Self-care reproductive health innovations are increasingly valued as practices that enable women to manage their fertility with greater autonomy. While self-care, by definition, takes place beyond the clinic walls, many self-care practices nonetheless require initial or follow up visits to a health worker. Access to self-care hinges on the extent to which health care workers who serve as gatekeepers find the innovation appropriate and practical. Self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is being introduced and scaled in many countries. In late 2018, health workers in Uganda began offering self-injection of DMPA-SC in the public sector, and this study examines health workers’ views on the acceptability and feasibility of training women to self-inject. We conducted in-person interviews with 120 health workers active in the self-injection program to better understand provider practices, program satisfaction, and their views on feasibility. A subset of 77 health workers participated in in-depth interviews. Quantitative data was analyzed using Stata (v14) software, and chi square and student t tests used to measure between group differences. Qualitative data was analyzed using Atlas.ti, employing an iterative coding process, to identify key themes that resonated. The majority of health workers were very satisfied with the self-injection program and reported it was moderately easy to integrate self-injection training into routine service delivery. They identified lack of time to train clients in the clinic setting, lack of materials among community health workers, and client fear of self-injection as key challenges. Community health workers were less likely to report time challenges and indicated higher levels of satisfaction and greater ease in offering self-injection services. The relatively high acceptability of the self-injection program among health workers is promising; however, strategies to overcome feasibility challenges, such as workload constraints that limit the ability to offer self-injection training, are needed to expand service delivery to more women interested in this new self-care innovation. As self-injection programs are introduced and scaled across settings, there is a need for evidence regarding how self-care innovations can be designed and implemented in ways that are practical for health workers, while optimizing women’s successful adoption and use.
In collaboration with ministries of health, PATH and key partners launched the first pilot introductions of subcutaneous depot medroxyprogesterone acetate (DMPA-SC, brand name Sayana® Press) in Burkina Faso, Niger, Senegal, and Uganda from July 2014 through June 2016. While each country implemented a unique introduction strategy, all agreed to track a set of uniform indicators to chart the effect of introducing this new method across settings. Existing national health information systems (HIS) were unable to track new methods or delivery channels introduced for a pilot, thus were not a feasible source for project data. We successfully monitored the four-country pilot introductions by implementing a four-phase approach: 1) developing and defining global indicators, 2) integrating indicators into existing country data collection tools, 3) facilitating consistent reporting and data management, and 4) analyzing and interpreting data and sharing results. Project partners leveraged existing family planning registers to the extent possible, and introduced new or modified data collection and reporting tools to generate project-specific data where necessary. We routinely shared monitoring results with global and national stakeholders, informing decisions about future investments in the product and scale up of DMPA-SC nationwide. Our process and lessons learned may provide insights for countries planning to introduce DMPA-SC or other new contraceptive methods in settings where stakeholder expectations for measurable results for decision-making are high.
PATH partnered with the United Nations Population Fund (UNFPA) and country ministries of health (MOHs) to coordinate pilot introductions of subcutaneous depot medroxyprogesterone acetate (subcutaneous DMPA or DMPA-SC, brand name Sayana Press) in Burkina Faso, Niger, Senegal, and Uganda from July 2014 through June 2016 in order to expand the range of methods available to women, particularly in remote locations. The pilot introductions aimed to answer key questions that would inform decisions about future investments in DMPA-SC and scaling up product availability and service-delivery innovations nationally. These questions included the extent to which DMPA-SC would appeal to first-time users of modern contraception, as well as adolescent girls and young women; whether DMPA-SC would add value to family planning programs or simply replace DMPA-IM or other modern methods; and the trends in injectables use when introducing DMPA-SC (or any injectable) at the community level for the first time. We implemented a multi-country monitoring system to track key indicators, including the number of doses administered by category of user (e.g., new users, by client age group) or delivery channel. Providers generally collected these data using their national programs’ standard family planning registers. Data were analyzed for cumulative information and to examine trends over time using Microsoft Power Query for Excel and Tableau. Across the 4 countries, nearly half a million DMPA-SC doses were administered and approximately 135,000 first-time users of modern contraception were reached. Furthermore, 44% of the doses administered in 3 of the countries with data were to adolescent girls and young women under age 25. Switching from DMPA-IM to DMPA-SC was not widespread, ranging from 7% in Burkina Faso to 16% in Uganda. Results from these pilot introductions demonstrate that DMPA-SC has the potential to expand community-level access to injectables, maximize task-sharing strategies, and reach young women and new acceptors of family planning. Considered within the context of each country’s setting, training approach, and introduction strategy, these results can help stakeholders in other countries make informed decisions about whether and how to include this contraceptive option in their family planning programs.