Vaccination Visits Research Articles

A collaborative approach to developing sustainable behaviour change interventions for childhood obesity prevention: Development of the Choosing Healthy Eating for Infant Health (CHErIsH) intervention and implementation strategy.

There is growing recognition of the need for effective behaviour change interventions to prevent chronic diseases that are feasible and sustainable and can be implemented within routine health care systems. Focusing on implementation from the outset of intervention development, and incorporating multiple stakeholder perspectives to achieve this, is therefore essential. This study explores the development of the Choosing Healthy Eating for Infant Health (CHErIsH) childhood obesity prevention intervention and implementation strategy to improve infant feeding behaviours. Five qualitative and quantitative evidence syntheses, two primary qualitative studies, and formal/informal consultations were conducted with practice, policy, research, and parent stakeholders. The Behaviour Change Wheel was used to guide the integration of findings. The CHErIsH intervention targets parent-level behaviour change and comprises (1) brief verbal messages and (2) trustworthy resources, to be delivered by health care professionals (HCPs) during routine infant vaccination visits. The implementation strategy targets HCP-level behaviour change and comprises (1) a local opinion leader, (2) incentivized training, (3) HCP resources and educational materials, (4) electronic delivery prompts, (5) awareness-raising across all primary care HCPs, and (6) local technical support. This study provides a rigorous example of the development of an evidence-based intervention aimed at improving parental infant feeding behaviours, alongside an evidence-based behaviour change strategy to facilitate implementation and sustainability in primary care. This approach demonstrates how to systematically incorporate multiple stakeholder perspectives with existing literature and move from multiple evidence sources to clearly specified intervention components for both the intervention and implementation strategy. Statement of Contribution What is already known? Incorporating insights from practice, policy, and public/patient stakeholders plays a key role in developing behaviour change interventions that are feasible and sustainable and can be implemented within routine health care systems. However, there are limited examples that provide in-depth guidance of how to do this using a systematic approach. What this study adds? This study describes an innovative use of the Behaviour Change Wheel to integrate multiple sources of evidence collected from practice, policy, research, and parent stakeholders to concurrently develop an evidence-based intervention to improve parental infant feeding behaviours and an implementation strategy to facilitate sustainable delivery by health care professionals in routine primary care.

The use of natural language processing to identify vaccine-related anaphylaxis at five health care systems in the Vaccine Safety Datalink.

The objective was to develop a natural language processing (NLP) algorithm to identify vaccine-related anaphylaxis from plain-text clinical notes, and to implement the algorithm at five health care systems in the Vaccine Safety Datalink. The NLP algorithm was developed using an internal NLP tool and training dataset of 311 potential anaphylaxis cases from Kaiser Permanente Southern California (KPSC). We applied the algorithm to the notes of another 731 potential cases (423 from KPSC; 308 from other sites) with relevant codes (ICD-9-CM diagnosis codes for anaphylaxis, vaccine adverse reactions, and allergic reactions; Healthcare Common Procedure Coding System codes for epinephrine administration). NLP results were compared against a reference standard of chart reviewed and adjudicated cases. The algorithm was then separately applied to the notes of 6 427 359 KPSC vaccination visits (9 402 194 vaccine doses) without relevant codes. At KPSC, NLP identified 12 of 16 true vaccine-related cases and achieved a sensitivity of 75.0%, specificity of 98.5%, positive predictive value (PPV) of 66.7%, and negative predictive value of 99.0% when applied to notes of patients with relevant diagnosis codes. NLP did not identify the five true cases at other sites. When NLP was applied to the notes of KPSC patients without relevant codes, it captured eight additional true cases confirmed by chart review and adjudication. The current study demonstrated the potential to apply rule-based NLP algorithms to clinical notes to identify anaphylaxis cases. Increasing the size of training data, including clinical notes from all participating study sites in the training data, and preprocessing the clinical notes to handle special characters could improve the performance of the NLP algorithms. We recommend adding an NLP process followed by manual chart review in future vaccine safety studies to improve sensitivity and efficiency.

Effect of mobile phone text message reminders on improving completeness and timeliness of routine childhood vaccinations in North-West, Ethiopia: a study protocol for randomised controlled trial

IntroductionNon-attendance and delay in vaccination schedules remain a big challenge to healthcare workers. With the continuous growth of mobile network coverage and exponential penetration of mobile devices in the developing...

Home-based records and vaccination appointment stickers as parental reminders to reduce vaccination dropout in Indonesia: A cluster-randomized controlled trial

IntroductionLimited evidence is available about the effectiveness of strategies to remind caregivers when to bring children back for future vaccinations in low- and middle-income country settings. We evaluated the effectiveness of two reminder strategies based on home-based vaccination records (HBR) in Indonesia. MethodsIn this cluster-randomized controlled trial involving 3616 children <1 year of age, 90 health facilities were randomly assigned to either a control group or one of two intervention groups: (1) HBR-only group, where healthcare workers provided an HBR to any child without an HBR during a vaccination visit and instructed the caregiver to keep it at home between visits, or (2) HBR + sticker group, where, in addition to HBR provision, healthcare workers placed vaccination appointment reminder stickers on the HBR. The primary outcome was receipt of the third dose of diphtheria-tetanus-pertussis-containing vaccine (DTPcv3) within 7 months and the secondary outcome was receipt of a timely DTPcv3 dose. ResultsControl group DTPcv3 coverage was 81%. In intention-to-treat analysis, neither intervention group had significantly different DTPcv3 coverage compared with the control group (RR = 0.94, 95% confidence interval [CI] 0.87; 1.02 for HBR-only group; RR = 0.97, 95% CI 0.90; 1.04 for HBR + sticker group) by study end. However, children in the HBR + sticker group were 50% more likely to have received a DTPcv3 vaccination (RR = 1.46, 95% CI 1.02, 2.09) within 60 days of DTPcv1 vaccination, compared with children in the control group; children in the HBR-only group were not more likely to have done so (RR = 1.05, 95% CI 0.71, 1.55). DiscussionReminder stickers had an immediate effect on coverage by improving the proportion of children who received a timely DTPcv3 dose but no effect on the proportion who received DTPcv3 after 7 months. Coupling reminder stickers with strategies to address other reasons why children do not return for vaccination visits should be further explored.

Accessible metrics of access: Novel tools to measure immunization coverage in rural sub-Saharan Africa

Immunization rates in most sub-Saharan African countries fall far below stated targets. Measuring access in resource-limited settings, however, is challenging, especially with the data available at the district level, which is the primary administrative division for most immunization programs. Despite calls to improve routine data collection and use, there remains a lack of structured methods and practical tools to target underserved populations. Herein, we describe a prospective study that aims to develop, pilot, and validate a set of user-friendly tools to identify geographic areas with limited access to immunization services and by extension, low immunization coverage. The approach will leverage routinely-collected data from public health facilities combined with novel methods of household mapping to perform spatial analyses using open-access platforms. In addition, we will triangulate the analyses across datasets representing common reasons for care seeking – namely, visits for vaccination, antenatal care, and malaria – to improve the accuracy of our estimates. The ultimate goal of this project is to equip front-line providers and district level program managers with novel tools that facilitate timely and accurate analysis of routinely-collected data to guide immunization efforts.

Text message reminders to improve infant immunization in Guatemala: A randomized clinical trial

ObjectiveMillions of infants worldwide remain under-immunized and at risk for unnecessary morbidity and mortality. Text messaging may offer a low-cost solution. We aimed to evaluate text message reminders to improve infant immunization in Guatemala. MethodsA randomized clinical trial was conducted at four public health clinics in rural and urban Guatemala. Infants ages six weeks to six months presenting for the first visit of the primary immunization series were randomly and equally allocated to an intervention or usual care group. Intervention participants were sent three text reminders before the second and third vaccine visits. The main outcome was timeliness of the second and third visits of the primary immunization series. ResultsOf 1088 families approached for enrollment between March to November 2016, 871 were eligible and 720 (82.7%) participated; only 54 families did not own a cell phone. Due to country-wide vaccine shortages, visit completion was used as a proxy for overall immunization coverage. In intention to treat analysis, both intervention and usual care groups had high rates of visit completion, but intervention participants presented on the scheduled date more often (151 [42.2%] of 358 intervention vs. 111 [30.7%] of 362 usual care participants for visit 2, p = 0.001, and 112 [34.0%] of 329 intervention vs. 90 [27.0%] of 333 usual care participants for visit 3, p = 0.05). Intervention caregivers were significantly more likely to want to receive future text message reminders for vaccines and other appointments and were more willing to pay for these reminders. ConclusionCaregivers who were sent text message reminders in urban and rural Guatemala were less delayed for their child’s immunization visits and reported high user satisfaction. Text message reminders may be an effective tool to increase infant vaccination coverage in low-income settings by reminding parents to vaccinate.Trial Registration: NCT02567006 at clinicaltrials.gov.

Determinants of timeliness in early childhood vaccination among mothers with vaccination cards in Sindh province, Pakistan: a secondary analysis of cross-sectional survey data

ObjectiveUntimely vaccination refers to receiving the given dose before (early) or after (delayed) the recommended time window. The purpose of this study was to assess the extent of timeliness of...

Choosing Healthy Eating for Infant Health (CHErIsH) study: protocol for a feasibility study

IntroductionChildhood obesity is a public health challenge. There is evidence for associations between parents’ feeding behaviours and childhood obesity risk. Primary care provides a unique opportunity for delivery of infant...

The use and significance of vaccination cards

ABSTRACT Vaccination cards are useful health records that contain information about vaccination dates and dosage. This information is helpful for parents, vaccination providers, and public health researchers. However, as they currently are structured, many vaccination cards are very difficult to read by non-experts, like parents, and even by health-care providers. Many families also lose these vaccination cards; among the top 10 countries with the most unvaccinated children, the proportion of families who were able to find their vaccination cards and give them to researchers was low, ranging from 20.7% in the Democratic Republic of the Congo to 69.2% in South Africa. Moreover, some families report that not having a vaccination card during a vaccination visit resulted in them being unable to obtain a vaccine (8% in one study in Ethiopia and 16% in one study in Bangladesh). This commentary provides recommendations about how vaccination cards should be used by parents, health-care providers, and researchers, and comments on their continued relevance in an era with increased use of electronic registries.

Trends and Characteristics of Security Incidents Involving Aid Workers in Health Care Settings: A 20-Year Review.

In recent years, several high-profile attacks on hospitals providing medical aid in conflict settings have raised international concern. The International Humanitarian Law prohibits the deliberate targeting of health care settings. Violation of this law is considered a war crime and impacts both those delivering and receiving medical aid. While it has been demonstrated that both aid workers and health care settings are increasingly being targeted, little is known about the trends and characteristics of security incidents involving aid workers in health care compared to non-health care settings. Data from the publicly available Aid Worker Security Database (AWSD) containing security incidents involving humanitarian aid workers world-wide were used in this study. The security incidents occurring from January 1, 1997 through December 31, 2016 were classified by two independent reviewers as having occurred in health care and non-health care settings, and those in health care settings were further classified into five categories (hospital, health clinic, mobile clinic, ambulance, and vaccination visit) for the analysis. A stratified descriptive analysis, χ2 Goodness of Fit test, and Cochran-Armitage test for trend were used to examine and compare security incidents occurring in health care and non-health care settings. Among the 2,139 security incidents involving 4,112 aid workers listed in the AWSD during the study period, 74 and 2,065 incidents were in health care settings and non-health care settings, respectively. There was a nine-fold increase from five to 45 incidents in health care settings (χ2 = 56.27; P &lt; .001), and a five-fold increase from 159 to 852 incidents in non-health care settings (χ2 = 591.55; P &lt; .001), from Period 1 (1997-2001) to Period 4 (2012-2016). Of the 74 incidents in health care settings, 23 (31.1%) occurred in ambulances, 15 (20.3%) in hospitals, 13 (17.6%) in health clinics, 13 (17.6%) during vaccination visits, and six (8.1%) in mobile clinics. Bombings were the most common means of attack in hospitals (N = 9; 60.0%), followed by gun attacks (N = 3; 20.0%). In health care settings, 184 (95.3%) were national staff and nine (4.7%) were international staff. Security threats are a growing occupational health hazard for aid workers, especially those working in health care settings. There is a need for high-quality data from the field to better monitor the rapidly changing security situation and improve counter-strategies so aid workers can serve those in need without having to sacrifice their lives.

PIN18 COSTS OF ADULT VACCINATION IN MEDICAL SETTINGS AND PHARMACIES: AN OBSERVATIONAL STUDY

Vaccination is known to prevent diseases, yet factors such as vaccination costs cause uptake rates to remain low, especially among adults. The objective of the study was to examine whether the average direct healthcare costs of receiving adult vaccination differs between various settings. This is a retrospective observational cross-sectional study using MarketScan® Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits Databases. Individuals at least 19 years of age on the vaccination date of pneumococcal or flu vaccine and at least 60 years of age on the vaccination date of zoster vaccine were identified using both the medical and pharmacy claims and were required to have continuous enrollment for at least 365 days before and 60 days after the vaccination date. The selection period was January 1, 2015-December 31, 2015. Primary study outcome for each vaccine was the average vaccination costs, which included the total cost for the vaccine, administration cost and physician visit fee. Results were stratified by vaccination setting, geographic region, and health plan. Of those receiving pneumococcal conjugate, pneumococcal polysaccharide, zoster, or influenza vaccines, approximately 7%, 6%, 52%, and 27%, respectively, received them at a pharmacy compared to approximately 81%, 83%, 44%, and 62%, respectively, receiving them at physician offices. Overall, the mean (SD) total costs per vaccine administration at physician offices, pharmacies, and other medical settings were as follows: pneumococcal conjugate vaccination: $183.40 ($63.29), $170.83 ($18.44), and $166.74 ($103.88), respectively; pneumococcal polysaccharide vaccination: $97.50 ($37.64), $88.02 ($13.68), $107.56 ($91.23) respectively; zoster vaccination: $231.06 ($45.49), $204.79 ($16.61), and $211.15 ($62.16), respectively; and influenza vaccination: $41.09 ($26.62), $27.60 ($7.87), and $30.84 ($30.63), respectively. The mean commercial direct costs per adult vaccination were lower in pharmacies compared with physician offices. Education on vaccine administration in the pharmacy is needed to help reduce vaccination cost for adults.

Development of an Intervention to Reduce Pain and Prevent Syncope Related to Adolescent Vaccination.

There is a lack of research into the perspectives of patients, parents, and clinicians regarding strategies for vaccine-related pain and syncope prevention that may improve the adolescent vaccination experience and encourage future vaccination. To develop an intervention on the basis of preference for strategies to reduce pain and prevent syncope associated with adolescent vaccination. We conducted focus groups and interviews with 8 recently vaccinated Kaiser Permanente Northwest (KPNW) members aged 11 to 17 years and their parents to explore perceptions of pain and syncope after vaccination as well as receptivity to potential interventions. Additionally, we interviewed 7 clinical staff who routinely vaccinate children. We conducted content analysis to identify promising interventions and conducted a data synthesis workshop to select a final intervention for piloting. All participants expressed willingness to use previsit education, breathing exercises, social support or distraction, and water consumption. Patients and parents expressed a need for verbal education and messaging about potential vaccine-related outcomes, and clinicians noted a need to identify patients who are anxious before a vaccination visit. Most participants suggested a "comfort menu" intervention, to include comfort and distraction items that medical staff offer adolescents before and during vaccination. Patients, parents, and clinicians acknowledged the value of interventions to reduce pain and syncope after adolescent vaccination. Stakeholders identified a comfort menu as the intervention to be piloted at 2 KPNW pediatric clinics. Further research is needed to test the effectiveness of the "Vaccination Comfort Menu" intervention in improving vaccination experiences and continued receipt of vaccinations.

Evaluation of a multi-level intervention to improve postpartum intrauterine device services in Rwanda

Background. The copper intrauterine device is one of the most safe, effective, and cost-effective methods for preventing unintended pregnancy. It can be used postpartum irrespective of breastfeeding to improve birth spacing and reduce unintended pregnancy and maternal-child mortality. However, this method remains highly underutilized. Methods. We developed a multi-level intervention to increase uptake of the postpartum intrauterine device (PPIUD, defined as insertion up to six weeks post-delivery) in Kigali, Rwanda. High-volume hospitals and health centers were selected for implementation of PPIUD counseling and service delivery. Formative work informed development of a PPIUD counseling flipchart to be delivered during antenatal care, labor and delivery, infant vaccination visits, or in the community. Two-day didactic counseling, insertion/removal, and follow-up trainings were provided to labor and delivery and family planning nurses followed by a mentored practicum certification process. Counseling data were collected in government clinic logbooks. Insertions and follow-up data were collected in logbooks created for the implementation. Data were collected by trained government clinic staff and abstracted/managed by study staff. Stakeholders were involved from intervention development through dissemination of results. Results. Two hospitals (and their two associated health centers) and two additional health centers were selected. In 6-months prior to our intervention, 7.7 PPIUDs/month were inserted on average at the selected facilities. From August 2017-July 2018, we trained 83 counselors and 39 providers to provide PPIUD services. N=9,020 women received one-on-one PPIUD counseling after expressing interest in family planning who later delivered at a selected health facility. Of those, n=2,575 had PPIUDs inserted (average of 214.6 insertions/month), a 29% uptake. Most PPIUDs (62%) were inserted within 10 minutes of delivery of the placenta. Conclusions. This successful, comprehensive intervention has the potential to make a significant impact on PPIUD uptake in Rwanda. The intervention is scalable and adaptable to other sub-Saharan African countries.

Can vaccination coverage be improved by reducing missed opportunities for vaccination? Findings from assessments in Chad and Malawi using the new WHO methodology.

BackgroundIn 2015, the World Health Organization (WHO) updated the global methodology for assessing and reducing missed opportunities for vaccination (MOV), when eligible children have contact with the health system but are not vaccinated. This paper presents the results of two pilot assessments conducted in Chad and Malawi.MethodsUsing the ten-step global WHO MOV strategy, we purposively selected districts and health facilities, with non-probabilistic sampling of <24 month old children for exit interviews of caregivers and self-administered knowledge, attitudes, and practices (KAP) surveys of health workers. MOV were calculated based on a child’s documented vaccination history (i.e., from a home-based record (HBR) or a health facility vaccination register), including selected vaccines in the national schedule.ResultsRespondents included caregivers of 353 children in Chad and of 580 children in Malawi. Among those with documented vaccination history, 82% (195/238) were eligible for vaccination in Chad and 47% (225/483) in Malawi. Among eligible children, 51% (99/195) in Chad, and 66% (149/225) in Malawi had one or more MOV on the survey date. During non-vaccination visits, 77% (24/31) of children eligible for vaccination in Chad and 92% (119/129) in Malawi had a MOV compared to 46% (75/164) and 31% (30/96) during vaccination visits, respectively. Among health workers, 92% in Chad and 88% in Malawi were unable to correctly identify valid contraindications for vaccination.ConclusionThe new MOV tool was able to characterize the type and potential causes of MOV. In both countries, the findings of the assessments point to two major barriers to full vaccination of eligible children—a lack of coordination between vaccination and curative health services and incomplete vaccination during vaccination visits. National immunization programs should explore tailored efforts to improve health worker practices and to increase vaccine delivery by making better use of existing health service contacts.

Hair torniquet syndrome, an unusual presentation: A case report and review of literature

Introduction: Hair tourniquet syndrome is rare presentations that are not often encountered in orthopedic OPD’s. The syndrome was recognized long back but there have only been a few published reports in regard to the sequel it follows. The usual case presentation was an infant that had been crying in an inconsolable manner and upon careful examination was found to have a digit or a body part entangled by a hair or a textile thread causing a tourniquet like effect but our case was unique as it was an incidental finding. Case Report: This case reports a 5 months old healthy female child that was accidentally found to have a hair wrapped around her left fourth toe on her regular routine vaccination visit. Conclusion: This presentation is quite different than the presentation usually encountered or those presented previously in literature. The diagnosis of the syndrome requires a high index of suspicion, it may present a diagnostic dilemma therefore through awareness of the condition is important.

COVERAGE RATES OF ROUTINE VACCINATIONS AND THE POTENTIAL REASONS OF LOW COVERAGE FOR LIBYAN CHILDREN IN 2017: A CROSS-SECTIONAL STUDY

Background: Vaccinations are still important weapon in modern prevention programs. Limited studies were conducted to assess the childhood vaccination program in Libya. The study aimed to document the coverage rates of routine vaccinations and factors associated with low coverage rate in north-western region of Libya. Methods: A cross-sectional study was prospectively carried out to calculate the coverage rates of routine vaccinations for children aged from the birth to 18 months in Libya. The data were collected from vaccination cards of children who were seeking the vaccine at four public vaccination centers in big three cities located in north-western region of Libya. The data collected during the period from 11 Dec 2017 to 17 Mar 2018 from the vaccination centers. The centers were visited in 44 times for data collection using a questionnaire during the business days. Results: The study checked the vaccination cards of 916 children during the routine vaccination visit at the vaccination centers. Coverage rates of most vaccinations were high (more than 90%). The low coverage rates were found in rotavirus vaccine in second and third doses, 81.3% and 72.2% respectively as well as penta vaccine had a low coverage rate (69.4%). The timeliness of vaccination appointments was irregular in 64.2%. The major reasons of vaccination appointment delay were busy, no vaccine available and careless&#x0D; Conclusion: National childhood vaccination program is still in good performance. The regular supply of the vaccines and strengthen the parent's awareness for vaccination importance should be taken in the consideration to keep the program in good quality of service for high level of the immunity against vaccine preventable diseases.

Impact of vaccine delays at the 2, 4, 6 and 12\u2009month visits on incomplete vaccination status by 24\u2009months of age in Quebec, Canada

BackgroundTimeliness in the administration of recommended vaccines is often evaluated using vaccine delays and provides more information regarding the susceptibility of children to vaccine-preventable diseases compared with vaccine coverage at a given age. The importance of on-time administration of vaccines scheduled at the first visit is well documented, but data are scarce about the impact of vaccine delays at other visits on vaccination status by 24 months of age. Using vaccine delays for the first three doses of DTaP-containing vaccines and for the first dose of measles-containing vaccines as markers of timeliness at the 2, 4, 6 and 12 month visits, we estimated the proportion of incomplete vaccination status by 24 months of age attributable to a vaccine delay at each of these visits.MethodsWe used the data from six cross-sectional coverage surveys conducted in the Province of Quebec from 2006 to 2016 which included 7183 children randomly selected from the universal health insurance database. A vaccine dose was considered delayed if received 30 days or more after the recommended age. The impact of new vaccine delays at each visit on incomplete vaccination status by 24 months of age was estimated with the attributable risk in the population.ResultsThe proportion of children with vaccine delay was 5.4% at 2 months, 13.3% at 4 months, 23.1% at 6 months and 23.6% at 12 months. Overall, 72.5% of all 2-year-old children with an incomplete status by 24 months were attributable with a vaccine delay, of which 16.1% were attributable with a first vaccine delay at 2 months, 10.6% at 4 months, 14.0% at 6 months and 31.8% at 12 months.ConclusionsWhile great emphasis has been put on vaccine delays at the first vaccination visit, the prevalence of vaccine delays was greater with later visits and most children with an incomplete vaccination status by 24 months had a vaccine delay occurring during these later visits. Interventions to improve timeliness should address vaccine delays at each visit and not only focus on the first visit.

Maternal Education Is Inversely Related to Vaccination Delay among Infants and Toddlers

To determine the association between parents' level of education and delay in vaccination among infants and toddlers. A case-control study done in 2015-2016. Charts of 2- to 4-year-old children vaccinated in 5 neighborhood Maternal-Child Health Centers (MCHCs) in southern Israel were examined for demographic variables. Five vaccination opportunities between age 7 months and 18 months were selected to test for delays. In each MCHC, children vaccinated at the longest time-period after planned vaccination dose (fifth quintile) were compared with those vaccinated during the middle quintile. Using this relative delay approach rather than absolute delay approach permitted us to adjust the findings to the prevailing environmental and to cultural and programmatic variations between the various neighborhoods. Each of the planned vaccination visits and overall, demographic and health behavior-related variables that were significantly associated to delays by univariate analysis were tested by multivariate analysis and further adjusted by using stepwise logistic regression, using goodness of fit measures. Data for 2072 subjects were collected (398-426 per MCHC). Fathers' education was not associated with delays. In contrast, mothers' education was inversely associated with the probability of vaccination delay by 4%-9% (depending on the vaccination visit) for each year of schooling beyond 10 years. Using the relative delay approach, we demonstrated that maternal education, measured by schooling years, was independently inversely associated with risk of vaccination delay. This suggests that education can be regarded as an important positive component of the overall disease prevention planning at national and global levels.

Evaluation of a multi-level intervention to improve postpartum intrauterine device services in Rwanda.

Background. The copper intrauterine device is one of the most safe, effective, and cost-effective methods for preventing unintended pregnancy. It can be used postpartum irrespective of breastfeeding to improve birth spacing and reduce unintended pregnancy and maternal-child mortality. However, this method remains highly underutilized. Methods. We developed a multi-level intervention to increase uptake of the postpartum intrauterine device (PPIUD, defined as insertion up to six weeks post-delivery) in Kigali, Rwanda. High-volume hospitals and health centers were selected for implementation of PPIUD counseling and service delivery. Formative work informed development of a PPIUD counseling flipchart to be delivered during antenatal care, labor and delivery, infant vaccination visits, or in the community. Two-day didactic counseling, insertion/removal, and follow-up trainings were provided to labor and delivery and family planning nurses followed by a mentored practicum certification process. Counseling data were collected in government clinic logbooks. Insertions and follow-up data were collected in logbooks created for the implementation. Data were collected by trained government clinic staff and abstracted/managed by study staff. Stakeholders were involved from intervention development through dissemination of results. Results. Two hospitals (and their two associated health centers) and two additional health centers were selected. In 6-months prior to our intervention, 7.7 PPIUDs/month were inserted on average at the selected facilities. From August 2017-July 2018, we trained 83 counselors and 39 providers to provide PPIUD services. N=9,020 women received one-on-one PPIUD counseling after expressing interest in family planning who later delivered at a selected health facility. Of those, n=2,575 had PPIUDs inserted (average of 214.6 insertions/month), a 29% uptake. Most PPIUDs (62%) were inserted within 10 minutes of delivery of the placenta. Conclusions. This successful, comprehensive intervention has the potential to make a significant impact on PPIUD uptake in Rwanda. The intervention is scalable and adaptable to other sub-Saharan African countries.

Evaluation of a multi-level intervention to improve postpartum intrauterine device services in Rwanda

Background. The copper intrauterine device is one of the most safe, effective, and cost-effective methods for preventing unintended pregnancy. It can be used postpartum irrespective of breastfeeding to improve birth spacing and reduce unintended pregnancy and maternal-child mortality. However, this method remains highly underutilized. Methods. We developed a multi-level intervention to increase uptake of the postpartum intrauterine device (PPIUD, defined as insertion up to six weeks post-delivery) in Kigali, Rwanda. High-volume hospitals and health centers were selected for implementation of PPIUD counseling and service delivery. Formative work informed development of a PPIUD counseling flipchart to be delivered during antenatal care, labor and delivery, infant vaccination visits, or in the community. Two-day didactic counseling, insertion/removal, and follow-up trainings were provided to labor and delivery and family planning nurses followed by a mentored practicum certification process. Counseling data were collected in government clinic logbooks. Insertions and follow-up data were collected in logbooks created for the implementation. Data were collected by trained government clinic staff and abstracted/managed by study staff. Stakeholders were involved from intervention development through dissemination of results. Results. Two hospitals (and their two associated health centers) and two additional health centers were selected. In 6-months prior to our intervention, 7.7 PPIUDs/month were inserted on average at the selected facilities. From August 2017-July 2018, we trained 83 counselors and 39 providers to provide PPIUD services. N=9,020 women received one-on-one PPIUD counseling after expressing interest in family planning who later delivered at a selected health facility. Of those, n=2,575 had PPIUDs inserted (average of 214.6 insertions/month), a 29% uptake. Most PPIUDs (62%) were inserted within 10 minutes of delivery of the placenta. Conclusions. This successful, comprehensive intervention has the potential to make a significant impact on PPIUD uptake in Rwanda. The intervention is scalable and adaptable to other sub-Saharan African countries.