Evaluating the Integration of Family Planning and Voluntary Counseling and Testing in Kenya

Key Points

• Providing contraceptive services at VCT centers is an opportunity to prevent unintended pregnancies among clients whose needs may not be met through traditional family planning services.

• Operations research in Kenya suggests that integrating family planning into VCT services is feasible and acceptable.

• An integration  intervention improved providers' discussions about fertility desires and contraceptive methods with clients, without compromising the length of client-provider interaction or client waiting time.

• Although many VCT clients were considered  at risk of unintended pregnancy, the intervention had little effect on contraceptive method choice and distribution.

• Monitoring VCT quality of care and contraceptive choice, distribution, and uptake should persist as integration efforts continue.

Summary

Operations research by Family Health International (FHI) and partners to evaluate the integration of family planning into voluntary counseling and testing (VCT) in Kenya suggests that it is feasible and acceptable. The intervention in 14 VCT centers improved several aspects of family planning provision without compromising VCT services. However, although a large proportion of VCT clients were considered at risk of unintended pregnancy, the intervention had little effect on contraceptive method choice or distribution. Advocacy and training activities should stress the importance of screening VCT clients for risk of unintended pregnancy with the goal of reducing unmet contraceptive need. VCT quality of care and contraceptive method choice, distribution, and uptake should continue to be monitored.

Overview

Evidence is accumulating that contraception is a powerful and cost-effective HIV prevention approach that enables HIV-infected women to prevent unintended pregnancies and avert mother-to-child transmission. However, evidence is needed of service delivery strategies that effectively respond to the contraceptive needs of HIV clients without detracting from HIV services. To help generate such evidence, Family Health International (FHI) and partners conducted operations research on the effectiveness of integrating family planning services into voluntary counseling and testing (VCT) services in Kenya.

The Kenyan Ministry of Health, with technical assistance from FHI, EngenderHealth, JHPIEGO, and the AMKENI Project (a USAID funded reproductive health service delivery project) developed and initiated implementation of a strategy for providing family planning services at VCT centers. The new strategy highlights four levels of integration, each contingent on available resources at individual facilities (see Preparedness of Voluntary Counseling and Testing Centers in Kenya to Provide Family Planning).

In the present operations research, an integration intervention was evaluated at 14 VCT centers in Kenya that offered at least the first level of integration, as specified in the strategy. The first level includes�in addition to traditional VCT services�provision of basic pregnancy risk assessment and counseling services, and the availability of oral contraceptive pills and condoms on site.

Specifically, researchers evaluated the effects of the intervention on VCT providers' discussions of fertility desires, contraceptive method counseling, and method distribution or referral. 

Intervention

The main activities of the intervention, which was conducted between August 2004 and March 2005, were development of a training curriculum, advocacy and sensitization, and training of VCT providers on family planning integration. The training helped providers learn how to screen clients for unintended pregnancy risk, counsel on all methods, and provide pills and condoms and referrals for other methods.

To raise awareness of the benefits of contraception for VCT clients and of the feasibility of integrating family planning into VCT services in Kenya, nine advocacy and sensitization meetings were held with provincial health management teams.

Thirty-eight trainers were trained on integrating family planning services into VCT services. These trainers then trained approximately two VCT providers from 62 VCT centers, including the 14 study centers. A total of 101 providers were trained, and supervision visits were provided to more than two-thirds of the trainees for added support. 

A subset of 14 VCT centers was chosen for the operations research. Data were collected both before the intervention (June 2004) and after the intervention (April/May 2005). Nearly 900 interviews were conducted with VCT supervisors, providers, and clients; nearly 700 client-provider interactions were observed.

Results

Of 60 providers included in the post-intervention analysis, only 20 (33%) had been trained on family planning integration. Although at least two providers per facility were trained, a possible explanation for the low number of trained providers encountered is that some trained providers were no longer working in the study sites. The following are among the major findings, primarily comparing pre- and post-intervention results.

Family Planning Discussions and Provision

Comparing pre- to post-intervention we found that:

• VCT providers were nearly twice as likely to discuss a client's desire to have more children (11% to 20%).
• Providers were only slightly more likely to discuss clients' current use of family planning (23% to 28%).
• Providers were more likely to discuss family planning methods with their clients (46% to 63%).
• Providers were more likely to counsel clients about what family planning services were available outside of the VCT centers (6% to 20%).
• The intervention had a small effect on clients' reports of contraceptive distribution (17% to 29%). Condoms were the only method distributed.

Comparing providers who participated in the training to those who did not, we found that trained providers performed better on all indicators.

Of note, between 27% and 29% of VCT clients were determined to be at risk of unintended pregnancy, defined as being sexually active and not using contraception, but not wanting to become pregnant within the next two years. More female clients than male clients were at risk (approximately one-third versus one-quarter). Approximately 8% of women who visit VCT centers were estimated to be both infected with HIV and at risk of unintended pregnancy.

Quality of Care

• The mean length of counseling sessions and client waiting time increased by six and nine minutes, respectively, but neither difference could be attributed to the intervention.
• VCT counseling content was not affected.
• Half of supervisors, providers, and clients said that introducing family planning improved VCT quality.
• Forty percent of clients did not receive any family planning information post intervention.

Recommendations

If integration efforts are scaled up in Kenya:

• Advocacy efforts should stress the large proportion of VCT clients at risk of unintended pregnancy.
• More efforts are needed to increase contraceptive uptake to reduce unmet need for contraception among clients.
• Trainings and supervision should aim to improve provider skills in screening for pregnancy risk so that providers can target informed choice contraceptive counseling to clients who need it.
• Training more than two VCT providers per VCT center should improve clients' access to family planning services in VCT.
• Continuous monitoring of VCT quality and method choice counseling, distribution, and uptake is important as integration efforts continue.

This work was supported by the U.S. Agency for International Development (USAID). The contents do not necessarily reflect USAID views and policy.

For more information, read the full study report or contact FHI's Research to Practice Initiative.