Burkina Faso Protocol to Conduct Implementation Research on Introducing and Scaling Up Self-Administered Depo-Medroxyprogesterone acetate within Health Systems

Implementation steps: The intervention will be directed by the Ministry of Health (MOH) and carried out by a team representing all levels of the district health system in Garango health district between September 2022 and August 2023. Implementation will transpire according to five steps. Step 1: The Garango District Health Management Team (DHMT) will carry out a baseline needs assessment at all levels of care that were involved in the trainings that had been used in the district to introduce Subcutaneous Depomedroxyprogesterone Acetate (DMPA-SC) self-administration, with a focus on the CSPS-level, to obtain practical knowledge of how to maximize effective coverage of the FP service in Garango district. DHMT members will conduct the needs assessment themselves, or they will ask lower-level staff members of their staff at the district-level to complete data collection tasks on their behalf. The activities they will implement for the needs assessment will be the same as the activities they routinely use to prepare for new initiatives be it research related or simply programmatic (e.g., review related desk review documents, convene one-on-one and group meetings to obtain insights and strategic information from health care workers and other staff of the district, and then make decisions on what to do). Interviews with care providers will last between 30-45 minutes and interviewers will follow a topic guide. Interviews will mostly be conducted by staff persons of DHMT members. DHMT members will facilitate group meetings with 6-8 health facility managers and may also use a topic guide to structure this discussion if necessary. These meetings will last between 60 and 90 minutes. The DHMT will use this information they obtain during the needs assessment to develop a Quality Improvement Collaborative (QIC) charter that articulates the specific objectives and activities that DHMT and health system stakeholders in Garango will follow to improve how DMPA-SC self-administration is made available, and to improve efforts to generate demand for the method. This will also include the appointment of actors – i.e., DHMT members and their staff, health workers from health centers and primary health care facilities, community health workers, staff from pharmacies where DMPA-SC is available – to take responsibility for specific activities, Step 2: Actors appointed in step 1 will work toward operationalizing the QIC charter into a feasible action plan that can be carried out with the resources and structures in place in Garango (November - December 2022). As stated above, ‘actors’ refers to DHMT members and their staff, health workers from health centers and primary health care facilities, community health workers, and staff from pharmacies where DMPA-SC is available. Different groups of actors will be assigned to different activities of the QIC charter. Members of the respective groups will work together to operationalize their activities into a concrete series of steps they will follow to implement each QIC activity. To ‘operationalize’ these activities, each group will convene a meeting (or multiple meetings) to agree on a vision for what their respective QIC activities will be, and proceed to collaboratively break down the activity into a sequence of steps (i.e., an action plan). Activities that involve the community will involve community stakeholders, such as community health workers. Groups will be permitted to conduct their group meetings and discussions as they wish, but they will be asked to require that participants take tuns speaking, actively listen when not speaking and that a group member takes notes. These notes will be collected by a member of the study team and archived safely so that there is documentation of QIC charter implementation processes. Step 2 deliberations and action planning will take place within 1 month of completion of the Step 1 needs assessment. Step 3 and 4: During step 3, the QIC members will launch the implementation of the action plans they developed in step 2. Step 3 will commence within 1 month of completing of the discussions and action planning in step 2. Launch of the action plans that will occur in step 3 will include cascade trainings on DMPA-SC self-administration and other capacity building activities that are tailored to the needs of QIC teams that, at this time, will enact their plans to expand the reach throughout communities of knowledge of the method and opportunities to uptake and continue self-injection (January to June 2023). Step 3 will take place in the first three months (Jan-Mar 2023) and include onsite trainings and frequent engagement between trainers appointed by the DHMT (in the QIC) and facilities’ staff. Step 4 will take place in the last three months (Apr-Jun 2023) and comprise of periodic supervision visits in which the DHMT appointed trainers visit their trainees onsite approximately once per month. The groups assigned responsibility for trainings will have the opportunity to adapt existing regimens and materials to meet their needs and detail on this will be available after step 2. However, now we can provide information on the anticipated format, content and frequency of activities. Trainings will consist of small group discussions and demonstrations, mostly taking place at facilities while trainees are ‘on the job’. Information and knowledge traditionally imparted in lectures will be packaged into modules that trainers will impart during these sessions. Sessions will consist of a trainer and 4-5 trainees. Trainees will be staff of primary health care facilities and the community health workers that report to them. Whereas there will be some emphasis on didactic learning, trainings will focus on competencies and emphasize practical skill development. Since providers are already authorized to deliver contraception to clients, during training sessions they will be coached on ways to improve their performance not only with respect to method provision, but also counseling, infection prevention and control, ascertaining clients’ underlying fertility intentions or concerns and advising them on alternative contraceptive methods, if appropriate, as well as referral for other reproductive health care services. The frequency of trainings will be concentrated in the beginning of the 6-month period allocated for this activity. We anticipate that trainers will spend 2 hours at each primary health care site every other week for the first 3 months of this step and then 1 visit to each site per month for the last 3-months of this step. Follow up visits during the final 3-months of this step will last, on average, 1 hour. The stakeholders responsible for the trainings will have the opportunity to adapt existing training materials, if necessary, or use existing training materials without adaptation if they prefer. These materials include worksheets based on the curricula, checklists, job aids (for distribution to health care workers), informational leaflets (for distribution to clients). Other capacity building activities may include partnering facility staff that are new to initiating clients to self-administration of DMPA-SC with staff members that are more experienced, and building skills of the latter to coach and mentor their less experienced peer. Similarly, as these trainings progress, district staff may observe that some facilities are performing better than others, and based on this, they may coordinate peer-exchanges between facility teams. Peer exchanges would emphasize the more strongly performing team imparting lessons and coaching peers from the facility that is not performing as well. The purpose of this step is to strengthen the district’s training processes to help ensure that skill building and demand generation opportunities reach the lowest level of the district health system, where women that desire DMPA-SC for self-injection are mostly likely to come for the method. Given the competency-based, on the job nature of the trainings, and they fact that all facility-based health care workers engaged in trainings are already allowed by national policy to deliver the method to women, during this step health care workers will also train women in self-injection. In doing so they will follow all existing policy and clinical guidelines related to this intervention. This will include training clients to self-inject, directly observing the client self-administer one dose, and then prescribing two additional doses for the women to take with her as she leaves the facility (to take 90 and 180 days later). Health care workers will use any existing, government approved measures to monitor clients adherence to the method. These include home visits from a community health worker (if the client agrees to receive a home visit at the time she initiates self-injection at the primary health care facility). In addition, clients will be instructed to return to the facility after self-administering their second and third doses and bringing with them a plastic container contains used syringes (plastic containers are dispensed to women when they are initiated to self-administration at the health facility). Step 5: During step 5, QIC members will reconvene and review the experience of action plan implementation and adaptation for the previous 6-months, deliberate on lessons learned and recommendations for future programming and scale up in Burkina Faso (July to August 2023). It is anticipated that the review process will comprise of 2 workshops, each approximately 2-hours in duration, to review barriers and facilities to effective action plan implementation. Detailed reports containing lessons learned and recommendations will be written up by the DHMT staff with assistance from members of the research team. These reports will be made available in electronic format to stakeholders from other districts in Burkina Faso and the Ministry of Health.