Contextual factors influencing the roles of patent medicine vendors in the provision of injectable contraception services in Nigeria.

BACKGROUND: Patent medicine vendors (PMVs) play vital roles in the delivery of family planning services in Nigeria and other developing countries. There is a growing recognition of the need to integrate them into the formal health care system as a strategy to increase the contraceptive prevalence rate and achieve universal health coverage. Though promising, the success of this proposition is largely dependent on a critical analysis of the factors which influence their operations. This study was designed to identify the contextual factors influencing the provision of injectable contraceptive services by PMVs and the broader effects of their activities on the health system to inform similar interventions in Nigeria. METHODS: This was a qualitative study guided by the UK Medical Research Council's Framework for Complex Interventions. Twenty-seven in-depth interviews were conducted among officials of the association of PMVs, health workers, government regulatory officers and programme implementers who participated in a phased 3-year (2015-2018) intervention designed to enhance the capacity of PMVs to deliver injectable contraceptive services. The data were transcribed and analyzed thematically using NVIVO software. RESULTS: The contextual factors which had implications on the roles of PMVs were socio-cultural and religious, the failing Nigerian health system coupled with government regulatory policies. Other factors were interprofessional tensions and rivalry between the PMVs and some categories of health care workers and increasing donors' interest in exploring the potentials of PMVs for expanded healthcare service provision. According to the respondents, the PMVs bridged the Nigerian health system service delivery gaps serving as the first point of contact for injectable contraceptive services and this increased contraceptive uptake in the study sites. A negative effect of their operation is the tendency to exceed their service provision limits, which has spurred a planned tiered PMV accreditation system. CONCLUSIONS: This study has highlighted the contextual factors which define the roles and scope of practice of PMVs involved in injectable contraceptive service provision. Strategies and interventions aimed at expanding the healthcare delivery roles of PMVs must be encompassing to address the broader contextual factors which underpin their capacities and functions.

The effect of job aids on knowledge retention among Patent and Proprietary Medicine Vendors trained to administer injectable contraceptives: longitudinal results from implementation science in Nigeria.

BACKGROUND: To increase access to voluntary family planning (FP) services, Nigerian policymakers are debating how to task share injectable contraceptive services to drug shop owners known as Patent and Proprietary Medicine Vendors (PPMVs). Task sharing FP services to drug shops is a promising practice, but information is needed on how to ensure high quality FP services. This analysis assesses the effects of job aids on PPMVs' knowledge of injectable contraceptives 9 months after receiving a standardized training. METHODS: One hundred ninety-four PPMVs were trained on FP counseling and administration of injectable contraceptives in Bauchi, Cross River, Ebonyi and Kaduna states. PPMVs were interviewed before, after, and 9 months after the training. Three variables were used to assess injectable contraceptive knowledge: 1) intramuscular depot-medroxyprogesterone acetate (DMPA-IM) knowledge: a combination of three questions related to device type, injection location, and reinjection frequency; 2) subcutaneous DMPA (DMPA-SC) knowledge: a combination of the same three questions but for DMPA-SC; and 3) knowledge of at least 4 of the 7 common injectable side effects. Three separate adjusted logistic regression models were conducted to determine the factors that influence PPMV knowledge of injectable contraceptives 9 months after the training. RESULTS: Over half of PPMVs (56%) reported using at least two job aids at 9 months. PPMVs' knowledge of DMPA-IM, DMPA-SC and side effects were low before the training but increased immediately after. Nine months later, knowledge remained higher than pre-test levels but generally reduced compared to posttest levels. PPMVs who reported using at least two FP job aids were 2.6 (95% CI: 1.4-5.1) times more likely to have DMPA-IM knowledge 9 months after the training compared to those who used one or no job aids, while adjusting for PPMV characteristics. Similar results were observed for knowledge of DMPA-SC (AOR: 2.5; 95% CI: 1.2-4.6) and side effects (AOR: 2.5; 95% CI: 1.3-4.8). CONCLUSION: PPMVs who used at least two FP job aids were more likely to correctly answer key injectable contraceptive questions 9 months after training. Incorporating proven job aids into routine trainings is a low-cost strategy that can reinforce knowledge and help PPMVs to retain information.

Process evaluation of an intervention to improve access to injectable contraceptive services through patent medicine vendors in Nigeria: a mixed methods study.

BACKGROUND: The low utilisation of modern contraceptives in many low- and middle-income countries remains a challenge. Patent medicine vendors (PMVs) that operate in the informal health sector, have the potential to address this challenge. Between 2015 and 2018, the Population Council, in collaboration with the Federal and State Ministries of Health and the Pharmacy Council of Nigeria, trained PMVs in six states to deliver injectable contraceptive services. Outcome evaluation demonstrated increased client uptake of injectable contraceptive services; however, there is limited information on how and why the intervention influenced outcomes. This study was conducted to elucidate the processes and mechanism through which the previous intervention influenced women's utilisation of injectable contraceptive services. METHODS: The study utilised a mixed methods, convergent parallel design guided by the UK Medical Research Council framework. Quantitative data were obtained from 140 trained PMVs and 145 of their clients in three states and 27 in-depth interviews were conducted among relevant stakeholders. The quantitative data were analysed descriptively, while the qualitative data were analysed thematically. RESULTS: The results revealed that even after the completion of the PMV study which had a time-bound government waiver for injectable contraceptive service provision by PMVs, they continued to stock and provide injectables in response to the needs of their clients contrary to the current legislation which prohibits this. The causal mechanism that influenced women's utilisation of injectable contraceptives were the initial training that the PMV received; the favourable regulatory environment as demonstrated in the approval provided by government for PMVs to provide injectable contraceptives for the duration of the study; and the satisfaction and the confidence the female clients had developed in the ability of the PMVs to serve them. However, there were gaps with regards to the consistent supply of quality injectable contraceptive commodities and in PMVs use of job aids. Referral and linkages to government or private-owned facilities were also sub-optimal. CONCLUSION: PMVs continue to play important roles in family planning service provision; this underscores the need to formalize and scale-up this intervention to aid their integral roles coupled with multi-faceted initiatives to enhance the quality of their services.