Results From the Uganda Self-Injection Best Practices Project

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.

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.

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.

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.

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.

This policy landscape can be leveraged by applicants interested in applying to the DMPA-SC Regulatory Advocacy Catalytic Opportunity Fund (COF). The landscape was originally developed in 2020 to understand policies and regulations, including over-the-counter regulations, that impact women’s access to DMPA-SC and identify short- and long-term advocacy opportunities. In 2022, it was refreshed to understand policy shifts and additional advocacy opportunities in a subset of 12 of the original 18 countries currently eligible for the Regulatory Advocacy COF. Insights from the policy landscape have informed the design and eligibility criteria of the Regulatory Advocacy COF, proactively identified opportunities, and provided frameworks and guidance for interested applicants.

The desire for private sector family planning programs to have the ability to overbrand/overpackage the Pfizer Inc. DMPA-SC product, Sayana® Press, has existed since initial product introduction planning discussions among global partners in 2008–2009. The PATH-JSI DMPA-SC Access Collaborative solicited input from the team’s regional technical advisors, country coordinators, and local partners to better understand the status of overbranding, and any related advocacy­­, in the countries where we work.

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.

The private sector holds great potential to reduce unmet need for family planning, and many countries are poised to adopt a total market approach for increasing contraceptive access through private pharmacies and drug shops. Policies supporting scale-up of family planning service provision and expanding method options such as DMPA-SC self-injection, must be prioritized in these entities.

The PATH-JSI DMPA-SC Access Collaborative and partners have gained valuable insights with relevance to private sector engagement on self-injection. This webinar held February 15, 2022 highlighted lessons learnt, challenges, recommendations, and considerations for policies supporting private sector engagement in self-injection in different country contexts. Specific topics included:

• Financing and commodity production ecosystems
• Procurement and supply chains
• Service delivery and programming
• Data reporting and monitoring
• Advocacy
• Demand generation

The discussion was moderated by Allen Namagembe, Deputy Project Director, Uganda DMPA-SC Access Collaborative, PATH.

Panelists:

• Dr. Kayode Afolabi, Director and Head, Reproductive Health Division, Federal Ministry of Health, Nigeria
• Dr. Daniella Munene, Member, National Executive Committee, Pharmaceutical Society of Kenya
• Dr. Hortense Randrianaivo, President, Association of Pharmacists of Madagascar
• Mr. Célestin Compaore, Regional Project Director, DMPA-SC, Jhpiego, Burkina Faso