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Author: Holly M Burke


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

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

Women’s satisfaction, use, storage and disposal of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) during a randomized trial

To describe women’s experiences with subcutaneous depot medroxyprogesterone acetate (DMPA-SC) to inform scale-up of self-administered DMPA-SC. We conducted a 12-month randomized controlled trial in Malawi to measure DMPA-SC continuation rates. A total of 731 women presenting at six Ministry of Health clinics or to community health workers (CHWs) in rural communities were randomized to receive DMPA-SC administered by a provider or be trained to self-inject DMPA-SC. Data collectors contacted women after the reinjection window at 3, 6 and 9 months to collect data on satisfaction and use; self-injectors were also queried about storage and disposal of DMPA-SC. We compared frequencies of injection experiences and satisfaction by study group and over time.

Institutional author(s): FHI 360, College of Medicine, University of Malawi
Individual author(s): Holly M Burke, Mario Chen, Mercy Buluzi, Rachael Fuchs, Silver Wevill, Lalitha Venkatasubramanian, Leila Dal Santo, Bagrey Ngwira
Publication date: May, 2018

Journal article Contraception journal

Client and provider experiences with self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) in Malawi

As low- and middle-income countries (LMICs) consider adding self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) to their contraceptive method mix, learning about family planning clients’ and providers’ experiences with self-injectable DMPA-SC during trials will inform introduction and scale-up efforts. We conducted semistructured interviews with 30 randomly selected adult women enrolled in the self-administration group of a 12-month randomized controlled trial studying DMPA-SC continuation rates in rural Malawi. We asked about their experiences learning to self-inject, self-injecting, remembering when to reinject, and storing and disposing of DMPA-SC. We also interviewed 12 providers — clinic-based providers (CBPs) and community-based health surveillance assistants (HSAs) — who trained clients to self-inject DMPA-SC during the trial. We asked about their experiences training and supporting women to self-inject DMPA-SC during the trial and their recommendations for scale-up of self-administered DMPA-SC.

Institutional author(s): FHI 360, College of Medicine, University of Malawi
Individual author(s): Holly M Burke, Catherine Packer, Mercy Buluzi, Elise Healy, Bagrey Ngwira
Publication date: April, 2018

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Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomised controlled trial

Injectable contraceptives are popular in sub-Saharan Africa but have high discontinuation rates due partly to the need for provider-administered re-injection. We compared continuation rates of women who self-injected subcutaneous depot medroxyprogesterone acetate (DMPA-SC) and women who received DMPA-SC from a health-care provider, including community health workers (CHWs).We did an open-label randomised controlled trial based at six Ministry of Health clinics in rural Mangochi District, Malawi. Health-care providers recruited adult women who presented at the six clinics or to CHWs in rural communities in the clinic catchment areas. Participants received DMPA-SC and were randomised (1:1) to receive provider-administered injections or training in how to self-inject DMPA-SC. Randomisation was done via a computer-generated block randomisation schedule with block sizes of four, six, and eight and stratified by study site, generated by an independent statistician. Self-injectors administered the first injection under observation and were sent home with three doses, written instructions, and a calendar. The provider-administered group received a DMPA-SC injection and a calendar, and were asked to return for subsequent injections. Data collectors contacted participants after the 14-week re-injection window at 3, 6, and 9 months to collect continuation data. At 12 months after enrolment or early discontinuation, women had their final interview, which included pregnancy testing. The primary outcome was discontinuation of DMPA-SC, as assessed in the intention-to-treat population. We used Kaplan-Meier methods to estimate the probabilities of continuation and a log-rank test to compare groups. Safety was assessed in the as-treated population, which consisted only of participants who successfully received at least one DMPA-SC injection after randomisation. This trial is registered with ClinicalTrials.gov, number NCT02293694.This study lasted from Sept 17, 2015, to Feb 21, 2017. 731 women underwent randomisation, with 364 assigned to the self-administered group and 367 to the provider-administered group. One woman in the self-injection group withdrew at month 0. Treatment was discontinued by 99 women in the self-administered group and 199 women in the provider-administered group. The 12 month continuation rate was 73% in the self-injection group and 45% in the provider-administered group, giving an incidence rate ratio of 0·40 (95% CI 0·31–0·51; p<0·0001). Adverse events deemed to potentially be treatment-related were reported by ten women (20 events) in the self-administered group and 17 women (28 events) in the provider-administered group. Five serious adverse events were reported during the trial by four women; two events related to DMPA-SC (menorrhagia and anemia requiring hospital admission) were reported by the same woman in the provider-administered group and resolved without sequelae. The other serious adverse events, including one death, were deemed to be unrelated to DMPA-SC. Women who self-injected DMPA-SC had significantly higher rates of continuation than those receiving provider-injected DMPA-SC. Community-based provision of injectable contraception for self-injection in low-resource settings seems to be safe and feasible. Self-administration of DMPA-SC should be made widely available.

Institutional author(s): FHI 360
Individual author(s): Holly M Burke, Mario Chen, Mercy Buluzi, Rachael Fuchs, Silver Wevill, Lalitha Venkatasubramanian, Leila Dal Santo
Publication date: March, 2018

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Observational study of the acceptability of Sayana® Press among intramuscular DMPA users in Uganda and Senegal

This study measured acceptability of DMPA-SC (Sayana® Press) among intramuscular DMPA (DMPA-IM) users. Current DMPA-IM users in Senegal and Uganda accepted DMPA-SC, and most preferred DMPA-SC over DMPA-IM. DMPA-SC can be safely introduced into family planning programs and administered by trained community health workers, with expectation of client uptake.

Contraception. 2014. May;89(5):361-7. Epub 2014 Feb 6. https://doi.org/10.1016/j.contraception.2014.01.022

 

 

Institutional author(s): FHI 360
Individual author(s): Holly M Burke, Monique P. Mueller, Brian Perry, Catherine Packer, Leonard Bufumbo, Daouda Mbengue, Ibrahima Mall, Bocar Mamadou Daff, Anthony K Mbonye
Publication date: February, 2014

Journal article Observational study of the acceptability of Sayana® Press among intramuscular DMPA users in Uganda and Senegal

Provider acceptability of Sayana® Press: results from community health workers and clinic-based providers in Uganda and Senegal.

Sayana® Press (SP), a subcutaneous formulation of depot medroxyprogesterone acetate (DMPA) in Uniject™, has potential to be a valuable innovation in family planning (FP) because it may overcome logistic and safety challenges in delivering intramuscular DMPA (DMPA IM). However, SP’s acceptability is unknown. We measured acceptability of SP among clinic-based providers (Senegal only) and community health workers. This open-label observational study was conducted in clinics in three districts in Senegal and community-based services in two districts in Uganda. Providers administered SP to clients seeking reinjection of DMPA IM. We conducted in-depth interviews with 86 providers (52 in Senegal, 34 in Uganda) to assess their experiences providing SP to clients.

Institutional author(s): FHI 360, Centre de Formation et de Recherche en Santé de la Reproduction (CEFOREP), Senegal Ministry of Health and Social Action, Uganda Ministry of Health
Individual author(s): Holly M Burke, Monique P. Mueller, Catherine Packer, Brian Perry, Leonard Bufumbo, Daouda Mbengue, Bocar Mamadou Daff, Anthony K Mbonye
Publication date: January, 2014

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