Trained VHTs demonstrate self-injection during OGS visit to Bugweri District, Namunyumya HC II. Source: Laura Wando/WellShare International.
WellShare International is integrating DMPA SC self-injection in six sub-counties of Iganga and Bugweri Districts, Uganda in the context of a full and informed choice family planning program. Community Health Workers, known as Village Health Team (VHT) members in Uganda, and health workersoffered injectable contraceptives within youth-friendly community-based family planning services. In the WellShare program, they were trained to train their adolescent clients to self-inject DMPA-SC.
In July and August 2018, WellShare conducted a refresher training for 70 VHTs and 18 health workers in four sub-counties in Bugweri District and two in Iganga District. Following training, the providers were able to train clients to self-inject when they selected DMPA-SC as their method, as long as the clients were eligible to use DMPA-SC and opted to take part. After successful training and observed self-injection, most clients were given a simple job aid with self-injection instructions and a calendar along with two DMPA SC units to take home so that they could reinject themselves when due for reinjection.
Providers were able to integrate counseling and training for self-injection into their existing service package for new and returning clients. Key aspects of the approach were: 1) use of job aids and a calendar to determine reinjection dates with the client, 2) discussion with clients on safe storage options for self-injection units, and 3) identification of locally available safe disposal containers to store used units until they returned to their providers.
Before the training in self-injection, one VHT, from Buyanga Sub–County, Bugweri District, had tried several times to reach out with reproductive health information and counselling to one 14-year-old girl. Nakimera (not her real name) was already sexually active, and had refused to protect herself against pregnancy, saying that she was still young and not yet married. Unfortunately, when Nakimera was 17 years old, she became pregnant. She sought an abortion, but experienced complications and almost died.
Nakimera remembered the VHT who had talked to her a couple years before and sought her out to obtain information and services to avoid getting pregnant again. This VHT had just finished training in self-injection. She counseled Nakimera on contraceptive options. When Nakimera opted for DMPA SC, the VHT asked her if she would like to inject herself if trained. Nakimera was excited, and was able to correctly inject herself on her first try in front of the VHT. . She took home two units for reinjection, along with a calendar to help her remember and calculate reinjection dates and a job aid explaining and illustrating the steps one goes through to self-inject. Nakimera found the self-injection option convenient for her, she does not have to worry about taking contraception at school and the reinjection windows coincided with school term holidays so she wouldn’t need to miss school when she returns for resupply.
Nakimera knew that many of her peers would also benefit from the self-injection approach, which seemed a better alternative than seeking contraceptives from the Health Centers or VHT homes. She talked about it amongst her peers and mobilized over 15 adolescents to come to the VHTfor family planning services. Naikandi says she meets the adolescents at a borehole when they have come to collect water, educates them on reproductive health and family planning, and invites those who opt for self-injection to her home to conduct the training. A total of 15 adolescents mobilized by Nakimera opted for DMPA-SC and have since trained and are self-injecting. However, self-injection is not always the first choice for DMPA-SC users. Some prefer to keep coming back and reinjecting themselves at the VHT’s home because they have nowhere to store the units and some parents are unaware that their daughters are using the method.
Wellshare’s program is also contributing to the evidence base. WellShare and FHI 360 are jointly conducting implementation science research to describe the experiences of DMPA-SC self-injectors, including the acceptability of self-injection among adolescents and discreet users and a special study on waste management. Results will be disseminated later this year.
- Self-injection eases family planning access for clients including adolescents.
- Positive peer influence through family planning champions is very sustainable.
- Traumatic experiences sometimes prompt women and adolescents to make family planning decisions.
- Provider flexibility and friendliness can greatly improve community-based family planning services.
- Adolescent clients do affirm the common slogan of “where there’s a will, there’s a way.” When a VHT is willing to serve adolescent clients, adolescents will go miles to find the assistance they need.