Acceptability and feasibility of community-based provision of urine pregnancy tests to support linkages to reproductive health services in Western Kenya: a qualitative analysis

Background: The majority of women living in rural Kenya access antenatal care (ANC) late in pregnancy, and approximately 20% have an unmet need for family planning (FP). This study aimed to determine whether training community health volunteers (CHVs) to deliver urine pregnancy testing (UPT), post-test counselling, and referral to care was an acceptable and feasible intervention to support timely initiation of ANC and uptake of FP. Methods: We applied community-based participatory methods to design and implement the pilot intervention between July 2018 and May 2019. We conducted qualitative content analysis of 12 pre-intervention focus group discussions (FGDs) with women, men, and CHVs, and of 4 post-intervention FGDs with CHVs, each with 7–9 participants per FGD group. Using a pragmatic approach, we conducted inductive line-by-line coding to generate themes and subthemes describing factors that positively or negatively contributed to the intervention’s acceptability and feasibility, in terms of participants’ views and the intervention aims. Results: We found that CHV-delivered point of care UPT, post-test counselling, and referral to care was an acceptable and feasible intervention to increase uptake of ANC, FP, and other reproductive healthcare services. Factors that contributed to acceptability were: (1) CHV-delivery made UPT more accessible; (2) UPT and counselling supported women and men to build knowledge and make informed choices, although not necessarily for women with unwanted pregnancies interested in abortion; (3) CHVs were generally trusted to provide counselling, and alternative counselling providers were available according to participant preference. A factor that enhanced the feasibility of CHV delivering UPT and counselling was CHV’s access to appropriate supplies (e.g. carrying bags). However, factors that detracted from the feasibility of women actually accessing referral services after UPT and counselling included (1) downstream barriers like cost of travel, and (2) some male community members’ negative attitudes toward FP. Finally, improved financial, educational, and professional supports for CHVs would be needed to make the intervention acceptable and feasible in the long-term. Conclusion: Training CHVs in rural western Kenya to deliver UPT, post-test counselling, and referral to care was acceptable and feasible to men, women, and CHVs in this context, and may promote early initiation of ANC and uptake of FP. Additional qualitative work is needed to explore implementation challenges, including issues related to unwanted pregnancies and abortion, the financial burden of volunteerism on CHVs, and educational and professional supports for CHVs. The pilot intervention was implemented in Port Victoria and Turbo, two rural communities in western Kenya. Port Victoria is located in Busia County, with a population of 893,681 [12]. Almost 90% of Busia’s population lives in rural areas [13], and less than 40% of the population owns a mobile phone [14]. Turbo is located in Uasin Gishu County, with a population of 1,163,186 [12]. Fifty-six percent of Turbo’s population lives in rural areas [13], and 51.4% of the population owns a mobile phone [14]. Health services in both Port Victoria and Turbo are available through the Academic Model Providing Access to Healthcare (AMPATH), an academic, public, and private partnership led by Moi University Medical School that provides comprehensive population health services to over 8 million people across 800 care sites in Western Kenya [15]. We used community-based participatory methods to design, pilot, and evaluate the feasibility and acceptability of an intervention where CHVs delivered UPT, offered post-test counselling, and provided women with referrals to ANC, FP, and other reproductive healthcare services. The pilot benefited from pre-existing relationships between CHVs in the community and the research team through the established CHV maternal health program at AMPATH. The design, pilot implementation, and evaluation process is outlined below in 7 steps (Fig. 1). From July to November 2018, we conducted 12 pre-intervention focus group discussions (FGDs) with CHVs, women, and men to guide intervention planning. We analyzed data from the pre-intervention FGDs using the DEPICT model for collaborative coding developed for participatory research (Fig. 1, steps 3–6) [16]. Each transcript was read by at least two team members (CB, ACD, CK, VN, JT, and FY). The team met for two sessions to discuss the data and design a concept map and preliminary code book. The team presented the concept map to the CHVs and elicited their feedback through journey-mapping. Journey mapping is a design technique that has been used elsewhere in healthcare to explore patient experiences and engage diverse stakeholders in intervention design [17]. CHVs worked through journey maps of potential clients’ experiences accessing UPT (for example, an adolescent who is sexually active and seeking UPT without her parents knowledge, an older woman with HIV, and a young woman who had been raped) to explore issues that might guide intervention design and implementation. Intervention design process Pilot implementation took place between December 2018 and May 2019. Fifteen CHVs in each community were recruited from the established AMPATH CHV program to participate in the pilot. CHVs were informed about the aims of the research study and that as part of the study they would receive training on how to deliver UPT, time UPT appropriately after menstruation, interpret UPT results, and provide post-test counselling and referral. Training also included instruction on topics requested by CHVs, including how to provide counselling to participants who had experienced rape, stigma, sexually transmitted infections, and infertility. CHVs informed women in the community about the opportunity to receive free point of care UPT, and offered enrolment in the study to women who wanted UPT and/or who described signs or symptoms associated with pregnancy at a CHV visit. Women who chose to enrol were contacted by the study research assistant, who explained the study procedures and obtained verbal consent over the phone. Women who declined to enrol in the study were still able to receive free UPT and post-test counselling and referral. Women who consented to enrol completed a pre-UPT survey which collected demographic information and their reasons for seeking UPT. They agreed to be contacted by study staff to complete a survey on access to care post-UPT. Quantitative data on participant demographics and outcomes are reported separately. CHVs provided participants with a UPT (see Fig. 2). Women were given the options of: urinating in a cup and performing the test with assistance from the CHV, or performing the test herself privately then returning to the CHV to discuss the results. Image of the urine pregnancy test kit, front and back Participants were given the choice between two methods of post-test counselling: counselling from the CHV in-person, or from a study staff member by telephone. Counselling focused on linking to the appropriate reproductive health service(s), including ANC, FP, infertility care, and more. Abortion is not legal in Kenya except in certain circumstances, for example, if the life or health of the mother is in danger [18], and access to safe abortion services is limited. For information on safe, legal abortion care, CHVs were trained to refer women to a study staff via a confidential telephone number. This study was approved by the Moi University/Moi Teaching and Referral Hospital Institutional Review and Ethics Committee, the Indiana University Institutional Review Board, and the Kenyan National Commission for Science Technology and Innovation (NACOSTI). We also received permission to run the intervention in Busia and Uasin Gishu Counties from County Health Team leaders. Participants in the FGDs and community-based participatory activities (journey mapping, see Fig. 1) gave written informed consent. Participants who received UPT in the pilot intervention gave verbal informed consent. To protect participant privacy, no identifying information was included in transcripts during data analyses. Furthermore, study findings were shared with stakeholders, beginning with the communities who participated in the research. All methods were carried out in accordance with relevant guidelines and regulations. This study includes qualitative data collected in pre-intervention FGDs (6 per location; 2 with CHVs, 2 with women, and 2 with men), and post-intervention FGDs (2 per location with CHVs who delivered the intervention). Invitations to join the FGDs were spread via announcements to CHVs and word of mouth. Each FGD included 7–9 participants recruited via convenience sampling and was moderated by experienced facilitators including the author CK. Some FGDs were observed by authors CB or JT. FGD participants were informed about the aims of the study and that their comments would contribute to implementation and evaluation of the UPT pilot. FGDs were conducted in community health centers and lasted two to three hours. Pre-intervention FGDs focused on questions about the acceptability of CHV-delivered UPT, counselling, and referral; potential barriers; acceptability and feasibility of phone-based and in-person modes of post-test counselling; and factors that might affect linkage to care post-UPT. Post-intervention FGDs explored the experiences of CHVs who delivered the intervention. FGDs were guided by a moderator using FGD guides available in Additional file 1. Discussions were held in Kiswahili and audio-recorded, then professionally transcribed and translated into English. We took a pragmatist orientation to qualitative content analysis. A pragmatist approach, as described by Patton et. al., is characterized by an emphasis on experience, outcomes of action, and shared beliefs, without defining a particular perspective on the nature of reality or truth [19]. Qualitative content analysis is a descriptive methodology for searching out, describing, and contextualizing meaning within a text [20]. Acceptability was operationalized as community members’ willingness to access UPT and CHVs’ willingness to provide UPT in a way that met the program’s aim of increasing uptake of ANC, FP, and other reproductive healthcare services. Feasibility was operationalized as community members’ ability to use UPT, and CHVs’ ability to provide UPT, in a way that met the program’s intended aim of increasing uptake of ANC, FP, and other reproductive health services. Coding focused on identifying factors that affected acceptability and feasibility. Codes representing similar ideas were collected together into themes and sub-themes and sorted by whether they affected acceptability, feasibility, or both [21]. As described above, team members (CB, ACD, CK, VN, JT, and FY) inductively coded pre-intervention FGD transcripts and developed a concept map and code book. For the post-intervention FGDs, MK coded the transcripts using the code book and developed additional inductive codes, and the team met to review codes, themes, and subthemes. MK then re-coded the pre- and post-intervention transcripts using a finalized codebook, and CK checked codes, themes, and subthemes by coding a sample of transcripts. Codes, themes, and subthemes were discussed and reviewed by the team at meetings throughout the coding process and discrepancies were resolved by discussion. MK kept reflexive memos throughout coding. Reflexive memos and discussions addressed that the authors as Canadian, Kenyan, American researchers are to varying degrees structurally and socially distant from the participants, and that biases about approaches to certain topics, for example, termination of pregnancy or reproductive healthcare for adolescents, may differ within the research team and between the research team and participants. Discussions and memos focused on attempting to stay close to the data in our descriptions and interpretation. We used NVIVO 12 software for data management. Please also see the COREQ checklist for this study included in Additional file 2.