Jane Cover

Acceptance patterns and decision-making for human papillomavirus vaccination among parents in Vietnam: an in-depth qualitative study post-vaccination

BackgroundThe GAVI Alliance’s decision in late 2011 to invite developing countries to apply for funding for human papillomavirus (HPV) vaccine introduction underscores the importance of understanding levels of HPV vaccine acceptance in developing country settings. In this paper, we present findings from qualitative research on parents’ rationales for vaccinating or not vaccinating their daughters (vaccine acceptance) and their decision-making process in the context of an HPV vaccination demonstration project in Vietnam (2008–2009).MethodsWe designed a descriptive qualitative study of HPV vaccine acceptability among parents of girls eligible for vaccination in four districts of two provinces in Vietnama. The study was implemented after each of two years of vaccinations was completed. In total, 133 parents participated in 16 focus group discussions and 27 semi-structured interviews.ResultsFocus group discussions and in-depth interviews with parents of girls vaccinated revealed that they were generally very supportive of immunization for disease prevention and of vaccinating girls against HPV. The involvement of the National Expanded Program of Immunization in the demonstration project lent credibility to the HPV vaccine, contributing to high levels of acceptance. For parents who declined participation, concerns about side effects, the possibility that the vaccine was experimental, and the possible impact of the vaccine on future fertility rose to the surface. In terms of the decision-making process, many parents exhibited ‘active decision-making,’ reaching out to friends, family, and opinion leaders for guidance prior to making their decision.ConclusionVietnam’s HPV vaccination experience speaks to the importance of close collaboration with the government to make the most of high levels of trust, and to reduce suspicions about new vaccines that may arise in the context of vaccine introduction in developing country settings.

Evaluating the feasibility and acceptability of self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA) in Senegal: a prospective cohort study

Objectives Expanding contraceptive options through self-injection may improve access and confidentiality. There are few published studies on contraceptive self-injection in sub-Saharan Africa and none in West Africa, a region with high unmet need. This study was performed to assess feasibility of subcutaneous DMPA self-injection in Senegal; objectives were to (1) measure the proportion of participants who self-injected competently 3 months after training, (2) measure the proportion who self-injected on time (defined conservatively as within 7 days of reinjection date), and (3) assess acceptability of self-injection. Study design In this prospective cohort study, 378 women aged 18–49 years were trained to self-inject by study nurses. Three months later, women returned unprompted to the clinic to self-inject, and technique and visit timing were evaluated. Women continuing with a third self-injection were followed up at home after their next scheduled injection date. At each interaction, participants were interviewed to learn about their experience; additional questions during the final home visit focused on storage and disposal practices, and acceptability. Results Among the 337 participants followed up 3 months post-training, 310 self-injected, and 87% did so competently. Factoring in women who declined to self-inject, electing to have the provider administer the injection instead, a total of 80% [95% confidence interval (CI) = 75–84%] self-injected competently 3 months post-training, and 84% [95% CI=80–88%] reinjected on time, while 72% [95% CI=67–77%] were both on time and competent. The vast majority (93%) expressed a desire to continue. Conclusions Self-injection is feasible and acceptable among most study participants in Senegal. Implications These first research results on contraceptive self-injection in West Africa indicate initial feasibility and acceptability of the practice. Results underscore the importance of designing self-injection programs that empower and support women, including those with limited education.

Immunogenicity of bivalent HPV vaccine among partially vaccinated young adolescent girls in Uganda.

BACKGROUND Investigations of vaccine efficacy and immunogenicity for adult females receiving fewer than three doses of human papillomavirus (HPV) vaccine have suggested protection against infection and precancerous lesions. We investigated the immunogenicity of bivalent HPV vaccines among adolescent girls from Uganda who received one, two, or three vaccine doses. METHODS Young girls vaccinated through a government program in Uganda were invited to participate. HPV16- and HPV18-specific antibodies were measured at ≥24 months after the last vaccine dose using an enzyme linked immunoassay in girls who received one (n=36), two (n=145), or three (n=195) doses. RESULTS Nearly all subjects (99%) were HPV16 and HPV18 seropositive at the time of blood-draw. Geometric mean antibody levels (GMTs) were: HPV16₁-dose=230 EU/mL, HPV16₂-dose=808 EU/mL, and HPV16₃-dose=1607 EU/mL; HPV18₁-dose=87 EU/mL, HPV18₂-dose=270 EU/mL, and HPV18₃-dose=296 EU/mL. The GMT ratio for 2:3 doses was 0.50 (HPV16) and 0.68 (HPV18) and did not meet the non-inferiority criteria (i.e., lower bound of 97.5% confidence interval of the GMT ratio greater than 0.50). The GMT ratio for 1:3 doses for HPV16 and HPV18 was inferior, but absolute GMTs for one dose were higher than adult women who received one dose (HPV16=124 EU/mL, HPV18=69 EU/mL) where efficacy has been demonstrated. CONCLUSIONS Even though immunogenicity with less than three doses did not meet a priori non-inferiority thresholds, antibody levels measured ≥24 months after last dose were similar to those of adult women who have been followed for more than eight years for efficacy.

Operational assessments of Sayana® Press provision in Senegal and Uganda

OBJECTIVE Sayana® Press (SP) is a unique injectable contraceptive (depot medroxyprogesterone acetate, or DMPA) administered subcutaneously in the Uniject(TM) injection system.(1) SP simplifies the injection process; it requires no assembly of components and is easily disposable. This new technology appears to be well suited for community-based delivery of injectable contraception. The study objective was to evaluate SP management and administration in low-resource settings, focusing on how the delivery logistics, administration time, storage and waste-management requirements compare to the traditional intramuscular DMPA injectable (DMPA IM). STUDY DESIGN We conducted 58 semistructured interviews with clinic providers and community health workers in Senegal and Uganda to identify the merits, challenges and appeal of SP relative to DMPA IM. RESULTS Providers identified logistical challenges with the management and administration of DMPA IM, including stock outs, transportation, storage constraints, and, in a few instances, waste disposal. Most providers (between 63% and 88%, depending on the logistics issue) do not expect SP to either aggravate or solve those problems. Some envisioned that SP could facilitate supply management (5%), storage (11%) and waste disposal (22%). The all-in-one packaging of SP was perceived to reduce the incidence of mismatched supplies (syringes and vials), and its smaller size was expected to ease space constraints and reduce the frequency of safety box incineration. CONCLUSION Adding SP to the method mix is unlikely to have a profound impact on clinic operations but may lessen logistical problems related to supply, storage and waste management. IMPLICATIONS Community health workers and clinic providers who administer SP may see some modest improvements in service delivery logistics. Particularly in settings where service delivery logistical challenges are more pronounced, offering SP may facilitate injectable contraceptive delivery.

Consumer perspectives on a pericoital contraceptive pill in India and Uganda.

CONTEXT Studies suggest that women in some countries have adopted emergency contraceptive pills as a routine method of family planning. This practice indicates there may be latent demand for a pericoital contraceptive pill taken only when a woman has sexual intercourse, and labeled and marketed for use as a regular contraceptive method. METHODS To understand the appeal and potential market for a pericoital contraceptive pill, 39 focus groups and 23 in-depth interviews were conducted with women and men in Lucknow, Uttar Pradesh, India, and Kampala, Uganda. A total of 281 individuals participated in this qualitative study. RESULTS In general, women embraced the idea of a female-controlled method that would be easier than taking a daily oral contraceptive pill and that could be taken either before or after sexual intercourse; in Uganda, especially, women approved of the fact that the method could be taken without a partners knowledge. Although we do not yet know the extent of side effects for this method, women expressed some concerns about the level and nature of potential side effects. CONCLUSIONS The results suggest that a pericoital contraceptive pill would be well-received by consumers in both country settings. If its efficacy and side effects are acceptable, a pericoital contraceptive pill could fill a gap for female-controlled, discreet, coitus-related contraception, particularly among women who do not have sex very frequently.

Continuation of injectable contraception when self-injected v. administered by a facility-based health worker: A non-randomized, prospective cohort study in Uganda

Objective The purpose of this study was to compare 12-month continuation rates for subcutaneous depot medroxyprogesterone acetate (DMPA-SC) administered via self-injection and DMPA-IM administered by a health worker in Uganda. Study design Women seeking injectable contraception at participating health facilities were offered the choice of self-injecting DMPA-SC or receiving an injection of DMPA-IM from a health worker. Those opting for self-injection were trained one-on-one. They self-injected under supervision and took home three units, a client instruction guide and a reinjection calendar. Those opting for DMPA-IM received an injection and an appointment card for the next facility visit in 3 months. We interviewed participants at baseline (first injection) and after 3 (second injection), 6 (third injection) and 9 (fourth injection) months, or upon discontinuation. We used Kaplan–Meier methods to estimate continuation probabilities, with a log-rank test to compare differences between groups. A multivariate Cox regression identified factors correlated with discontinuation. Results The 12-month continuation rate for the 561 women self-injecting DMPA-SC was .81 [95% confidence interval (CI) .78–.84], and for 600 women receiving DMPA-IM from a health worker, it was .65 (95% CI .61–.69), a significant difference at the .05 level. There were no differences in pregnancy rates or side effects. The multivariate analysis revealed that, controlling for covariates, self-injecting reduced the hazard for discontinuing by 46%. A significant interaction between injection group and age suggests that self-injection may help younger women continue injectable use. Conclusions The significant difference in 12-month continuation between women self-injecting DMPA-SC and women receiving DMPA-IM from a health worker — which remains significant in a multivariate analysis — suggests that self-injection may improve injectable contraceptive continuation. Implications While injectable contraceptives are popular throughout much of sub-Saharan Africa, they have high rates of discontinuation. This study is the second from an African country to demonstrate that self-injection may improve injectable continuation rates and may do so without increasing the risk of pregnancy or adverse events.

Is contraceptive self-injection cost-effective compared to contraceptive injections from facility-based health workers? Evidence from Uganda

Objective To assess the cost-effectiveness of self-injected subcutaneous depot medroxyprogesterone acetate (DMPA-SC) compared to health-worker-administered intramuscular DMPA (DMPA-IM) in Uganda. Study design We developed a decision-tree model with a 12-month time horizon for a hypothetical cohort of approximately 1 million injectable contraceptive users in Uganda to estimate the incremental costs per pregnancy averted and per disability-adjusted life year (DALY) averted. The study design derived model inputs from DMPA-SC self-injection continuation and costing research studies and peer-reviewed literature. We calculated incremental cost-effectiveness ratios from societal and health system perspectives and conducted one-way and probabilistic sensitivity analyses to test the robustness of results. Results Self-injected DMPA-SC could prevent 10,827 additional unintended pregnancies and 1620 maternal DALYs per year for this hypothetical cohort compared to DMPA-IM administered by facility-based health workers. Due to savings in womens time and travel costs, under a societal perspective, self-injection could save approximately US

Stakeholder and provider views regarding pericoital contraceptive pills in India and Uganda.

1 million or

A prospective cohort study of the feasibility and acceptability of depot medroxyprogesterone acetate administered subcutaneously through self-injection

84,000 per year, depending on the self-injection training aid used. From a health system perspective, self-injection would avert more pregnancies but incur additional costs. A training approach using a one-page client instruction sheet would make self-injection cost-effective compared to DMPA-IM, with incremental costs per pregnancy averted of

THE GEOGRAPHY OF FRINGE BANKING

15 and per maternal DALY averted of