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      Building on safety, feasibility, and acceptability: the impact and cost of community health worker provision of injectable contraception

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          Abstract

          This project in Zambia contributes to our understanding of the impact of community-based provision of injectables on method choice and uptake and of the costs of adding DMPA to an established community-based family planning program. The project also illustrates the importance of involving stakeholders from the outset, analyzing costs relevant to scale up, and engaging in policy change dialogue not at the end, but rather throughout project implementation.

          Abstract

          This project in Zambia contributes to our understanding of the impact of community-based provision of injectables on method choice and uptake and of the costs of adding DMPA to an established community-based family planning program. The project also illustrates the importance of involving stakeholders from the outset, analyzing costs relevant to scale up, and engaging in policy change dialogue not at the end, but rather throughout project implementation.

          ABSTRACT

          Background:

          A critical shortage of doctors, nurses, and midwives in many sub-Saharan African countries inhibits efforts to expand access to family planning services, especially in rural areas. One way to fill this gap is for community health workers (CHWs) to provide injectable contraceptives, an intervention for which there is growing evidence and international support. In 2009, with approval from the Government of Zambia (GoZ), FHI 360 collaborated with ChildFund Zambia to design and implement such an intervention as part of its existing CHW family planning program.

          Methods:

          The safety of CHW provision of injectable DMPA (depot medroxyprogesterone acetate) was measured by client reports and by a 21-item structured observation checklist. Feasibility and acceptability were measured by interviews with CHWs and a subset of DMPA clients. The impact of adding DMPA to pill and condom provision was assessed by family planning uptake among the clients of trained CHWs from February 2010 to February 2011. Costs were documented using spreadsheets over the period November 2009 to February 2011.

          Results:

          Scores were high on all measures of safety, feasibility, and acceptability. Couple-years of protection (CYP, protection from pregnancy for 1 year) was provided to 51 condom clients, 391 pill clients, and 2,206 DMPA clients. Of the 1,739 clients new to family planning, 85% chose injectable DMPA, while 13% chose pills and 2% chose condoms. Continuation rates were also high, at 63% after 1 year as compared with 47% for pill users. Incremental costs per couple-year were US$21.24 if 50% of users continue with CHW-provided DMPA.

          Conclusion:

          The study affirms that the provision of injectable contraceptives by CHWs is safe, acceptable, and feasible in the Zambian context, with very high rates of uptake in hard-to-reach areas. High continuation rates among clients mean that costs of the intervention can be low when added to an existing community-based distribution program—a finding that is relevant to program replication (now underway in Zambia).

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          Most cited references 5

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          Provision of DMPA by community health workers: what the evidence shows.

          To reduce a large unmet need for family planning in many developing countries, governments are increasingly looking to community health workers (CHWs) as an effective service delivery option for health care and as a feasible option to increase access to family planning services. This article synthesizes evidence on the feasibility, safety and effectiveness of community-based delivery of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA). Manual and electronic search and systematic review of published and unpublished documents on delivery of contraceptive injectables by CHWs. Of 600 identified documents, 19 had adequate information on injectables, almost exclusively intramuscular DMPA, provided by CHWs. The data showed that appropriately trained CHW demonstrate competency in screening clients, providing DMPA injections safely and counseling on side effects, although counseling appears equally suboptimal in both clinic and community settings. Clients and CHWs report high rates of satisfaction with community-based provision of DMPA. Provision of DMPA in community-based programs using CHWs expanded access to underserved clients and led to increased uptake of family planning services. We conclude that DMPA can be provided safely by appropriately trained and supervised CHWs. The benefits of community-based provision of DMPA by CHWs outweigh any potential risks, and past experiences support increasing investments in and expansion of these programs. Published by Elsevier Inc.
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            Community-based health workers can safely and effectively administer injectable contraceptives: conclusions from a technical consultation.

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              • Abstract: not found
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              Community-based distribution of injectable contraceptives: introduction strategies in four sub-Saharan African countries.

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                Author and article information

                Journal
                Glob Health Sci Pract
                Glob Health Sci Pract
                ghsp
                ghsp
                Global Health, Science and Practice
                Global Health: Science and Practice
                2169-575X
                November 2013
                09 October 2013
                : 1
                : 3
                : 316-327
                Affiliations
                [a ]FHI 360, Division of Health Services Research , Research Triangle Park, NC, USA
                [b ]FHI 360, Division of Research Utilization , Research Triangle Park, NC, USA
                [c ]FHI 360, TB CARE I , Lusaka, Zambia
                [d ]ChildFund Zambia , Lusaka, Zambia
                [e ]Republic of Zambia Ministry of Health , Lusaka, Zambia
                Author notes
                Correspondence to Dawn Chin-Quee ( dchin-quee@ 123456fhi360.org ).
                Article
                GHSP-D-13-00025
                10.9745/GHSP-D-13-00025
                4168589
                © Chin-Quee et al.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of this license, visit http://creativecommons.org/licenses/by/3.0/

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