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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

DMPA-SC and self-injection training materials

The Training Resource Package (TRP) for Family Planning’s Progestin-Only Injectable module includes sessions V and VI which are focused on DMPA-SC and self-injection, as well as a number of related handouts and resources. Developed in partnership with the Access Collaborative, these materials are intended for training health care providers who offer progestin-only injectable contraception (“injectables”) in the public or private sector.

The TRP website features training information and materials for a wide range of family planning methods. This includes curriculum components and tools for trainers to design, implement, and evaluate family planning and reproductive health training.

Institutional author(s): USAID, World Health Organization (WHO), UNFPA, PATH
Publication date: 2022

Training supply recommendations for DMPA-SC rollout

DMPA-SC is a three-month injectable contraceptive that is easy to use and uniquely suited for self-injection. Demonstration and practice injections are a key part of training programs for both health workers and self-injection clients. Based on lessons learned in five countries, this memo summarizes PATH’s recommendations regarding devices for injection demonstration and practice, injection practice models, and waste disposal.

Institutional author(s): PATH
Publication date: 2022

Looking back, thinking forward, and scaling up: Insights from the DMPA-SC Access Collaborative

The DMPA-SC Access Collaborative hosted this April 21, 2021 webinar highlighting lessons learned to date through four years of data-driven technical assistance and coordination to ensure that women have increased access to self-injection as a contraceptive option, delivered through informed choice programming. The discussion focused on key topics for the introduction and scale-up of self-injection—and self-care interventions more broadly—at the country level including:

  • Policy and advocacy for new product introduction.
  • How to coordinate scale-up of a new product.
  • Using data to inform program introduction and scale-up.
  • Effective innovations and adaptations in provider training.

This discussion was moderated by Monica Mutesa, Zambia Country Coordinator, DMPA-SC Access Collaborative, PATH. Speakers included:

  • Caitlin Corneliess, Project Director, DMPA-SC Access Collaborative, PATH
  • Adewole Adefalu, Nigeria Country Coordinator, DMPA-SC Access Collaborative, JSI
  • Allen Namagembe, Uganda Deputy Director, DMPA-SC Access Collaborative, PATH
  • Avotiana Rakotomanga, Madagascar Country Coordinator, DMPA-SC Access Collaborative, JSI
  • Alain Kabore, Regional Technical Advisor, DMPA-SC Access Collaborative, PATH

For more information, please contact FPoptions@path.org.

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

DMPA-SC digital training resources for health workers and clients

By leveraging digital training tools, family planning programs can integrate new approaches that help reduce the costs, time, and inconvenience associated with traditional classroom training. The Access Collaborative has developed digital training resources for health workers and clients learning to administer DMPA-SC.

A 10-lesson DMPA-SC eLearning course for health workers is available for free in English and French and can be taken on computer or mobile device with internet access. Content includes an emphasis on informed choice counseling, new lessons on calculating the injection date and conducting follow-up visits, and updated information on training clients to self-inject.

In addition to the eLearning course, PATH and JSI have developed short 5- to 7-minute DMPA-SC training videos for both self-injection clients and health workers. Available in English and French, the videos can be translated or adapted to fit in program contexts.

If you are interested in introducing DMPA-SC digital training approaches in your program, please contact the Access Collaborative at FPoptions@path.org.

Institutional author(s): PATH, JSI
Publication date: 2020

DMPA-SC training videos for clients and health workers

These short training videos are intended for both self-injection clients and health workers learning to administer the contraceptive DMPA-SC. The 5-minute self-injection training video is intended for women who have made the decision to self-inject DMPA-SC in the context of informed choice counseling. The 7-minute training video is for health workers who are giving injections to women who have chosen to use DMPA-SC in the context of informed choice counseling.

If you are interested in customizing these videos for your family planning program, we can make the voiceover scripts and video files available. To request these files please email FPoptions@path.org.

Institutional author(s): PATH, JSI
Publication date: 2019

How to Introduce and Scale Up DMPA-SC

Practical Guidance from PATH Based on Lessons Learned During Pilot Introduction

This guide was created to support ministry of health and nongovernmental partners as they develop strategies to introduce and scale up subcutaneous DMPA (DMPA-SC, brand name Sayana Press) to increase contraceptive options and access. Available in English and French, the publication provides practical guidance based on results, evidence, and learning from the pilot introductions of DMPA-SC in Burkina Faso, Niger, Senegal, and Uganda.

Institutional author(s): PATH
Publication date: 2018

DMPA-SC self-injection empathy-based training materials

The DMPA-SC self-injection empathy-based training package developed by the PSI Delivering Innovation in Self-Care (DISC) project is intended to guide ministries of health, family planning/reproductive health projects, and any implementing organization that is interested in integrating an empathy-based approach to improve health providers’ quality of care.

Institutional author(s): Population Services International (PSI)
Publication date: 2023

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

DMPA-SC integration in preservice training: Lessons from Uganda

Updating family planning and reproductive health preservice training is an important approach to make an impact on the health workforce and foster successful programs. In 2021, the DMPA-SC Access Collaborative, in collaboration with Uganda’s Ministry of Health and Ministry of Education and Sports, conducted a regional training for clinical and health training institutions on the topic of DMPA-SC including self-injection. This training integrated DMPA-SC content into the health provider preservice curriculum, trained tutors, and helped advance national scale-up of self-injection. As a result, 92 Ugandan health training institutions included self-injection content in their preservice curriculum for nurses, midwives, and clinical officers, and 190 tutors were trained—which will help ensure training of many more providers in the future.

During this process, the Access Collaborative gained valuable insights with relevance to other country contexts. This webinar held on January 27, 2022 highlighted lessons learnt, challenges, recommendations, and considerations for the inclusion of self-injection content in provider preservice training. In the Ugandan context, these include:

  • How inclusion of self-injection in preservice training can help reach FP2030 country commitments.
  • Virtual preservice training approaches during the COVID-19 pandemic.
  • Costs for the inclusion of self-injection in preservice training.
  • The role of regulators and the Ministry of Health in ensuring availability of DMPA-SC for preservice training.

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