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Bershteyn A, Resar D, Kim HY, Platais I, Mullick S. Optimizing the pipeline of multipurpose prevention technologies: opportunities across women's reproductive lifespans. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1169110. [PMID: 37325241 PMCID: PMC10266103 DOI: 10.3389/frph.2023.1169110] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
HIV/AIDS and maternal mortality are the two leading causes of death among women of reproductive age in sub-Saharan Africa. A growing body of research investigates opportunities for multipurpose prevention technologies (MPTs) that prevent unintended pregnancy, HIV, and/or other sexually transmitted infections (STIs) with a single product. More than two dozen MPTs are currently in development, most of them combining contraception with HIV pre-exposure prophylaxis, with or without protection from other STIs. If successful, such MPTs could offer women benefits at multiple levels: greater motivation for effective use; lower product administration burden; accelerated integration of HIV, STI, and reproductive health services; and opportunities to circumvent stigma by using contraception as a "fig leaf" for HIV and/or STI prevention. However, even if women find respite from product burden, lack of motivation, and/or stigma in contraceptive-containing MPTs, their use of MPTs will be interrupted, often multiple times, over the reproductive lifecourse due to desire for pregnancy, pregnancy and breastfeeding, menopause, and changes in risk. Interruptions to the benefits of MPTs could be avoided by combining HIV/STI prevention with other life-stage-appropriate reproductive health products. New product concepts could include combining prenatal supplements with HIV and STI prevention, emergency contraception with HIV post-exposure prophylaxis, or hormone replacement therapies for menopause with HIV and STI prevention. Research is needed to optimize the MPT pipeline based on the populations underserved by available options and the capacity of resource-constrained health systems to deliver novel preventative healthcare products.
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Affiliation(s)
- Anna Bershteyn
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Danielle Resar
- Clinton Health Access Initiative, Boston, MA, United States
| | - Hae-Young Kim
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Ingrida Platais
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Saiqa Mullick
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
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Corneliess C, Cover J, Secor A, Namagembe A, Walugembe F. Adolescent and Youth Experiences With Contraceptive Self-Injection in Uganda: Results From the Uganda Self-Injection Best Practices Project. J Adolesc Health 2023; 72:80-87. [PMID: 36243559 PMCID: PMC9746348 DOI: 10.1016/j.jadohealth.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/08/2022] [Accepted: 08/12/2022] [Indexed: 12/15/2022]
Abstract
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 (2017-2019) project 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; 86.1% 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.
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Affiliation(s)
| | - Jane Cover
- PATH, Sexual and Reproductive Health Team, Seattle, Washington
| | - Andrew Secor
- PATH, Sexual and Reproductive Health Team, Seattle, Washington
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Ali G, Porter Erlank C, Birhanu F, Stanley M, Chirwa J, Kachale F, Gunda A. Perspectives on DMPA-SC for self-injection among adolescents with unmet need for contraception in Malawi. Front Glob Womens Health 2023; 4:1059408. [PMID: 37034400 PMCID: PMC10073669 DOI: 10.3389/fgwh.2023.1059408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 03/02/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction Malawi has made progress in expanding access to modern contraceptive methods over the last decade, including the introduction of depot-medroxyprogesterone acetate subcutaneous (DMPA-SC) in 2018. DMPA-SC offers women the option to self-inject at home and may benefit adolescents with unmet need for contraception due to its discretion. This qualitative study was conducted to assess perspectives and preferences of adolescents with unmet need for contraception regarding the self-injection option of DMPA-SC in Malawi. Methods Six focus group discussions were conducted involving 36 adolescents with unmet need for contraception (aged between 15 and 19 years, married and never-married) in October 2021 in three districts in Malawi. Data were coded inductively and analyzed thematically, using Dedoose software. Two validation workshops were conducted with other adolescents with unmet need in February 2022 to elucidate the preliminary findings. Results DMPA-SC attributes such as discretion and reduced facility visits were ranked most appealing by both married and never-married adolescents, particularly for adolescents needing covert contraception use. Concerns about self-injection included fear of pain, injury, and doubt in ability to self-inject. Never-married adolescents had additional concerns around privacy at home if using covertly, and fears of affecting long-term fertility. Overall, health surveillance assistants (community-based healthcare workers) were voted to be the most private, convenient, and affordable sources for potential DMPA-SC self-injection training. Conclusion Self-injection of DMPA-SC may offer an appealing option for adolescents in Malawi, aligning most closely to the needs of married adolescents who may wish to delay or space pregnancies conveniently and discreetly, and who also may face fewer access barriers to receiving self-injection training from health care providers. Access barriers including stigma and concerns about privacy at home for adolescents needing to use contraception covertly would need to be adequately addressed if never-married adolescents were to consider taking up this option.
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Affiliation(s)
- Gracious Ali
- Sexual, Reproductive, Maternal and Newborn Health program, Clinton Health Access Initiative (CHAI) Inc., Lilongwe, Malawi
- Correspondence: Gracious Ali
| | - Chelsey Porter Erlank
- Analytics and Implementation Research Team, Clinton Health Access Initiative (CHAI) Inc., London, United Kingdom
| | - Frehiwot Birhanu
- Sexual, Reproductive, Maternal and Newborn Health program, Clinton Health Access Initiative (CHAI) Inc., Lilongwe, Malawi
| | | | - Jessie Chirwa
- Reproductive Health Directorate, Malawi Ministry of Health, Lilongwe, Malawi
| | - Fannie Kachale
- Reproductive Health Directorate, Malawi Ministry of Health, Lilongwe, Malawi
| | - Andrews Gunda
- Clinton Health Access Initiative (CHAI) Inc., Lilongwe, Malawi
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Testing a counseling message for increasing uptake of self-injectable contraception in southern Malawi: A mixed-methods, clustered randomized controlled study. PLoS One 2022; 17:e0275986. [PMID: 36256638 PMCID: PMC9578616 DOI: 10.1371/journal.pone.0275986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 09/27/2022] [Indexed: 11/19/2022] Open
Abstract
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.
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Morozoff C, Cover J, Namagembe A, Nsangi D, Komunyena Tumusiime J, Stout A, Kidwell Drake J. Contraceptive self-injection through routine service delivery: Health worker perspectives from Uganda. Front Glob Womens Health 2022; 3:890017. [PMID: 36204255 PMCID: PMC9531016 DOI: 10.3389/fgwh.2022.890017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 08/17/2022] [Indexed: 11/15/2022] Open
Abstract
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.
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Ruderman LW, Packer C, Zingani A, Moses P, Burke HM. "Men can take part": examining men's role in supporting self-injectable contraception in southern Malawi, a qualitative exploration. Reprod Health 2022; 19:174. [PMID: 35945601 PMCID: PMC9361263 DOI: 10.1186/s12978-022-01476-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The male engagement framework for reproductive health, which presents men as family planning users, supportive partners, and agents of change, is being increasingly incorporated into family planning strategies worldwide. We applied this framework to understand the perspectives of and role that men play in supporting the use of self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC). METHODS We conducted a qualitative analysis using data from a study conducted in southern Malawi to develop and test a counseling message to introduce DMPA-SC and self-injection. We conducted 4 focus group discussions (FGD) with male community leaders and partners of DMPA-SC users, 13 interviews and FGDs with public and private sector family planning providers, and 30 interviews with female clients. We explored all participant groups' perspectives on what could facilitate or prevent women from choosing self-injection, including views on men's attitudes towards DMPA-SC and self-injection. RESULTS Overall, participants expressed ways that men could be engaged as cooperative users, supportive partners, and agents of change, and felt that this would help build a more supportive environment for DMPA-SC self-injection use. Men held favorable opinions of DMPA-SC self-injection: they felt that it is useful, described ways they could actively and emotionally support their partners in its use, and described their role in normalizing it. CONCLUSIONS We suggest that DMPA-SC self-injection has the potential to be both a female-controlled and a cooperative method, based on the ability for women to use it autonomously and the option to encourage male partner involvement (only where the woman welcomes this). Shifting the conversation from viewing men as a barrier to men as a resource may allow us to harness the social capital of men and transform traditional power dynamics, therefore establishing more enabling environments to support autonomy and choice for DMPA-SC and self-injection use.
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Affiliation(s)
- Lucy W Ruderman
- Reproductive, Maternal, Newborn and Child Health Division, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| | - Catherine Packer
- Reproductive, Maternal, Newborn and Child Health Division, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA.
| | - Akuzike Zingani
- Centre for Health, Agriculture Development Research and Consulting (CHAD), Blantyre, Malawi
| | - Philemon Moses
- Centre for Health, Agriculture Development Research and Consulting (CHAD), Blantyre, Malawi
| | - Holly M Burke
- Reproductive, Maternal, Newborn and Child Health Division, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
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Curtis KM, Nguyen A, Reeves JA, Clark EA, Folger SG, Whiteman MK. Update to U.S. Selected Practice Recommendations for Contraceptive Use: Self-Administration of Subcutaneous Depot Medroxyprogesterone Acetate. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2021; 70:739-743. [PMID: 34014910 PMCID: PMC8136426 DOI: 10.15585/mmwr.mm7020a2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR), adapted by CDC from global guidance developed by the World Health Organization (WHO), provides evidence-based guidance on contraceptive use for U.S. health care providers (1). During January-February, 2021, CDC evaluated the 2019 WHO recommendation on self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) (2). CDC adopted the WHO recommendation on the basis of moderate-certainty evidence that self-administered DMPA-SC is safe and effective, and has higher continuation rates compared with provider-administered DMPA. The new U.S. SPR recommendation states that self-administered DMPA-SC should be made available as an additional approach to deliver injectable contraception. Provider-administered DMPA should remain available. Self-administered DMPA-SC is a user-controlled method that has the potential to improve contraceptive access and increase reproductive autonomy. Self-administered DMPA-SC should be offered in a noncoercive manner through a shared decision-making process between patients and their health care providers, with a focus on patient preferences and equitable access to the full range of contraceptive methods.
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Affiliation(s)
- Kathryn M Curtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Antoinette Nguyen
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Jennifer A Reeves
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Elizabeth A Clark
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Suzanne G Folger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Maura K Whiteman
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
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Burke HM, Packer C, Wando L, Wandiembe SP, Muwereza N, Pradhan S, Zingani A, Ngwira B. Adolescent and covert family planning users' experiences self-injecting contraception in Uganda and Malawi: implications for waste disposal of subcutaneous depot medroxyprogesterone acetate. Reprod Health 2020; 17:117. [PMID: 32746860 PMCID: PMC7396890 DOI: 10.1186/s12978-020-00964-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background 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. Methods We conducted cross-sectional qualitative studies in 2019 with 50 self-injectors in Uganda and 60 in Malawi. We purposively selected approximately half adolescents and included those trained by clinic-based providers and community health workers. We conducted semi-structured interviews and thematic data analysis and compared the findings across settings. Results Just under half of both samples were adolescents, substantially more of whom were covert users in Uganda (68%) than Malawi (~ 10%). Most participants reported being told to store used units in a container and return them to health workers. About two-thirds of Uganda participants had disposed of at least one unit by the interview, most commonly returning them to health workers. Over one-third of Malawi participants had disposed of at least one unit by the interview, slightly more disposed into latrines compared to returning to health workers. Participants in both settings reported compliance with health workers’ disposal instructions as a primary reason for their disposal method. One-fifth of Uganda participants, mostly adolescent covert users, and one-quarter in Malawi said they were told they could dispose into latrines, and often did so. The majority in both settings said they would prefer to dispose units in latrines because they worried about needlestick injuries to others and because it was convenient. Some Uganda adolescent covert users felt returning units to health workers was challenging due to privacy concerns. Conclusions While most self-injectors disposed of used units as instructed, findings from both studies suggest that returning units to health workers is not preferred and may not be feasible for some adolescent covert users. More convenient disposal solutions should be identified.
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Affiliation(s)
- Holly M Burke
- Reproductive, Maternal, Newborn and Child Health, FHI 360, 359 Blackwell Street, Suite 200, Durham, North Carolina, 27701, USA.
| | - Catherine Packer
- Reproductive, Maternal, Newborn and Child Health, FHI 360, 359 Blackwell Street, Suite 200, Durham, North Carolina, 27701, USA
| | - Laura Wando
- WellShare International, PO Box 35514, Kampala, Uganda
| | | | - Nelson Muwereza
- N&E Consult International Limited, PO Box 75686, Makerere Hill Kampala, Uganda
| | - Subarna Pradhan
- Reproductive, Maternal, Newborn and Child Health, FHI 360, 359 Blackwell Street, Suite 200, Durham, North Carolina, 27701, USA
| | - Akuzike Zingani
- University of Malawi, Polytechnic, PO Box 303, Chichiri, Blantyre 3, Malawi
| | - Bagrey Ngwira
- University of Malawi, Polytechnic, PO Box 303, Chichiri, Blantyre 3, Malawi
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