Using Local Data to Move 30 years of Evidence into Practical Solutions: The Case of Community-based Distribution of Injectable Contraceptives in Africa Presented by Christine Lasway, FHI
The Problem and the 30Yr Old Solution
Moving Evidence into Practical Solutions in Africa Settings
Challenges and Facilitating factors
Where we are now?
The Data, The Problem Preferred Method for future use Unmet Need for FP Services
How to bridge the gap between high demand and high unmet need?
How do we get DMPA closer to more people who need it?
The 30Yr Old Solution Community-based distribution of injectable contraceptives!
Existing Supportive Data
Bangladesh (1970s), Latin America (1990s), Nepal (2000s)
Attributes of innovation
Administration of the injection is carried out by a community member with limited (or no) clinical training
Provision is in the client’s home or close by
Applicability in the African Context
CBD of Family Planning already exists for Pills and Condoms
Clients’ Privacy is afforded by DMPA and with CBD
Moving Evidence into Practice in African Settings
Non-clinical health workers are not trained to give safe injections
Regulations restrict paramedicals from giving injections
Concern that CBDs will give “other kinds” of injections to earn income
Moving Evidence into Practice in African Settings
Utilized existing 30 yr data/information to garner interest of the intervention in Africa.
Generated local data to answer key questions:
Is it feasible for a non-clinical/CBD to safely and effectively administer DMPA?
Would access ( defined as increased use ) be improved?
Used local data to inform policy and programmatic change
Used local data to guide new research questions to strengthen evidence base
1. Utilized Existing Data to Garner Interest
Consulted with several MoHs on the intervention
Uganda selected as study site
Joint design of the research study and intervention with partners and MoH
Engaged those who opposed the innovation
Established a guiding body or national core team
Sensitized and engaged community members
Study Area Characteristics
T FR > National Average
CPR is 3%-5%
Served by a sub-district hospital, 6 health centers, and 11 health posts
Over 50% of residents walk over 1 hour to a health clinic
2. Generating Local Data
Safety and Feasibility Study, Nakasongola, Uganda (2004-2005)
Post-intervention Comparison of new CBD and Health Clinic Clients on:
Continuation (2nd Injection at 6 months),
Incidence of injection-site morbidities
Training on Safe injection practices
Waste disposal practices
Uganda - Key Study Findings No difference found between CBD and Clinic administration of DMPA 0.3% 0% 85% Clinic n=328 0% Infection/Abscess 0.7% Temporary Numbness 88% Continuation (2 nd Injection at 6 months) CBD n=449 Item Assessed
Tailored and targeted communication of results to a variety of audiences/venues.
Advocacy at global and country levels
Educational Tours/Field Visits
Created implementation guide with detailed steps for introducing the intervention in a program
Assessed scalability of the intervention
Conducted further research studies to strengthen local evidence base
3. Using Data to Inform Policy & Programmatic Change
Programmatic and Policy Improvements:
Scaled-up – new areas & groups
Sustained momentum & awareness
New funds secured in-country
Policy to come?
Supportive policy change enacted
The Madagascar Study (2006-2007)
Results: the practice was acceptable, safe, and increased CPR
National scale up underway
Programmatic / Policy Improvements:
Kenya identified & launching
Momentum in other countries
TUNISIA MOROCCO SAHARA ALGERIA MAURITANIA MALI NIGER LIBYA CHAD EGYPT SUDAN ETHIOPIA DJIBOUTI ERITREA SOMALIA KENYA TANZANIA DEMOCRATIC CENTRAL RWANDA GABON EQUATORIAL ANGOLA CONGO NIGERIA BENIN DTVOIRE SIERRA SENEGA L GHANA THE GUINEA LIBERIA CAMEROON MALAWI ZAMBI A MOZAMBIQUE MADAGASCAR ZIMBABWE BOTSWANA SWAZILAND LESOTHO NAMIBIA ANGOLA WESTERN UGANDA OF THE CONGO REPUBLIC BURUNDI GUINEA REP. OF TOGO COTE BURKINA FASO GUINEA LEONE GAMBIA BISSAU SOUTH REPUBLIC AFRICAN THE AFRICA Implementing Policies changed Interested
4. New Research Questions – Same Goal, Different Approaches
Exploring feasibility of other non-clinical health workers to safely inject, e.g.: Drug shop dispensers
Self-Injection of DMPA
Differing requirements for “sufficient” data amongst countries to facilitate changes in policy and practice
Gaining trust on the utility of the data
Requests for introductory trials in individual countries amid limited resources
Sustainability issues with CBD programs
Factors that facilitated data use…
Sustained advocacy efforts.
Creation of implementation guide to facilitate adoption of innovation by other programs/organizations.
All levels understand utility of data and evidence-based decision making.
Consistent funding to support research utilization.
Understanding of the local decision-making process.
With Local Data, Change is Happening in Africa 2004 TUNISIA MOROCCO SAHARA ALGERIA MAURITANIA MALI NIGER LIBYA CHAD EGYPT SUDAN ETHIOPIA DJIBOUTI ERITREA SOMALIA KENYA TANZANIA DEMOCRATIC CENTRAL RWANDA GABON EQUATORIAL ANGOLA CONGO NIGERIA BENIN DTVOIRE SIERRA SENEGA L GHANA THE GUINEA LIBERIA CAMEROON MALAWI ZAMBI A MOZAMBIQUE MADAGASCAR ZIMBABWE BOTSWANA SWAZILAND LESOTHO NAMIBIA ANGOLA WESTERN UGANDA OF THE CONGO REPUBLIC BURUNDI GUINEA REP. OF TOGO COTE BURKINA FASO GUINEA LEONE GAMBIA BISSAU SOUTH REPUBLIC AFRICAN THE AFRICA 2009