Strengthening integration of family planning with HIV/AIDS and other services: Experience from three Kenyan cities

Background: Kenya has made remarkable progress in integrating a range of reproductive health services with HIV/AIDS services over the past decade. This study describes a sub-set of outcomes from the Bill & Melinda Gates Foundation (BMGF)-funded Jhpiego-led Kenya Urban Reproductive Health Initiative (Tupange) Project (2010-2015), specifically addressing strengthening family planning (FP) integration with a range of primary care services including HIV testing and counselling, HIV care services, and maternal, newborn and child care. Methods: A cross-sectional study was conducted between August and October 2013 in the cities of Mombasa, Nairobi and Kisumu in Kenya to assess the level of FP integration across six other service delivery areas (antenatal care clinic, maternity wards, postnatal care clinic, child welfare clinic, HIV testing and counseling (HTC) clinics, HIV/AIDS services in comprehensive care clinics). The variables of interest were level of integration, provider knowledge, and provider skills. Routine program monitoring data on workload was utilized for sampling, with additional data collected and analyzed from twenty health facilities selected for this study, along with client exit interviews. Descriptive analysis and Chi-square/ Fishers Exact tests were done to explore relationships between variables of interest. Results: Integration of FP occurred in all the five service areas to varying degrees. Service provider FP knowledge in four service delivery areas (HTC clinic, antenatal clinic, postnatal clinic, and child welfare clinic) increased with increasing levels of integration. Forty-seven percent of the clients reported that time spent accessing FP services in the HTC clinic was reasonable. However, no FP knowledge was reported from service providers in HIV/AIDS comprehensive care clinics in all levels of integration despite observed provision of counseling and referral for FP services. Conclusions: Integration of FP services in other primary care service areas including HTC clinic can be enhanced through targeted interventions at the facility. A holistic approach to address service providers’ capacity and attitudes, ensuring FP commodity security, and creating a supportive environment to accommodate service integration is necessary and recommended. Additional studies are necessary to identify ways of enhancing FP integration, particularly with HIV/AIDS care services. A cross sectional design was utilized. The Johns Hopkins School of Public Health IRB (IRB No. 4993) and the Kenyatta National Hospital / University of Nairobi (KNH/UON) Ethics Review Committee approved the study. The study was conducted between August and October 2013 in the three cities – Nairobi, Mombasa and Kisumu – as a component of the Bill & Melinda Gates Foundation (BMGF)-funded Jhpiego-led Kenya Urban Reproductive Health Initiative (Tupange) Project. The cities were selected on the basis that they accounted for over 50% of Kenya’s urban population of about 5 million, according to the 2009 Kenya Population and Housing Census [29]. Six service areas of interest were identified for assessment on service integration in the public and private health facilities. These areas are antenatal care (ANC) clinics, maternity wards, child welfare clinic (CWC), postnatal care (PNC) clinics, HIV/AIDS care services in comprehensive care clinics (CCCs), and HIV testing and counselling (HTC) clinics. The Tupange project was a five-year project (2010–2015), implemented by a consortium of five partners: Jhpiego; Center for Communication Programs (CCP); Marie Stopes International (MSI); National Council for Population and Development (NCPD); and Pharm Access Africa Limited (PAAL) [30]. The project was initiated at a time when the national health efforts were focused on provision of HIV and primary health care services to the rural population, leaving the FP needs of the urban poor inadequately addressed, despite the rapid urbanization of the major cities in Kenya [30]. Tupange’s goal was to increase contraceptive prevalence rate by 20 percentage points among the urban poor in five urban cities in Kenya [31]. The project implemented multiple interventions to strengthen health systems and improve access to quality FP services at the facility and community level by equipping facilities, and training and mentoring service providers. The Tupange project supported public and private health facilities through scheduled visits to facilities by a team of experts to enhance the uptake of long and permanent contraceptive methods, ensure FP commodity security, and advocate for increased resource allocation towards reproductive health services [31]. The Tupange project developed a Provider Initiated FP (PIFP) model (Fig. 1) where service providers actively initiated integrated discussions on FP and HIV/AIDS with the clients, counselled appropriately, and offered both FP method administration and HIV testing in an integrated manner. Tools to document FP integration in other service areas were incorporated in the routine reporting system and referral notes were used to refer clients within or outside the facility. The PIFP model is based on a continuum of FP service delivery across four levels (Fig. 1): Client referrals within and outside the facility was done to ensure that all clients received multiple services (as needed) in any single visit. Provider Initiated FP (PIFP) model Twenty of the 69 Tupange-supported high volume health facilities in three of the five Tupange cities were selected using probability proportionate to size sampling: nine in Nairobi, six in Mombasa, and five in Kisumu. The other two cities – Machakos and Kakamega – were scale-up sites thus not included in the first 2 years of the project. Criteria for selection was based on city, volume/workload, management category (hospital, clinic, health center), and managing authority/ownership (public/private/municipal). All of the facilities had a daily workload in all the service areas of approximately 50–100 clients based on data gathered for the 6 months preceding the survey. At participating health facilities, between five to six providers were selected for interview, one from each service areas of interest. All service providers in the 20 health facilities working in the six service areas were eligible to participate. Whenever there was more than one eligible service provider, the in-charge was selected and approached to participate. Two clients aged 15–54 years seeking services at any of the six service areas in 20 health facilities were selected through systematic sampling at the end of the visit for client exit interview at the respective service areas. Every fifth client was selected as this sampling technique provided research assistants (RAs) adequate time to complete the interview and embark on another one while at the same time limiting selection bias. Integration study data was collected by trained RAs between August and October 2013. The interview tools for each service area comprised of mixed (open and closed ended) questions on demographics, FP knowledge, experiences providing FP services, barriers to FP provision, and perceptions on how long it took clients to access services at the various service delivery points. Every client participating in the study was asked about the FP information and counselling they received from service providers during the visit, as well as their perspective of waiting time and integration of services. Overall, the data collection period for both service providers and clients lasted for 2 months. Interviews were conducted in locations within the facility where audio and visual privacy was guaranteed. Written consent to participate was obtained from all study participants. The study investigators defined levels of service integration as follows: Category 0: No integration; Category 1: Provision of FP information, education and communication (IEC) materials and counselling only and referral; and Category 2: FP counselling and provision of short-term and long-term methods. Short term methods are a range of contraceptive methods that are user dependent and need to be taken on a daily, weekly or monthly basis, and include all FP methods other than the long acting and reversible contraceptives (such as Intrauterine devices and contraceptive implants) and permanent methods. Descriptive statistics were used to summarize categorical data through counts and frequencies. Comparison of the following components in the three levels of integration was done: level of service FP knowledge, training and skills, and barriers to FP service provision. Chi-squared and Fisher’s Exact Tests were used to elucidate differences between, with a p-value significance level of < 0.05.