Menu
Menu
Menu
Menu
N/A
Objectives: The objective of this research is to assess the acceptability of the provision of subcutaneously administered depo medroxyprogesterone acetate (DMPA-SC) by nonclinically trained community health workers (CHWs) among acceptors in the rural province of Lualaba in the Democratic Republic of the Congo (DRC). Study design: In 2017, 34 CHWs received training in provision of DMPA-SC. Among other methods, DMPA-SC by CHWs was offered during household visits and at community outreach events. The initial survey included questions on acceptors’ demographic characteristics, contraceptive use history and experience with provision of DMPA-SC by a CHW. The follow-up included questions about side effects experienced and continuation of DMPA-SC by a CHW. Results: Seventy-four percent of initial acceptors of DMPA-SC (N=252) were first-time contraception users. Almost all (96.0%) felt very comfortable with a CHW performing the injection rather than a physician or nurse, and 97.6% perceived that the CHW was very comfortable performing the injection. A total of 239 women were interviewed at follow-up. Most expressed satisfaction with the method despite some side effects experienced. Almost all acceptors (97.9%) were satisfied with the information provided by CHWs, and 93.8% were satisfied with the overall service. Most (96.4%) would choose to continue receiving DMPA-SC by a CHW rather than in a health clinic, and 95.2% would recommend DMPA-SC by a CHW to a friend. Conclusions: Overall, administration of DMPA-SC by CHWs is acceptable to users in Lualaba. DMPA-SC can be safely provided within the community after proper training. Implications: This study validates the use of CHWs (without clinical training) to provide DMPA-SC in a rural sub-Saharan African setting. It also represents an important step in obtaining official MOH authorization for the scale-up of this mechanism of distribution to other underserved regions in the DRC.
In 2014, the United States Agency for International Development’s Evidence to Action for Strengthened Family Planning and Reproductive Health Services for Women and Girls Project (E2A) was enacted in the DRC [13]. Led by Pathfinder International, working in collaboration with the Ministry of Health (MOH), E2A aims to “improve the quality of integrated community-based family planning and maternal, newborn and child health services” [13]. The pilot intervention detailed in this paper is an extension of E2A’s work in the DRC. The E2A project covers 51 health areas in 15 health zones (HZs) in 3 provinces in the DRC: Lualaba, Kasai Central and Lomami [13]. Central to the E2A project is the cadre of CHWs (known locally as “RECOS” for relais communautaires) who receive direct support from local nurses and health authorities [13]. Under this project, CHWs conduct household visits and participate in community outreach events (Stratégie Avancée) to provide FP information and counseling, and a range of nonclinical contraceptive methods including male and female condoms, pills and Cycle Beads® [13]. Under E2A, a health team including a nurse from the fixed facility and one or more CHWs arrive in a central location once a month to provide health services. During each Stratégie Avancée, CHWs hold awareness sessions describing the full range of contraceptive methods. If a woman chooses a method CHWs are authorized to provide (pills, condoms or CycleBeads®), she participates in an individual counseling session to determine her eligibility for that method before receiving it from a CHW. Those who select a method requiring clinician administration (implant, intrauterine device or injectable) are directed to a registered nurse to administer the method. Under the E2A program, nurses provide DMPA-IM to clients interested in receiving an injectable. This pilot study expands the E2A project by training CHWs to provide DMPA-SC during Stratégie Avancée and home visits, freeing up the nurse to tend to other healthcare delivery services. CHWs who were already trained in the E2A project and met the selection criteria1 were invited to participate in the training of DMPA-SC provision. The training, which ranged from 5 to 7 days depending on the CHW’s knowledge and skill level, included a brief refresher of other contraceptive methods but focused on teaching CHWs to inject DMPA-SC and counsel on its side effects. It also included training with a standardized eligibility checklist specific for each available method. The checklist included pregnancy screening questions, but in some cases, rapid pregnancy tests (BetaHCG) were used to confirm pregnancy status. After demonstrating competence using anatomical models, CHWs also participated in a field exercise that included close supervision by their trainers in a real-world setting. Upon successful completion of the training, CHWs were supplied with DMPA-SC (in the form of Sayana® Press, manufactured by Pfizer, Inc., and delivered through the Uniject™ injection system) as a method they were authorized to provide in the community, both during the Stratégie Avancée and door-to-door. A total of 34 CHWs participated in the pilot. The average age of participating CHWs was 42.2 years, 52.9% (n=18) were female, almost three quarters were married (n=25), and all but one CHW had children (mean number: 5.8 children) [14]. The province of Lualaba was deliberately selected for this pilot due to civil unrest in the other provinces. Two HZs in Lualaba (Fungurume and Bunkeya) were selected according to three criteria: their rurality, relatively dense populations and accessibility. Table 1 provides demographic characteristics of the province of Lualaba compared to the DRC as a whole. Women in Lualaba are less educated, less likely to be using a modern method and are more likely to have an unmet need for limiting than women across the country. Weighted demographic characteristics of women ages 15–49 in the Province of Lualaba compared to the Democratic Republic of the Congo as a wholea Women who selected DMPA-SC by a CHW were invited to participate in a short survey about their experience. Upon agreeing, these acceptors were enrolled into the study. The sample includes a total of 252 women. Ten female interviewers received training on the questionnaire and survey protocol. The interview team accompanied CHWs to the Stratégie Avancée to enroll clients who selected and received DMPA-SC. Interviews followed an approved script, in which the study objectives were explained to the acceptor and informed consent was obtained. The initial survey included questions on acceptors’ demographic characteristics, contraceptive use history, and experience with counseling and injection of DMPA-SC by a CHW. In cases where DMPA-SC was provided during a home visit outside of the Stratégie Avancée, the interview took place following the same procedure provided an interviewer was available nearby to enroll the clients who agreed to participate. Approximately 12 weeks after the initial injection, the research team contacted each eligible respondent who received DMPA-SC, took part in the initial interview and agreed to be contacted for the follow-up survey. The follow-up included questions about side effects experienced and continuation of DMPA-SC by a CHW. All survey data were collected using encrypted smartphones programmed with the OpenDataKit (ODK) application. Transmission of the data through ODK to the online server, FormHub, provided the study personnel with immediate access to the data. Respondents received no compensation for their participation in this study. The survey data were analyzed using STATA/SE 13. Data collection for this research was approved by Tulane University Institutional Review Board (16-#911338) as well as by the Ethics Committee of the Kinshasa School of Public Health (#ESP/CE/071/2016).
N/A
