Stephanie Chung

Background: Stockouts of essential medicines remain a persistent challenge across the Global South, undermining healthcare access. Unmanned aerial vehicles or drones have emerged as a promising solution to improve delivery. Methods: We implemented a two-arm cluster randomised trial in eastern Madagascar. Hard-to-reach public-sector facilities were randomised to drone delivery or standard land-based delivery of medical commodities. Preintervention and postintervention data included audits, provider and client interviews and population-based surveys of reproductive-age women. Our primary outcomes were (1) current modern contraceptive use and (2) the probability of stockouts. Secondary outcomes included aligned and preferred contraceptive use, vaccine and malaria outcomes and perceived quality. For each outcome, we compared intervention and control clusters using analysis of covariance (ANCOVA) regressions. Facilities randomised to drone delivery received continuous service from September 2023 to October 2024; outcomes were measured at baseline (June–August 2023) and endline (October 2024–March 2025). Results: Between June and August 2023, 109 facilities were randomised to drone intervention (n=55) or control (n=54). Within the corresponding communities, a representative sample of 1199 reproductive-age women (n=605 treatment, 594 control) completed a baseline survey. In primary ANCOVA analyses, drone delivery had no measurable impact on current modern contraceptive use, stockouts of most commodities, malaria rapid diagnostic test stockouts or most client-reported quality measures. Supporting difference-in-difference analyses suggested possible reductions in malaria rapid diagnostic test stockouts and modest improvements in aligned and preferred contraceptive use, but these findings were not consistently replicated in the primary specification. Conclusion: In this cluster randomised trial, drone delivery did not measurably improve most stockout, service readiness, utilisation or client-reported quality outcomes. These findings suggest that drone delivery alone may be insufficient to improve commodity availability where upstream supply-chain constraints remain binding. Prior estimates of drone impact across a broad range of supplies may have been inflated by methodological limitations. Rigorous studies in additional settings are needed before further integration of drones into national health systems in the Global South. Trial registration number: AEARCTR-0011710.

Objective: To address the need for improved measurement of the ways contraception impacts the baseline menstrual cycle (i.e., contraceptive-induced menstrual changes; CIMCs) by assembling an interdisciplinary, global research collective to rigorously develop a person-centered measure for CIMCs in multiple languages. As the first step, this paper reports on our conceptual model development, which is the foundation for ongoing measure development. Study design: We conducted 18 focus groups with 106 people experiencing CIMCs while using hormonal or intrauterine contraception in Durban, South Africa, Santo Domingo, Dominican Republic, and Portland Oregon, United States. We used a virtual affinity mapping approach to analyze qualitative data, which was the basis of our conceptual model along with relevant theory and related models in the literature. Results: The conceptual model of experiences with CIMCs depicts the baseline menstrual cycle, including CIMCs and conceptually-linked effects and the impacts and perceptions of those CIMCs. We found key domains of changes in pain, bleeding volume, bleeding patterns, and characteristics of blood. Conclusion: Our CIMC conceptual model will inform development of a measure with evidence of validation across three language and global contexts. Adoption of a person-centered, standardized CIMC measurement across trials will improve knowledge and decision-making between methods. Implications: Defining an evidenced-based conceptual model for CIMCs expands our understanding of how contraceptive users experience and understand menstruation and CIMCs. We can use this model to improve and standardize measurement of CIMCs.

Long wait times at health facilities negatively affect contraceptive access and cause dissatisfaction with care. Conventional data collection methods, such as population-based surveys and exit interviews, may not accurately capture wait times due to methodological challenges including recall and social desirability bias. We compared mystery client observations conducted in all public facilities in Kisumu County, Kenya with data from a population-based sample of women of reproductive age (18–49, n = 744) in Kisumu County. We compared recalled wait times from women who used public facilities in the last year for their last contraceptive method with wait times recorded by mystery clients (n = 401) presenting as first-time family planning users, and analyzed quotes from mystery clients who mentioned long waits. Most mystery clients reported wait times between 1-2 h (49%) or over 2 h (33%), whereas most women surveyed in their homes recalled being seen within 30 min at their most recent visit for family planning (74%). When stratified by facility type, mystery clients waited the longest at dispensaries and basic health centers (median wait time of 110 min) and the shortest wait times at primary and secondary care hospitals (median of 82.5 min). In the survey, women recalled waiting a median of 15 min at basic health centers, 20 min at dispensaries, and 30 min at hospitals. Common causes of long waits reported by mystery clients in qualitative data included late facility openings, late providers, or prioritization of other patients. More than half of mystery clients reported spending less than 5 min with providers (59%), compared to only 8% of women surveyed. Triangulation of data between different sources can provide a more nuanced understanding of long wait times, their causes, and how they impact contraceptive seekers. We find that in comparison, these different methods of data collection answer distinct questions about wait times, time spent with provider, and their impacts on contraceptive seekers. Both forms of data are useful to policy makers and stakeholders. We recommend data collection efforts aimed at improving quality of services and adherence to national guidelines consider supplementing standard data collection methods with mystery clients.

Background: People have contraceptive autonomy when they can obtain their preferred contraceptive method. Non-preferred method use may result from inappropriate medical contraindications, which occur when providers apply incorrect contraceptive eligibility criteria during consultations. Non-preferred method use and inappropriate medical contraindications are understudied in the Global South, partially due to measurement challenges. Objectives: This study provides the first evidence in over two decades that inappropriate medical contraindications are still a barrier to preferred method use in the Global South and offer a new conceptual frame for a neglected medical barrier to contraceptive use. Design: We collected qualitative data from 49 in-depth interviews and 17 focus group discussions (n = 146) with women of reproductive age (15–49) in an anonymized African country. Methods: We deductively identified instances of preferred method denial for medical reasons, then analyzed these episodes to determine whether the medical reasons for denial were evidence-based. Results: We found that many women who reported preferred method denial described being offered medical reasons discordant with evidence-based guidelines, often resulting in what we determined to be contraceptive coercion. Specifically, we identified that (1) women experienced bi-directional contraceptive coercion with medical rationales, (2) women trusted providers’ medical authority and felt unable to ask for more information, and finally, (3) women’s personal reasons for their contraceptive preferences were rendered illegitimate by providers’ use of biomedical language and (often incorrect) medical rationales. Consequentially, some women self-reported information indicating a legitimate contraindication to the non-preferred method their provider encouraged them to use. Conclusion: Inappropriate medical contraindications are an under-studied facility-level barrier to contraceptive access that can result in contraceptive coercion, negative health outcomes, discontinuation of wanted methods, and loss of reproductive autonomy. Addressing inappropriate medical contraindications will require solutions that negotiate both structural factors and individual provider behavior to improve the quality of contraceptive service provision.

Background: Anemia is a significant health concern for women in low- and middle-income countries. Hormonal contraceptives, which can reduce heavy menstrual bleeding and prevent pregnancy and its resulting blood loss, are an underexplored opportunity for anemia reduction. Methods: Using Demographic and Health Survey data from 46 countries across four global regions, we examined country prevalence of anemia (i.e., hemoglobin below 12 g/dl via HemoCue testing) among women aged 15–49 years who were not pregnant. For each country, we used multivariable logistic regression to compare odds of anemia between women using hormonal contraceptive (users) to women using non-hormonal contraception or not using any contraception (nonusers). We merged data across countries to examine this effect stratified by contraceptive method and length of use and conducted a quantitative bias analysis of the anemia test. Results: Anemia prevalence ranged from 12% in Rwanda to 63% in Gabon. In the merged sample, the crude odds ratio comparing anemia in users of hormonal contraception to nonusers was 0.57 (95% confidence interval: 0.56–0.58); the adjusted odds ratio was 0.55 (0.39–0.79) when controlling for age, education, wealth, and rurality. In the stratified analysis of merged data, we found that users of all hormonal contraception had lower adjusted odds of anemia compared to nonusers (AOR: 0.51, 95% CI: 0.46–0.57), and that the protective effect was strongest among users of contraceptive injections (AOR:0.37, 95% CI 0.30–0.45). In our bias analysis, the crude odds of anemia for users ranged from 0.29 to 0.57 when varying anemia test sensitivity and specificity between 75% and 100%. Conclusions: Future research should directly examine the causal link between hormonal contraceptive use and anemia as a high impact non-contraceptive benefit of hormonal contraception, especially with understudied methods such as injectable contraception and contraceptive implants.

Objective We sought to develop consensus recommendations for improved measurement of contraceptive-induced menstrual changes (CIMCs) in contraceptive clinical trials to build upon previous standardization efforts. Study Design We undertook a virtual consensus-building process using a modified Delphi approach, incorporating aspects of Nominal Group Technique and the Jandhyala method. The process consisted of four half-day meetings, developing recommendations within five topical working groups, a series of consensus questionnaires to assess recommendation agreement on a 4-point Likert-like scale, and opportunities for input and feedback throughout the process. Recommendations required at least 75% consensus to be included. Results Our interdisciplinary group—from 26 organizations and 13 countries in five global regions across academia, nonprofit research organizations, the pharmaceutical industry, and funding agencies— developed 44 consensus recommendations. These included recommendations on standardization, patient-reported outcome measure development aligned with current regulatory guidance, trial design, protocol development, participant recruitment, data collection, data analysis, and areas for exploratory research. Seven recommendations were deemed a priority by over 85% of our group. Conclusion Using a formal consensus-building process, we reached high levels of agreement around recommendations for more standardized and patient-centered measurement of CIMCs in contraceptive clinical trials, now and in the future. Implications statement Consensus recommendations on measuring bleeding changes and related outcomes in contraceptive clinical trials can improve reporting of standardized, patient-centered outcomes in future product labeling. These improvements can enable providers to offer more relevant counseling on contraceptives and permit greater comparability and data synthesis across trials to inform clinical guidance.

Despite the importance of menstruation and the menstrual cycle to health, human rights, and sociocultural and economic wellbeing, the study of menstrual health suffers from a lack of funding, and research remains fractured across many disciplines. We sought to systematically review validated approaches to measure four aspects of changes to the menstrual cycle—bleeding, blood, pain, and perceptions—caus ed by any source and used within any field. We then evaluated the measure quality and utility for clinical trials of the identified instruments. We searched MEDLINE, Embase, and four instrument databases and included peer-reviewed articles published between 2006 and 2023 that reported on the development or validation of instruments assessing menstrual changes using quantitative or mixed-methods methodology. From a total of 8,490 articles, 8,316 were excluded, yielding 174 articles reporting on 94 instruments. Almost half of articles were from the United States or United Kingdom and over half of instruments were only in English, Spanish, French, or Portuguese. Most instruments measured bleeding parameters, uterine pain, or perceptions, but few assessed characteristics of blood. Nearly 60% of instruments were developed for populations with menstrual or gynecologic disorders or symptoms. Most instruments had fair or good measure quality or clinical trial utility; however, most instruments lacked evidence on responsiveness, question sensitivity and/or transferability, and only three instruments had good scores of both quality and utility. Although we took a novel, transdisciplinary approach, our systematic review found important gaps in the literature and instrument landscape, pointing towards a need to examine the menstrual cycle in a more comprehensive, inclusive, and standardized way. Our findings can inform the development of new or modified instruments, which—if used across the many fields that study menstrual health and within clinical trials—can contribute to a more systemic and holistic understanding of menstruation and the menstrual cycle.

Sexual and gender minorities (SGM) using online venues in India are usually not reached by government HIV interventions, remaining an understudied yet important population. We investigated sociodemographic characteristics, sexual behaviours along with familiarity, knowledge, and correlated factors around perceived accuracy of the Undetectable = Untransmittable (U = U) slogan. Grindr users in India completed an online, cross-sectional survey in May-June 2022. We included individuals ≥ 18 years old who reported sex with men (excluding those who were born female and or identified as cis-gender female). Associations with perceived U = U accuracy were estimated using adjusted prevalence odds ratios (aPOR) with 95% confidence intervals (95% CI). The survey was completed by 3,126 eligible participants. The median age was 28 years and most participants lived in urban areas and had graduate or postgraduate education. HIV prevalence was 3.1%. Only 14% reported familiarity with the U = U slogan and after an explanation was provided, 25% perceived it as completely accurate. This was associated with knowing their HIV status (HIV Negative aPOR 1.37 [95%CI 1.1, 1.71], HIV Positive aPOR 3.39 [95%CI 2.11, 5.46]), having heard of PrEP (aPOR1.58 [95%CI 1.29,1.92]) or have used PrEP (aPOR1.56 [95%CI 1.15, 2.12]) along with use of party drugs (aPOR1.51 [95%CI 1.0 2.10]), being in touch with NGOs (aPOR 1.61 [95%CI 1.27, 2.02], p < .001) and having attended LGBTQIA + events (aPOR1.38 [95%CI 1.1, 1.73]). SGMs in India had low familiarity and low perceived accuracy around U = U. Education about U = U and innovating new strategies to reach this hidden population could reduce stigma around HIV in India.