioid overdose for use in reversing suspected overdose events. This study seeks to examine trends and correlates of individuals obtaining a THN kit in BC between 2017 and 2020.MethodsRecords of THN kits distributed between 2017 and 2020 were the primary source of data for this analysis. Frequency tables were used to describe characteristics of people obtaining kits from THN sites. Correlates of individuals obtaining a THN kit to replace a previous kit reported as used to reverse an overdose were assessed with multivariate logistic regression.ResultsBetween January 1, 2017, and December 31, 2020, 240,606 THN kits were reported distributed by registered sites to members of the public, with 90,011 records indicating that a kit was obtained to replace a previous kit that had been used to reverse an overdose. There was a significant trend in increasing kits reported used by year (p < 0.01). The kit recipient’s risk of overdose was a significant predictor of having reported using a THN kit, and the strength of the association was dependent on gender (Male: Adjusted odds ratio (AOR) 5.37 [95% confidence interval (CI) 5.08 – 5.67]; Female: AOR 8.35 [95% CI 7.90 – 8.82]; Trans and gender expansive: AOR 3.68 [95% CI 2.82 – 4.79]).ConclusionsBetween 2017 and 2020, THN kits were used to reverse tens of thousands of overdose events in BC, with people at risk of overdose (i.e. people who use drugs [PWUD]) having greater odds of using a kit to reverse an overdose than those not at risk. Thus, PWUD are responsible for reversing the vast majority of overdoses. THN kits are being distributed to the people who use them most. However, additional strategies in conjunction with community-based naloxone distribution programs are needed to address the rising number of illicit drug toxicity deaths.

Community-based distribution of misoprostol for early abortion: Outcomes from a program in Sindh, Pakistan

ObjectiveTo evaluate the outcomes of a community-based distribution program in which lay providers offer women in Sindh, Pakistan misoprostol for early abortion. Study designWe reviewed monitoring logbooks to examine pregnancy outcomes and analyzed logbook data using descriptive statistics. ResultsIn late 2019, 120 women obtained abortion care through this program. None of the women (n = 0) were pregnant 4 weeks after initiating the regimen and none (n = 0) experienced complications requiring medical intervention. ConclusionsOutcomes from this initiative may be valuable for those working to expand access to misoprostol-alone for early abortion in other settings.

Impact of a community-based naloxone distribution program on opioid overdose death rates

BackgroundIn August 2013, a naloxone distribution program was implemented in North Carolina (NC). This study evaluated that program by quantifying the association between the program and county-level opioid overdose death (OOD) rates and conducting a cost-benefit analysis. MethodsOne-group pre-post design. Data included annual county-level counts of naloxone kits distributed from 2013 to 2016 and mortality data from 2000-2016. We used generalized estimating equations to estimate the association between cumulative rates of naloxone kits distributed and annual OOD rates. Costs included naloxone kit purchases and distribution costs; benefits were quantified as OODs avoided and monetized using a conservative value of a life. ResultsThe rate of OOD in counties with 1–100 cumulative naloxone kits distributed per 100,000 population was 0.90 times (95% CI: 0.78, 1.04) that of counties that had not received kits. In counties that received >100 cumulative kits per 100,000 population, the OOD rate was 0.88 times (95% CI: 0.76, 1.02) that of counties that had not received kits. By December 2016, an estimated 352 NC deaths were avoided by naloxone distribution (95% CI: 189, 580). On average, for every dollar spent on the program, there was $2742 of benefit due to OODs avoided (95% CI: $1,237, $4882). ConclusionsOur estimates suggest that community-based naloxone distribution is associated with lower OOD rates. The program generated substantial societal benefits due to averted OODs. States and communities should continue to support efforts to increase naloxone access, which may include reducing legal, financial, and normative barriers.

Lessons learned from a public sector community-based distribution program for scaling up DMPA-SC contraceptive services in Nigeria

Background: From August 2016 to December 2017, the United Nations Population Fund (UNFPA) in Nigeria, through three implementing partners, scaled up the public sector delivery of subcutaneous depot medroxyprogesterone acetate (DMPA-SC, brand name Sayana Press) across 10 states. The public sector program featured a proactive community-based distribution (CBD) model, led by community health extension workers (CHEWs) and supported by community health volunteers (CHVs). Methods: We conducted monitoring and evaluation (M&amp;E) alongside program implementation to understand the program’s reach, particularly in terms of clients served, and their proportions of new users of modern contraception and younger women. Key performance indicators (KPIs) were calculated from end-user data digitized from client registers. To evaluate performance trends over time and understand geographic variation, we analyzed quarterly data in Excel and Stata 15, and complemented these analyses with data from interviews conducted periodically with program staff and performance documentation submitted by implementing partners. Results: The program reached 144,505 clients, of whom 88% (n=127,315) were women. Among women reached, 92% (n=116,614) chose DMPA-SC. The program reached a high percentage of new users of modern contraception: 80% (n=93,075) of DMPA-SC clients were new users, as were 80% (n=111,350) of overall clients. However, only 26% (n=36,313) of clients were under 25. From performance reports and interviews with program staff, many involved credited the CBD model with reaching a client base largely comprised of new users of modern contraception. Conclusions: Our analysis of the Nigeria public sector DMPA-SC program suggests that the combination of DMPA-SC and proactive CBD may accelerate contraceptive uptake and reduce unmet need in Nigeria. While some strategies for increasing the cost-efficiency of the CBD emerged, future research on this delivery model should focus on key concerns about the modality’s sustainability.

Community-Based Antiretroviral Therapy (ART) Delivery for Female Sex Workers in Tanzania: 6-Month ART Initiation and Adherence

We conducted an implementation science study of a community-based ART distribution program for HIV-positive female sex workers (FSW) whereby clients received ART services through community-based mobile and home-based platforms. We compared 6-month treatment-related outcomes in the community-based ART arm (N = 256) to the standard facility-based ART delivery arm (N = 253). Those in the intervention arm were more likely to have initiated ART (100.0% vs. 71.5%; p = 0.04), be currently taking ART at the 6-month visit (100.0% vs. 95.0%; p < 0.01), and less likely to have stopped taking ART for more than 30 days continuously (0.9% vs. 5.7%; p = 0.008) or feel high levels of internalized stigma (26.6% vs. 39.9%; p = 0.001). In the adjusted regression model, internalized stigma (adjusted OR [aOR]: 0.5; 95% CI 0.28–0.83) and receiving community-based ART (aOR: 208.6; 95% CI 12.5–3479.0) were significantly associated with ART initiation. Community-based ART distribution model can improve linkage to and adherence to ART over standard facility-based ART programs for FSWs.

Translating Evidence into Policy Change: Advocacy for Community-Based Distribution of Injectable Contraceptives in Zambia

Community-based distribution (CBD) of injectable contraceptives has increased access to family planning for millions of women in rural areas in resource-limited settings. Despite the evidence of the success of this contraceptive delivery method, many nations have yet to integrate CBD into their family planning policies. The aim of this paper to describe the process through which PATH spearheaded efforts to successfully advocate for policy change to authorize non-clinical personnel in Zambia to provide injectable contraceptives. We describe a four-part framework for policy advocacy: (a) evidence building and technical assistance, (b) stakeholder engagement, (c) government engagement, and (d) knowledge dissemination. Advocacy for policy change to allow CBD of injectable contraceptives was long and iterative. Evidence to support advocacy efforts was built through a Zambian delegates’ study tour to Rwanda to witness Rwanda’s robust CBD program and a rapid assessment of Zambian pilot sites where non-clinical personnel were administering injectable contraceptives. Advocacy was led by PATH in partnership with key stakeholders from the Zambia Family Planning Technical Working Group (FPWTG), key government officials, and a special task force of stakeholders focused on advocating for CBD of injectable contraceptives. This task force used evidence from the study tour and rapid site assessment in national and international forums to demonstrate the beneficial effects of allowing non-clinical personnel to administer injectable contraceptives. The Zambian government authorized the policy change in 2016. The policy advocacy efforts of PATH, FPWTG, and the special task force demonstrate the need for an ample evidence base and sustained engagement of government and stakeholder groups.

Community-Based Response to Fentanyl Overdose Outbreak, San Francisco, 2015.

This report documents a successful intervention by a community-based naloxone distribution program in San Francisco. The program and its partner organizations, working with participants who use drugs, first identified the appearance of illicitly made fentanyl and increased outreach and naloxone distribution. Distribution of naloxone and reported use of naloxone to reverse opioid-involved overdoses increased significantly while the number of opioid-involved and fentanyl-involved overdose deaths did not. Community-based programs that provide training and naloxone to people who use drugs can serve as an early warning system for overdose risk and adaptively respond to the rapidly changing overdose risk environment.

Community-based distribution of iron-folic acid supplementation in low- and middle-income countries: a review of evidence and programme implications.

The present literature review aimed to review the evidence for community-based distribution (CBD) of iron-folic acid (IFA) supplementation as a feasible approach to improve anaemia rates in low- and middle-income countries. The literature review included peer-reviewed studies and grey literature from PubMed, Cochrane Library, LILAC and Scopus databases. Low- and middle-income countries. Non-pregnant women, pregnant women, and girls. CBD programmes had moderate success with midwives and community health workers (CHW) who counselled on health benefits and compliance with IFA supplementation. CHW were more likely to identify and reach a greater number of women earlier in pregnancy, as women tended to present late to antenatal care. CBD channels had greater consistency in terms of adequate supplies of IFA in comparison to clinics and vendors, who faced stock outages. Targeting women of reproductive age through school and community settings showed high compliance and demonstrated reductions in anaemia. CBD of IFA supplementation can be a valuable platform for improving knowledge about anaemia, addressing compliance and temporary side-effects of IFA supplements, and increasing access and coverage of IFA supplementation. Programmatic efforts focusing on community-based platforms should complement services and information provided at the health facility level. Provision of training and supportive supervision for CHW on how to counsel women on benefits, side-effects, and when, why, and how to take IFA supplements, as part of behaviour change communication, can be strengthened, alongside logistics and supply systems to ensure consistent supplies of IFA tablets at both the facility and community levels.

“It is just like having a period with back pain”: exploring women’s experiences with community-based distribution of misoprostol for early abortion on the Thailand–Burma border

IntroductionThe lack of economic development and longstanding conflict in Burma have led to mass population displacement. Unintended pregnancy and unsafe abortion are common and contribute to maternal death and disability. In 2011, stakeholders operating along the Thailand-Burma border established a community-based distribution program of misoprostol for early abortion, with the aim of providing safe and free abortion care in this low-resource and legally restricted setting. MethodsWe conducted 16 in-depth, in-person interviews with women from Burma residing on both sides of the border who accessed misoprostol through the community-based distribution initiative. We analyzed interviews for content and themes using deductive and inductive methods. ResultsOverall, women felt positively about their abortion experiences and the initiative. Previous abortion experiences and the recommendations of others shaped women's access. All participants, including those who remained pregnant after taking the misoprostol, would recommend the initiative to others. ConclusionCommunity-based distribution of misoprostol is an effective and culturally appropriate method of improving safe abortion care on the Thailand-Burma border. Supporting efforts to expand the harm reduction program to more communities and provide regular reproductive health and safe abortion trainings appears warranted. ImplicationsIn recent years, a number of organizations have launched programs dedicated to misoprostol-alone for early abortion. However, few have documented the experiences and perspectives of women. Our findings indicate providing misoprostol through lay provision in a legally restricted context is not only safe and effective but also culturally resonant.

Community-based distribution of misoprostol for early abortion: evaluation of a program along the Thailand–Burma border

BackgroundAlthough abortion is legal in Thailand for a number of indications, women from Burma residing in Thailand are rarely able to access safe services. We evaluated the outcomes of a community-based distribution program that provides migrant, refugee, and cross-border women from Burma with evidence-based information about and access to misoprostol for early pregnancy termination. MethodsAfter determination of eligibility based on self-report and counseling, trained Network members instructed women to vaginally administer two 800-mcg doses of misoprostol 24 h apart and a third dose one week later, if needed. We systematically reviewed data from monitoring logbooks recorded over a three-year period to examine pregnancy outcomes. We also conducted in-depth open-ended interviews with the three leaders of the two Networks to understand better their perceptions and experiences as providers and counselors. We analyzed logbook data using descriptive statistics and interviews for content and themes using both deductive and inductive techniques. ResultsFrom January 2012 through December 2014, 918 women received early abortion care using misoprostol through the community-based distribution program. Of these, 885 women (96.4%) were not pregnant at follow-up, 29 were pregnant at follow-up (3.2%), and four women were lost to follow-up (0.4%). Our interviews revealed that providers are motivated to participate due to concerns surrounding unsafe abortion in the community and frame their work as a public health intervention. ConclusionsThe documented outcomes from this initiative may be valuable for those working to reduce harm from unsafe abortion in other legally restricted, low-resource, and/or conflict-affected settings. ImplicationsOur findings demonstrate that community-based distribution of misoprostol can be a safe and effective strategy for increasing access to safe abortion, even in a legally restricted, low-resource setting. Determining if similar strategies can be successfully employed in other contexts appears warranted.

Providing free pregnancy test kits to community health workers increases distribution of contraceptives: results from an impact evaluation in Madagascar

ObjectivesTo improve access to contraceptives in remote and rural areas, sub-Saharan African countries are allowing community health workers (CHWs) to distribute hormonal contraceptives. Before offering hormonal contraceptives, CHWs must determine pregnancy status but often lack a reliable way to do so. No studies have evaluated the impact of providing CHWs with urine pregnancy test kits. We assessed the impact of giving CHWs free pregnancy test kits on the number of new clients purchasing hormonal contraceptives from CHWs. Study designWe implemented a randomized experiment in Eastern Madagascar among CHWs who sell injectable and oral hormonal contraceptives. A total of 622 CHWs were stratified by region and randomly assigned at the individual level. Treatment-group CHWs were given free pregnancy tests to distribute (n analyzed=272) and control-group CHWs did not receive the tests (n analyzed=263). We estimated an ordinary least-squares regression model, with the monthly number of new hormonal contraceptive clients per CHW as our primary outcome. ResultsWe find that providing CHWs with free pregnancy test kits increases the number of new hormonal contraceptive clients. Treatment-group CHWs provide hormonal contraceptives to 3.1 new clients per month, compared to 2.5 in the control group. This difference of 0.7 clients per month (95% confidence interval 0.13–1.18; p=.014) represents a 26% increase. ConclusionsGiving CHWs free pregnancy tests is an effective way to increase distribution of hormonal contraceptives. As pregnancy tests become increasingly affordable for health-care systems in developing countries, community-based distribution programs should consider including the tests as a low-cost addition to CHWs’ services. ImplicationsNo study has evaluated the impact of giving CHWs free urine pregnancy test kits for distribution to improve provision of hormonal contraceptives. Giving CHWs free pregnancy test kits significantly increases the number of clients to whom they sell hormonal contraceptives. Community-based distribution programs should consider including these tests among CHWs’ services.

Recommendations for scale-up of community-based misoprostol distribution programs

Community-based distribution of misoprostol for prevention of postpartum hemorrhage (PPH) in resource-poor settings has been shown to be safe and effective. However, global recommendations for prenatal distribution and monitoring within a community setting are not yet available. In order to successfully translate misoprostol and PPH research into policy and practice, several critical points must be considered. A focus on engaging the community, emphasizing the safe nature of community-based misoprostol distribution, supply chain management, effective distribution, coverage, and monitoring plans are essential elements to community-based misoprostol program introduction, expansion, or scale-up.

The challenge of promoting interventions to prevent disease in impoverished populations in rural western Kenya.

Poverty is a critical social determinant of health. A particular approach toward mitigating inequitable access to health services in Kenya has been through a community-based distribution program implemented by the Safe Water and AIDS Project (SWAP) that has achieved modest uptake of public health interventions. To explore reasons for modest uptake, we asked program participants about child health problems, daily tasks, household expenditures, and services needed by their communities. Respondents identified child health problems consistent with health data and reported daily tasks, expenses, and needed services that were more related to basic needs of life other than health. These findings highlight the challenges of implementing potentially self-sustaining preventive interventions at scale in poor populations in the developing world.

Community-Based Distribution of Injectable Contraceptives: Introduction Strategies in Four Sub-Saharan African Countries

Improving access to family planning services and expanding method choice are two fundamental proven strategies for increasing contraceptive prevalence in resource-poor settings.[1-4] Community-based family planning programs are designed to improve access by bringing services to hard-to-reach communities.[56] Such services are typically delivered by community health workers who are trained in family planning but lack formal clinical credentials. Working outside the health facility community health workers provide health education to promote family planning distribute contraceptives and refer clients for clinic-based services. For decades community-based distribution programs have been credited with expanding access to family planning services in otherwise underserved communities in Africa Asia and Latin America.[5].

Intravenous use of illicit buprenorphine/naloxone to reverse an acute heroin overdose

A case of heroin overdose reversed through the intravenous (IV) administration of a crushed sublingual tablet of buprenorphine/naloxone (Suboxone) by a lay responder is described. Although the sublingual administration of buprenorphine/naloxone to reverse an overdose has been reported elsewhere, this is the first report of IV administration. Healthcare professionals should be aware that injection drug users may respond to an opioid overdose by injecting buprenorphine/naloxone and should consequently counsel all opioid-using patients on the proper response to an overdose. Physicians should also consider prescribing naloxone to at-risk patients. The work of community-based naloxone distribution programs should be expanded.

Monitoring the Marketing, Distribution, and Use of Sprinkles Micronutrient Powders in Rural Western Kenya

In 2007, the US Centers for Disease Control and Prevention partnered with local Kenyan institutions to implement the Nyando Integrated Child Health and Education Project, an effectiveness study that used social marketing and a community-based distribution program to promote the sale of Sprinkles and other health products. To describe monitoring of wholesale sales, household demand, promotional strategies, and perceived factors influencing Sprinkles sales among vendors. Ongoing quantitative and qualitative monitoring of Sprinkles sales began in May 2007 in 30 intervention villages. Data sources included baseline and follow-up cross-sectional surveys; office records of Sprinkles sales to vendors; biweekly household monitoring of Sprinkles use; and qualitative data collection, including vendor focus groups and key informant interviews. A total of 550 children aged 6 to 35 months were enrolled at baseline, and 451 were available at 12-month follow-up. During this period, nearly 160,000 sachets were sold wholesale to vendors, with variability in sales influenced by the social, political, and economic context. Vendors living closer to the wholesale office purchased more Sprinkles, so a second office was opened closer to remote vendors. On average, 33% of households purchased Sprinkles during household monitoring visits. Training sessions and community launches were important for community support and raising awareness about Sprinkles. Vendor incentives motivated vendors to sell Sprinkles, and consumer incentives promoted purchases. Sprinkles program monitoring in Kenya was critically important for understanding sales and distribution trends and vendor perceptions. Understanding these trends led to strategic changes to the intervention over time.