Self-Injection Best Practices Project: Uganda

Publication date: 2017

Sayana Press is a registered trademark of Pfizer Inc. R E P R O D U C T I V E H E A L T H Self-Injection Best Practices Project: Uganda CONTRACEPTIVE SELF-INJECTION Access to a range of contraceptive choices allows each woman to find her best option for preventing unintended pregnancies. Injectable contraceptives have been widely used for decades, providing three months of protection from pregnancy between each injection. Self-injection of contraception is a new option that gives women even more control over whether and when to have children, and it can also decrease time and cost associated with quarterly trips to a clinic. Subcutaneous DMPA (DMPA-SC) is a new, easy-to- use injectable contraceptive that facilitates delivery in a wider variety of places—and its unique design makes it particularly well-suited for self-injection. Sayana® Press is currently the most widely available DMPA-SC product. UGANDA SELF-INJECTION BEST PRACTICES PROJECT Evidence from research and introduction in Uganda (see page 2) suggests that women are able to self-inject DMPA-SC following training from health providers. As the Uganda Ministry of Health plans for national rollout of self-injection, there is a need to learn how self-injection can be designed and implemented at scale, under routine conditions. PATH’s Self-Injection Best Practices project was developed to address this need. This project:  Identifies self-injection program components and models (see box) for public-sector facilities, community-based distribution, private-sector outlets, and safe spaces for young women and adolescent girls.  Implements these program models across delivery channels.  Evaluates self-injection program models to determine what works.  Disseminates optimal self-injection program components and delivery models to inform policy and practice in Uganda and beyond. PROGRESS TO DATE Identifying program models to implement/evaluate In early 2017, PATH applied principles of user-centered design to identify program models that focus on users’ needs, behaviors, constraints, and operating contexts. The process began with reflection on learning and results from self-injection studies and pilots in Uganda, as well as current best practices in family planning delivery in general. Program components spanned multiple topics, as illustrated below. Specific activities for refining draft program models included:  Journey maps: Program model designs were translated into “journey maps”—tools that help program designers walk through hypothetical client and provider experiences in a self-injection program.  Feedback meetings: Workshops were organized to collect feedback on the journey maps from clients, facility-based family planning providers, community health workers, the Ministry of Health, and implementing partners. To better understand the entire program experience for clients and providers, workshop participants role-played each step of the program using the journey map as a guide. Feedback from the actors and observers was solicited using semi- structured feedback guides.  Rapid pilot: Draft program models were revised following the feedback meetings, and a rapid pilot was launched in May 2017 in four facilities to gather insights from actual delivery experience. The rapid pilot’s objective was to assess what program components work best with local staff and clients, making adjustments to the program over a three-month period of intensive monitoring and engagement. (See next page for insights to date.) NEXT STEPS Implementation and evaluation Once the designs are finalized, various program models will be implemented and evaluated across the following delivery channels in 2017–2018:  Public-sector facilities and community health workers in multiple districts. DEFINITIONS Program component: A specific program design element that can be varied. Optimal program components: Those elements achieving the best results in terms of client proficiency, cost-efficiency, accessibility, and satisfaction among clients and providers. Program model: Full set of program components necessary to deliver self-injection. October 2017  Private-sector clinics and pharmacies/drug shops, in collaboration with the Uganda Health Marketing Group (UHMG).  Safe spaces for adolescent girls and young women, facilitated by Mildmay Uganda. Multiple aspects will be evaluated across the different delivery channels to identify the most successful program models for self-injection of DMPA-SC. Given the overall goal of avoiding unintended pregnancies, client self-injection proficiency is the most critical outcome necessary for a successful program. Cost- efficiency, accessibility, user satisfaction, provider practice, and provider perspectives on feasibility will also be assessed. BACKGROUND ON SELF-INJECTION Global approvals of contraceptive self-injection In 2015, Pfizer’s Sayana Press was approved for self-injection in the United Kingdom and several other European countries, and since then it has been approved in an increasing number of FP2020 countries, including Ghana, Mali, Myanmar, Niger, Nigeria, Uganda, and Zambia. The World Health Organization recommends self-administration of subcutaneous injectable contraception in circumstances where training and support are available for women. Experience with self-injection in Uganda Self-injection research and programs with DMPA-SC (specifically Sayana Press) have been ongoing in Uganda since 2015. In partnership with the Uganda Ministry of Health, PATH carried out studies to determine the feasibility and acceptability of self-injection in Uganda. Results from the study indicated that most participants could self-inject competently, three months after being trained one-on-one by a nurse at a public- sector facility. Participants also found self-injection to be easy and wished to continue self-injecting. These findings led to government willingness to offer self-injection outside of a research setting on a small scale. In late 2016, a self-injection pilot program was launched in public facilities in Mubende district. This is the first offer of self-injection outside of a research setting in sub-Saharan Africa. In total, 105 providers in 48 facilities were trained to offer the option of self-injection during routine family planning visits, representing more than 80 percent of health centers within the district. Among facilities reporting relevant data as of April 2017, about 20 percent of injectable contraception users had chosen to receive training on self-injection. The Uganda National Drug Authority approved integration of self-injection in product labeling for Sayana Press in March 2017, a key step toward national scale-up of the practice. The national scale-up task force on DMPA-SC will integrate self- injection in future plans for rollout of the product. KEY RESOURCES  PATH subcutaneous DMPA website  Self-injection training curriculum  Subcutaneous DMPA evidence-at-a-glance For further information, contact sayanapress@path.org PROGRAM INSIGHTS SO FAR Early results indicate that group training by community health workers and nursing assistants (rather than higher-level cadres of nurses or midwives) is a promising approach. It may be possible for women to learn the injection steps without actually practicing injections, especially if they are given brief and clear visual/written instructions. Women are able to store the unused devices at home relatively easily, often in a handbag or suitcase. Women prefer follow-up approaches that they can initiate themselves (e.g., visiting a community health worker or facility if needed). Providing a copy of the instructions used during training helps women with correct use, and women appreciate having a visual aid to take home for independent self-injection. Latrine disposal is preferred by clients, but it is not perceived by stakeholders to be sustainable; women may be open to returning used devices to a facility, community health worker, or local drug shop/pharmacy. Providing an impermeable and inconspicuous device (e.g., petroleum jelly container, wide- mouth water bottle) can support women to store used devices safely prior to disposal.

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