Community Programs Can Safely Increase Access to Injectables
Providing injectables in the community gives women the choice of injectables in rural areas of Ethiopia, Ghana, Papua New Guinea, Thailand, and parts of other countries where clinics are hard to reach (8, 44, 61, 101, 124, 139, 147). In Bangladesh community programs serve both urban and rural areas (164). Community programs offer injectables from mobile clinics, village clinics, periodic temporary outreach clinics, or at the homes of clients or community health workers. Injectables services have been added to community provision of oral contraceptives and condoms and offered along with immunizations, other maternal and child health services, and some curative services (44, 183, 186).
In most countries these efforts have consisted of pilot studies. Two exceptions are Bangladesh, which used elements of the Matlab Project in the government family planning program, and Ghana, which is scaling up the Navrongo Initiative in the nationwide Community-Based Health Planning and Services (CHPS) Initiative (138, 164).
Community provision has dramatically increased use of injectables. In the Navrongo Initiative, for example, contraceptive prevalence rose from 3.4% to 8.2% between 1993 and 1999, when 92% of contraceptive users were using injectables (44, 138). In this and other projects, many women chose injectables as their first modern method of contraception (44, 54, 138, 139). In some areas of Bangladesh, however, community provision had less of an effect on overall prevalence because women switched to injectables from other modern methods (66).
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A community nurse gives a contraceptive injection to a woman in Papua New Guinea. Small community programs in several countries and large-scale programs in a few have given women in rural areas the choice of injectables. © Kingston Namun/Mark Munguas, Courtesy of Photoshare
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Community Provision and Clinic Provision Prove Comparable in Quality
A study in Uganda compared the quality of the provision of injectables in the community and in the clinic. The study—carried out by Family Health International and Save the Children/USA in collaboration with the Ministry of Health (MOH) and Nakasongola local government—enrolled 449 community clients and 328 clinic clients and followed them up 13 weeks after their first injection of DMPA. Clinic providers were MOH nurses, and the community providers were local volunteers, who were affiliated with a clinic and had been providing free oral contraceptives and condoms in the community.
The community providers received classroom and clinical training, and they learned to screen clients with the help of a checklist (see Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN), in the companion issue of INFO Reports).
They gave injections in their homes or at the homes of their clients and were supervised by program and clinic staff and district health officers (183).
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Community provision has dramatically increased use of injectables in some areas.
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The study compared several factors that contribute to quality:
- Screening for medical eligibility: There were no reported screening mistakes made by community providers or clinic providers (182).
- Counseling: At follow-up the clients were asked about side effects and about specific points made by their providers. Levels of clients' knowledge of bleeding changes, sexually transmitted infections, and reasons to return to the clinic were the same for community and clinic groups, and both needed improvement. For example, 20% or less of community and clinic clients knew that no monthly bleeding was a common side effect of DMPA. One difference reported by clients was that in initial counseling community providers mentioned other contraceptive choices less often than did clinic providers.
- Injection safety: None of the 777 clients reported infections at the injection site, and no providers reported needlestick injuries. Overall, 24 of the 449 community clients (5%) reported problems, compared with 8 of the 328 clinic clients (2%). Most of the problems were minor, such as temporary numbness or mild pain at the injection site. Four of the eight community clients reported severe pain. Three had received their injection from the same provider, who was then given more training. In the Matlab Project in Bangladesh, an assessment reported four abscesses in over 14,000 DMPA injections (3).
- Disposal of waste: In Uganda community providers were instructed to place used needles and syringes into sharps containers and carry the boxes to a clinic, where they would be burned and buried. Also, they could throw used needles and syringes into pit latrines. The community providers handled syringes safely, but disposal of used syringes from both clinic and community providers needed improvement at some clinics (182). Disposal has also needed improvement in the Navrongo and CHPS initiatives in Ghana (1, 225).
- Continuation rates: The percentages who had second injections in Uganda were similar—88% among community clients and 85% among clinic clients. Few other studies have compared continuation rates in community and clinic programs. In one, a Mexican study of the combined injectable Cyclofem, the one-year continuation rate was 37% among the 640 community clients and 22% among 2,817 clinic clients (60).
In Bangladesh continuation rates were lower in some areas of the scaled-up government program than in the Matlab Project. The one-year continuation rate was 69% in the Matlab Project, in which each provider was responsible for a population of 1,200 and visited clients every two weeks. In eight scale-up areas where each provider was responsible for a population of 6,800 and visited clients every three months or more, one-year continuation rates in two areas were 35% and 46% (139).
- On-time repeat injections: In Uganda almost all continuing clinic and community clients received their second injections on time, 94% in both groups. A little more than half of community clients had their second injection at the community provider's home, and about one-third had the injection in their own home. The rest had the injection either at a clinic or an unrecorded location (183).
In trials in Bolivia and Guatemala also, many women had injections at clinics or the homes of community providers rather than in their own homes, most likely to maintain privacy (109).
In the Navrongo Initiative some women choose to visit the community provider on market days, and they count on her to know if they need an injection or can wait for the next visit (1).
Morale and Costs Are Concerns of Scaled-Up Programs
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Many women had injections at clinics or the homes of community providers rather than in their own homes, most likely to maintain privacy.
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The benefits of training last only as long as providers remain on the job. Turnover among community nurses has been high in the CHPS Initiative in Ghana. Community nurses work in difficult conditions, and some are stationed away from their families. To improve morale, the Ghana Health Service is increasing incentives for nurses to stay on the job and encouraging communities to select candidates and pay for their training. After training, the nurses return and work in their home areas (1, 138, 225).
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Community providers in Uganda practice safe injection techniques. With appropriate training, a range of health care providers can learn to give injections safely. Photo: John Stanback/Family Health International
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The cost of offering injectables and other health services in clients' homes has been a concern in Bangladesh. The government stopped household services in the late 1990s and set up community clinics to save money and increase efficiency by offering more services at each client visit (113, 164). The change in policy did not affect use of injectables or oral contraceptives in general, but it may have reduced access to health services for some poor and uneducated women (5, 113, 164). In a survey, over 80% of women said they valued home visits because the community provider gave them helpful information and their housework was not interrupted. A new government elected in 2002 resumed household services (113).
Today, as pilot projects are scaled-up, community provision of injectables challenges programs to ensure quality of care. Hiring and retaining enough providers, screening for medical eligibility, counseling, and waste disposal need attention in training and supervision (1, 66, 182, 225). Tomorrow, as more countries test and improve community provision of injectables, more women in isolated areas will have another contraceptive choice.
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