Application of the Implementation Outcomes Framework to Assess Facilitators and Barriers to PPIUD Initiative Implementation in Tanzania

Outcome and DefinitionFacilitatorBarrier
Implementation Outcomes
Acceptability: Perception among stakeholders that intervention is acceptable (e.g., satisfaction with PPIUD training content, complexity, comfort)
  • High satisfaction with PPIUD training

  • Lack of providers trained on PPIUD insertion

  • Lack of support from local health authorities

Adoption: Initial implementation of PPFP counseling and PPIUD insertion; Intention to try
  • Increased confidence following PPIUD training

  • Time constraints and inadequate staffing

  • Gaps in referral system between satellite clinics and hospitals

Fidelity: Delivered counseling as intended (e.g., reach, content, and target population)
  • Individual counseling replaced by group counseling

  • Diminished provider motivation

  • Counseling rushed or skipped

  • Skewed or incomplete counseling

Penetration: Diffusion of PPIUD Initiative within intervention facilities and to other non-intervention sites
  • Emphasis on PPIUD’s mechanism of pregnancy prevention during training

  • Objections from faith-based facilities

  • Expectation for remuneration among staff who did not receive initial training

Sustainability: Long-term maintenance and institutionalization of the PPIUD Initiative
  • Support for population policies and family planning programs to achieve fertility reduction goals

  • Breakdown of supply chain and stock-outs

Service Outcomes
Equity: Extent to which the PPIUD implementation is equally available/accessible to all intended beneficiaries
  • Differential treatment by health care providers

  • Financial barriers to accessing hospitals

  • Lack of community-based PPFP counseling and services

Client Outcomes

Client receptiveness/demand for services:

Client receptiveness to being counseled on PPFP and/or demand for receiving the PPIUD

  • Level of support from husband/partner

  • Shared intention among couples to space pregnancy for financial reasons

  • Community and gender norms related to birth spacing

  • Community diffusion of preference for PPIUD and peer recommendation

  • Women's trust in provider advice

  • Cost-free counseling and insertion services

  • Fear of insertion, concerns related to sexual experiences postinsertion, unexpected expulsion and experience of unanticipated side effects (results published elsewhere26).

Satisfaction with PPIUD services:

Client receptiveness to being counseled on PPFP and/or receiving PPIUD; Satisfaction with counseling and services

  • Delivery of counseling and services by female provider

  • Interpersonal aspects of care

  • Perceived provider incompetence

  • Abbreviations: PPIUD, postpartum intrauterine device; PPFP, postpartum family planning.