Skip to main content

Author: PATH


Adolescent and Youth Experiences With Contraceptive Self-Injection in Uganda

Results From the Uganda Self-Injection Best Practices Project

Purpose
We used qualitative and quantitative data to evaluate the differing experiences of adolescents and adult women in the contraceptive self-injection program in primary care settings in Uganda. From these results, we assessed barriers to adolescent DMPA-SC self-injection access and continuation and provide recommendations to address them.

Methods
The Self-Injection Best Practices project (2017–2019) in four districts trained clinic-based providers and Village Health Teams to provide self-injection training in clinics, community settings, and small group meetings for adolescent girls and young women. More than 12,000 women of reproductive age received self-injection services through the program, including 2,215 under 20 years. Structured surveys (n = 1,060) and in-depth interviews (n = 36) were conducted with randomly selected adolescent participants between July and November 2018. Mixed-effects logistic regression was used to assess quantitative differences in outcomes of interest between age groups.

Results
The study found no significant difference in self-injection proficiency or continuation between adolescents and adult women; 92.6% of adolescents self-injected independently when due for reinjection. Adolescents were significantly less likely than adults to report first hearing about self-injection from a community health worker. More adolescents expressed concern over discovery when seeking contraception at a clinic and fear of their DMPA-SC units being discovered at home. Adolescents were significantly less likely than adult women to mention convenience as a rationale for self-injecting, and more likely to mention wanting to learn a new skill and/or that friends recommended self-injection.

Discussion
Self-injection is a promising method of contraception for adolescents in Uganda, given comparable proficiency and continuation relative to adult women. Policies and programs should ensure rights-based access to a range of methods, including self-injection for this age group.

Institutional author(s): PATH
Individual author(s): Caitlin Corneliess, Jane Cover, Andrew Secor, Allen Namagembe, Fiona Walugembe
Publication date: October, 2022

Journal Article Journal of Adolescent Health article

Contraceptive self-injection through routine service delivery: Health worker perspectives from Uganda

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.

Institutional author(s): PATH
Individual author(s): Chloe Morozoff, Jane Cover, Allen Namagembe, Damalie Nsangi, Justine Tumusiime, Aurora Anna Stout, Jennifer Kidwell Drake
Publication date: September, 2022

Contraceptive self-injection through routine service delivery: Experiences of Ugandan women in the public health system

Contraceptive self-injection (SI) is a new self-care practice with potential to transform women’s family planning access by putting a popular method, injectable contraception, directly into the hands of users. Research shows that SI is feasible and acceptable; evidence regarding how to design and implement SI programs under real-world conditions is still needed. This evaluation examined women’s experiences when self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was introduced in Uganda alongside other contraceptive options in the context of informed choice. We conducted structured survey interviews with 958 randomly selected SI clients trained in three districts in 2019. SI clients demonstrated their injection technique on a model to permit an assessment of injection proficiency. A randomly selected subset of 200 were re-interviewed 10–17 months post-training to understand resupply experiences, waste disposal practices and continuation. Finally, we conducted survey interviews with a random sample of 200 clients who participated in training but declined to self-inject. Data were analyzed using Stata IC/14.2. Differences between groups were measured using chi square and t-tests. Multivariate analyses predicting injection proficiency and SI adoption employed mixed effects logistic regression. Nearly three quarters of SI clients (73%) were able to demonstrate injection proficiency without additional instruction from a provider. Years of education, having received a complete training, practicing, and taking home a job aid were associated with higher odds of proficiency. Self-reported satisfaction and continuation were high, with 93% reinjecting independently 3 months post-training. However, a substantial share of those trained opted not to self-inject. Being single, having a partner supportive of family planning use, training with a job aid, practicing, witnessing a demonstration and exposure to a full training were associated with higher odds of becoming an SI client; conversely, those trained in a group had reduced odds of becoming an SI client. The self-care program was successful for the majority of women who became self-injectors, enabling most women to demonstrate SI proficiency. Nearly all those who opted to self-inject reinjected independently, and the majority continued self-injecting for at least 1 year. Additional research should identify strategies to facilitate adoption by women who wish to self-inject but face challenges.

Institutional author(s): PATH
Individual author(s): Jane Cover, Allen Namagembe, Chloe Morozoff, Justine Tumusiime, Damalie Nsangi, Jennifer Kidwell Drake
Publication date: August, 2022

Access Collaborative technical assistance (TA) resource menu

The DMPA-SC Access Collaborative provides data-driven technical assistance (TA), resources, and tools that countries need for designing, implementing, and monitoring the introduction and scale up of DMPA-SC self-injection as part of an expanded range of contraceptive methods, delivered through informed choice programming.

In addition to general information and evidence on DMPA-SC, partners can access the support outlined in the menu below by submitting a request through the technical assistance request form, also linked below. Your request can be submitted by emailing the completed form to FPoptions@path.org.

Institutional author(s): PATH, JSI
Publication date: 2022

DMPA-SC Access Collaborative country briefs

The DMPA-SC Access Collaborative has published a collection of briefs on countries where we have provided focused technical assistance between 2017 and 2021. This includes the Democratic Republic of the Congo, Kenya, Madagascar, Nigeria, Uganda, and Zambia. Each brief describes the country’s introduction and scale-up experiences for DMPA-SC and self-injection, including accomplishments, challenges, innovations, key lessons, factors for success, and plans for the way forward.

 

Institutional author(s): PATH, JSI
Publication date: 2021

Launching the family planning data toolkit for DMPA-SC self-injection

On September 15, 2021, the PATH-JSI DMPA-SC Access Collaborative hosted this virtual launch and walk-through of the redesigned DMPA-SC Country Data Dashboard and new monitoring, learning, and evaluation (MLE) tools.

The AC data dashboard is an interactive tool that presents available data collected during DMPA-SC self-injection (SI) introduction and scale-up. The dashboard visualizes SI uptake, tracks implementation of key policies, and integrates data use practices to support data-driven decision making. Information presented on the dashboard has changed over time to reflect shifting needs of stakeholders. After undergoing a human centered design exercise to better understand information needs surrounding SI introduction and scale-up, the Access Collaborative recently redesigned the DMPA-SC Country data dashboard. This webinar introduced new data available and demonstrated new features on the dashboard.

The webinar also included an overview of the Access Collaborative’s new MLE toolkit developed to help meet the needs of ministries of health and implementing partners. This toolkit features three tools for dynamic decision-making: a data visualization principles guide, an Excel dashboard how-to guide, and a data use and indicators guide. The tools are primers in how to create dynamic and visually compelling SI program data displays (e.g., dashboards, presentations) that facilitate comprehension and use of SI data for family planning program decision-making. While the toolkit was developed with SI in mind, many of the principles could be applied to data visualization needs across family planning programs and methods.

Institutional author(s): PATH, JSI
Publication date: September, 2021

Costing and funding analysis for DMPA-SC program planning

Costed implementation plans play an important role in transforming family planning commitments into concrete programs and policies by informing budget creation and management as well as funding allocations and tracking. As part of introduction and scale-up planning across countries, the DMPA-SC Access Collaborative has worked with ministries of health and partners to create costed implementation plans for DMPA-SC specifically and map commitments or available budgets against costed plans to understand funding gaps. This brief describes the Access Collaborative’s costed implementation plan approach as well as costing tools available to enable countries to estimate their own plan’s requirements and potential funding gaps. For more information or assistance, please visit the Access Collaborative technical assistance page or contact FPoptions@path.org.

Institutional author(s): PATH, JSI
Publication date: 2021

Building capacity through digital approaches: Can eLearning replace in-person training?

Using eLearning to train health workers on family planning counseling can be an effective training approach, particularly when carefully planned and coordinated to maximize the benefits. On August 26, 2021, the DMPA-SC Access Collaborative hosted this webinar on eLearning for health workers learning to counsel clients on DMPA-SC including self-injection in Senegal and Uganda. During 2019-2020, this approach was launched and evaluated in four regions of Senegal and four districts in Uganda.

The findings and recommendations from the experiences in Senegal and Uganda may offer lessons for other countries wishing to implement digital learning approaches. The webinar presenters raised important considerations about stakeholder coordination, internet and technology access, eLearning platforms, establishing training targets, training content, and the important role of post-training supervision.

Institutional author(s): PATH, JSI
Publication date: August, 2021

Video

Toolkit for DMPA-SC monitoring, learning, and evaluation

Data has the power to convey the lived experiences of women and adolescents, highlighting the importance and potential of expanding choices to reduce unmet need for contraception. This monitoring, learning, and evaluation (MLE) toolkit features three tools for dynamic decision-making: A data visualization principles guide, an Excel dashboard how-to guide, and a data use and indicators guide. These are primers on how to create dynamic and visually compelling self-injection program data displays (e.g., dashboards, presentations) that facilitate comprehension and use of self-injection data for family planning program decision-making. While the MLE toolkit was developed with self-injection in mind, many of the principles could be applied to data visualization needs across family planning programs and methods. For more information about using the toolkit, visit Excelerate your self-injection program data: An Excel skill-building workshop series.

We want to hear from you! By completing this short survey, you can help us ensure the tools are meeting the needs of key stakeholders during new product introduction and scale-up. Please contact FPoptions@path.org with any questions or request for assistance.

Institutional author(s): JSI, PATH
Publication date: July, 2021

DMPA-SC supportive supervision toolkit

Supportive supervision plays a critical role to ensure high-performing health workers have the appropriate knowledge, skills, and motivation in order to deliver quality family planning (FP) services and informed choice counseling. This package includes three supportive supervision tools that can be used by regional or district health teams when conducting supervision visits at health facilities that offer FP services:

  1. Supportive supervision checklist to assess provision of family planning counseling
  2. Observation checklist to assess health workers counseling clients on DMPA-SC self-injection
  3. Remote supervision of family planning providers (includes family planning and self-injection)

Tools #1 and #2 can be used together or separately, depending on whether or not the supervision visits include follow-up with providers recently trained to counsel clients on DMPA-SC self-injection.

Tool #3 is intended for use in situations where in-person supervision is not possible; the supervision exercise can be conducted through phone or video. This tool includes guidance and instructions for supervisors who plan to conduct supervision remotely.

The tools are intended to serve as guides and can be adapted for specific settings as needed. For more information, contact FPoptions@path.org.

Institutional author(s): PATH, JSI
Publication date: July, 2021