SPOTLIGHT
From Norplant to Jadelle: Smooth Transition in a Dominican Republic Clinic
PROFAMILIA, a private nonprofit clinic in Santo Domingo, Dominican Republic, had been routinely providing Norplant for 30 years when it successfully switched to Jadelle in 2002. The clinic was eager to start providing the new implant because Jadelle is quicker to insert and remove than Norplant, has fewer complications with removal, and is less visible in the arm.
During the transition researchers studied the acceptability of Jadelle to clients and providers. The clinic offered both Norplant and Jadelle to all clients at the same subsidized price of about US$30. The clinic’s staff learned to provide Jadelle quickly and easily. Initially, some clients were hesitant to use an unfamiliar product. PROFAMILIA has now stopped offering Norplant, however, and its clients are satisfied with Jadelle as an alternative.
The study findings suggest that, especially where Norplant is well-known and liked, counseling clients about the comparative advantages of the new implants is necessary. This counseling led some women to choose Jadelle. Others, however, still preferred Norplant, while it was available. Once PROFAMILIA stopped offering Norplant, counseling was very effective in helping Norplant-seeking clients accept Jadelle.
Providers Adapted Quickly and Overwhelmingly Preferred Jadelle
Because the PROFAMILIA providers were familiar with Norplant, they needed little training to start offering Jadelle. The staff members attended a one-hour training followed by a question and answer session conducted by one of the researchers. The researcher discussed the two implants in terms of effectiveness, adverse events, continuation and termination rates, mechanism of action, and hormone levels in the blood. The researcher also explained insertion and removal procedures but did not perform either a live demonstration or use a model arm.
The majority of the providers were satisfied with this training. One-third would have liked an actual demonstration of insertion and removal as well. Still, none of the providers felt that the lack of a demonstration limited their ability to insert the new implants. A clinic supervisor reported that the staff became comfortable with Jadelle “immediately.”
After providing the new implant for 18 months, the providers almost unanimously preferred Jadelle over Norplant. They favored Jadelle because fewer rods made insertion and removal easier.
Some Clients Hesitant to Choose an Unfamiliar Product
At the PROFAMILIA clinic some women were more comfortable with the method that was well-known and recommended by friends and family, even when an alternative was available. Since there had been little local promotion of Jadelle, most women were unfamiliar with it. Providers explained to clients that inserting and removing Jadelle is quicker, but that Jadelle needs to be replaced after five years, while studies have shown that Norplant is effective for seven years. After hearing this information as well as receiving it on a printed sheet, each client chose the implant that she preferred. Nearly half of the clients chose Norplant. The most common reason cited for this choice was that Norplant had been recommended by a friend, relative, or provider. More than 40% of the women who chose Norplant mentioned that it is better known. Another 15% mentioned that it is registered in the country. Less than 15% said they preferred Norplant because it lasts longer, which is in fact its only potential clinical advantage over Jadelle.
Slightly more than half of the clients chose Jadelle. Their most common reason was the fewer number of rods, followed by easier insertion and removal and less visibility in the arm.
Because almost half of the clients chose Norplant, the researchers initially concluded that providers should continue to offer it while making the transition to Jadelle. While this might ensure that women are comfortable with their contraceptive options, recent experience suggests that it may not be necessary. PROFAMILIA no longer offers Norplant. When clients request it, the provider explains the differences between Jadelle and Norplant and says that Norplant is no longer available. A clinic supervisor noted that virtually all clients accept Jadelle after receiving this counseling rather than choosing a different contraceptive method or declining contraception altogether.
Counseling alone will not persuade every client to choose an unfamiliar product, but it is important to give women complete and comparative information. Inadequate counseling may cause women to avoid a new product for the wrong reason. For example, nearly 9% of those who preferred Norplant chose it for the greater number of capsules, incorrectly reasoning that the additional capsules make it more effective. Thorough, clear counseling on the characteristics of new implants is essential to avoid such misperceptions and to help women make well-informed choices.
Sources: Brache, 2007 (11); Brache, 2006 (12)
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