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Author: FHI 360


Scaling self-injection across sectors in Malawi

Lessons learned from training and support for health workers in the public and private sectors

Malawi has made significant progress in scaling up DMPA-SC and self-injection in the public sector with 100% of service delivery points activated. The country has also learned valuable lessons through private sector pilots and is in the process of finalizing new guidelines to authorize pharmacies and drugstores to provide self-injection training to clients. The country’s approach is widely appreciated as an example of effective government-led and partner-supported scale-up involving both the public and private sector.

This webinar hosted by the PATH-JSI DMPA-SC Access Collaborative Learning and Action Network on August 3, 2022 featured public and private partners’ insights on national scale-up of DMPA-SC and self-injection, with a focus on provider training and supportive supervision as well as strong cross-sectoral partnerships. Speakers included representatives from the Malawi Ministry of Health Reproductive Health Directorate, Clinton Health Access Initiative, FHI 360, and Population Services International.

Drawing from program data and research, panelists discussed practical lessons learned from Malawi’s national scale-up of public-sector provider training, public provider reflections on integrating self-injection, and experiences from a private sector provider training pilot. These lessons may benefit governments and public and private partners in other contexts who are in the process of introducing or scaling up DMPA-SC for self-injection.

Institutional author(s): PATH, JSI, Malawi Ministry of Health, Clinton Health Access Initiative (CHAI), FHI 360, Population Services International (PSI)
Publication date: August, 2022

Contraceptive Technology Innovation (CTI) Exchange

The Contraceptive Technology Innovation (CTI) Exchange is a platform for increasing global access to resources on contraceptive research, development, registration, and introduction through collaboration and knowledge sharing. The site features Calliope, the Contraceptive Pipeline Database, which provides information on new and future contraceptive products, including long-acting and novel products currently only available in limited markets.

Institutional author(s): FHI 360
Publication date: 2021

Tool Web page

Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN)

The DMPA/NET-EN checklist consists of questions designed to identify medical conditions that would prevent safe DMPA/NET-EN use or require further screening and assess whether a client might be pregnant. It also provides guidance and directions based on clients’ responses.

Institutional author(s): FHI 360
Publication date: June, 2017

Provision of Injectable Contraceptives within Drug Shops: A Promising Approach for Increasing Access and Method Choice

This 4-page brief is focused on the use of drug shops to increase access to injectable contraceptives.

Institutional author(s): FHI 360, JSI, USAID
Publication date: June, 2014

Brief Web page

Key Indicators for Community-based Access to Injectable Contraception Pilot Studies

An indicator is a measure of program performance that is tracked over time. This document presents potential process and outcome indicators organized according to the phase of the community-based access to injectables (CBA2I) pilot along with the related evaluation questions, data sources and measurement tools. The list can be adapted to local contexts and program goals to assess a pilot’s progress toward intended outputs and achievement of goals.

Institutional author(s): FHI 360
Publication date: July, 2011

Community-Based Health Workers Can Safely and Effectively Administer Injectable Contraceptives: Conclusions from a Technical Consultation

This brief presents the conclusions of a technical consultation of experts that reviewed extensive evidence and recommended that community-based provision of injectable contraceptives by trained community health workers is safe and effective. The document highlights program guidance and operational issues as well as priorities for new research.

Institutional author(s): FHI 360
Publication date: June, 2010

Report Community-Based Health Workers Can Safely and Effectively Administer Injectable Contraceptives: Conclusions from a Technical Consultation

Using Human-Centered Design to Explore Potential Users’ and Men’s Views of New Injectable Contraceptives in Kampala and Lagos

Background: Injectable contraceptives are the most used method in sub-Saharan Africa. We conducted market research to assess potential user attitudes toward 4- and 6-month injectables. We also present user suggestions for marketing these new injectables once they are available.

Methods: We implemented a 2-phase market research study from October through December 2021 in Kampala, Uganda, and Lagos, Nigeria. We conducted 11 focus group discussions (FGDs) with 51 participants in Kampala and 12 FGDs with 67 participants in Lagos. FGDs included current and potential injectable users and men stratified by marital status and age. Next, 23 women in Kampala and 24 in Lagos participated in cocreation workshops using human-centered design methods to explore marketing and communications strategies for each injectable. Data collection teams completed semistructured data extraction tables that were then analyzed thematically.

Results: Participants liked both injectable options due to the reduced number of facility visits that would save time and money and increase privacy. Primary concerns included side effects, delayed return to fertility, cost, self-efficacy to self-inject, and stock-outs. Participants in Kampala preferred a shorter reinjection window (or “grace period”) because it is easier to remember and they assumed it meant a quicker return to fertility, but participants in Lagos preferred a longer window because it provides extra time for reinjection. Citing norms around women needing to get pregnant quickly after marriage, participants in both sites felt that the 4-month injectable would benefit young people with busy lifestyles or limited access to facilities, whereas the 6-month injectable would benefit women who already had children.

Conclusions: We found that participants in Kampala and Lagos would prefer additional injectable options to meet the wide-ranging needs of users in different stages of their reproductive lives. Family planning program planners can apply the marketing insights we identified when these new injectables become available.

Institutional author(s): FHI 360
Individual author(s): Holly M Burke, Rebecca Callahan, Anna Lawton, Abigail Turinayo, Oluwatoyin Oyekenu, Sheila Niyonsaba, Oladunni Taiwo, Victor Muwonge Semaganda, Andy Awiti, Audrey Fratus, Fredrick Mubiru, Funmilola OlaOlorun
Publication date: December, 2023

Journal article Global Health: Science and Practice

Testing a counseling message for increasing uptake of self-injectable contraception in southern Malawi

A mixed-methods, clustered randomized controlled study

Objective: While self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) has well-documented benefits, uptake may be improved by addressing client concerns such as fear of self-injury and low self-efficacy. However, current training materials for family planning providers do not address these concerns. We used an iterative process with family planning providers and clients, male community leaders and partners, and stakeholders in Malawi to develop a counseling message addressing user-centered concerns about self-injection. We report on our testing of the effectiveness of this evidence-based message for increasing self-injection uptake in the context of full method choice.

Methods: We randomized 60 public facilities across two districts in southern Malawi to orient their providers to the message (treatment) or not (control). After strengthening data quality, we extracted routine service delivery data from the facilities six months before and after introducing the message. We compared pre- and post-orientation trends for the treatment and control groups using generalized linear mixed models. We conducted eight focus group discussions with a sample of providers oriented to the message.

Results: The message was feasible to implement and highly acceptable to providers. During June 2020–June 2021, 16,593 new clients used injectables in Mangochi district (52% DMPA-SC; 15% self-injected). In Thyolo district, 7,761 new clients used injectables during July 2020–July 2021 (29% DMPA-SC; 14% self-injected). We observed high variability in number of clients and self-injection uptake across facilities and over time, indicating inconsistent offering of self-injection. In both districts, we found significant increases in self-injection in treatment facilities after message introduction. However, this increase was not sustained, especially when DMPA-SC was unavailable or about to expire.

Conclusion: Based on the study findings, we recommend the evidence-based message be used in programs offering DMPA-SC self-injection services. However, effective use of the message is contingent upon a consistent supply of DMPA-SC.

Institutional author(s): FHI 360, Centre for Health, Agriculture Development Research and Consulting
Individual author(s): Holly M Burke, Catherine Packer, Akuzike Zingani, Philemon Moses, Alissa Bernholc, Lucy W Ruderman, Andres Martinez, Mario Chen
Publication date: October, 2022

Journal article PLoS ONE

The Highs, Lows, and Squishy Middle of Contraceptive Product Introduction

As part of the Global Health Science and Practice (GHTechX) conference, CHAI, FHI 360, PATH, the Population Council, PSI, and WCG hosted an April 22, 2021 session to synthesize lessons learned across contraceptive introduction of implants, DMPA-SC self-injection, hormonal IUS and other methods. During the session, experts from Kenya, Madagascar, Uganda, and the United States outlined essential steps for the process of contraceptive product introduction, described common challenges, and shared tools and approaches based on experiences with the three methods. Session slides are available below. To watch the recording of this and many other sessions, register for free on the GHTechX website.

Institutional author(s): Clinton Health Access Initiative (CHAI), FHI 360, PATH, Population Council
Publication date: April, 2021

Adolescent and covert family planning users’ experiences self-injecting contraception in Uganda and Malawi

Implications for waste disposal of subcutaneous depot medroxyprogesterone acetate

Self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is poised to increase access to contraception; however, governments are concerned about the waste management of used units. Self-injectors in Malawi and Uganda are currently instructed to store used units in containers and return them to health workers for disposal. However, this may not be feasible in low-resource settings, especially for younger or covert self-injectors. We describe adolescent (15–19 years) and adult (20–49 years) self-injectors’ disposal experiences in Uganda and Malawi. When possible, we compare covert and overt users’ experiences.

Institutional author(s): FHI 360
Individual author(s): Holly M Burke, Catherine Packer, Laura Wando, Symon Peter Wandiembe, Nelson Muwereza, Subarna Pradhan, Akuzike Zingani, Bagrey Ngwira
Publication date: August, 2020

Journal article Reproductive Health journal