Self-care provision of contraception: Evidence and insights from contraceptive injectable self-administration.

As new reproductive health products become available, women increasingly want to take a participatory role in their health. New developments and formulations of contraceptive products provide an opportunity to support this evolving trend toward self-care. Self-care, as defined by the World Health Organization (WHO), highlights the ability of individuals to promote health, prevent disease, and manage their own health with or without the support of a health care provider. The recently released WHO Guidelines on Self-Care Interventions for Health: Sexual and Reproductive Health and Rights included new self-care recommendations related to use of family planning, including self-injection of injectable contraceptives and over-the-counter provision of oral contraceptive pills. This paper focuses on the research evidence of self-administration (self-injection) of subcutaneous depot medroxyprogesterone acetate (DMPA-SC), and the practical experience of providers, women, and family planning programs adopting self-injection practices. We also explore the role of self-care in the provision of other contraceptives.

Continuation of self-injected versus provider-administered contraception in Senegal: a nonrandomized, prospective cohort study.

OBJECTIVES: The primary objective of this study was to compare the 12-month continuation rate for women who self-injected subcutaneous depot-medroxyprogesterone acetate (DMPA-SC) with that for women receiving intramuscular depot-medroxyprogesterone acetate (DMPA-IM) from a provider. This research contributes to the broader goal of identifying solutions to support women to use contraception for their full desired duration. STUDY DESIGN: Participants were clients from 13 clinics in the Dakar and Thiés regions of Senegal who had decided to use injectable contraception prior to enrollment. They chose self-injection of DMPA-SC or provider administration of DMPA-IM. Self-injectors were trained and given three units of DMPA-SC. The provider-injected group received DMPA-IM and returned to the clinics for future injections. We interviewed participants at baseline and after the second, third and fourth injections (the equivalent of 12 months of contraceptive coverage). We employed 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 650 women self-injecting DMPA-SC was 80.2%, while that for 649 women receiving DMPA-IM from a provider was 70.4% (p<.01). The difference in continuation between self-injectors and those receiving DMPA from a provider remained significant in a multivariate Cox regression model. The primary reason for discontinuation in both groups (44.7% self-injected; 44.5% provider-injected) was forgetting to reinject or reinjecting late. Fewer women reported side effects in the self-injection group than in the provider-administered group. CONCLUSIONS: The higher 12-month continuation rate for women self-injecting DMPA-SC relative to provider-administered DMPA-IM suggests that self-injection may help prevent pregnancy more consistently and continuously. IMPLICATIONS: Discontinuation of injectable contraception among women wishing to avoid pregnancy may increase unmet need in francophone West Africa. This study showed higher 12-month continuation rates for women who self-injected DMPA-SC, suggesting that this delivery method may improve injectable continuation.

Cost-effectiveness of self-injected DMPA-SC compared with health-worker-injected DMPA-IM in Senegal.

OBJECTIVES: To evaluate the cost-effectiveness of self-injected subcutaneous depot medroxyprogesterone acetate (DMPA-SC) compared to health-worker-administered intramuscular DMPA (DMPA-IM) in Senegal and to assess how including practice or demonstration injections in client self-injection training affects estimates. STUDY DESIGN: We developed a decision-tree model with a 12-month time horizon for a hypothetical cohort of 100,000 injectable contraceptive users in Senegal. We used the model to estimate incremental costs per disability-adjusted life year (DALY) averted. The analysis derived model inputs from DMPA-SC self-injection continuation and costing research studies and peer-reviewed literature. We evaluated the cost-effectiveness from societal and health system perspectives and conducted one-way and probabilistic sensitivity analyses to test the robustness of results. RESULTS: Compared to health-worker-administered DMPA-IM, self-injected DMPA-SC could prevent 1402 additional unintended pregnancies and avert 204 maternal DALYs per year for this hypothetical cohort. From a societal perspective, self-injection costs less than health worker administration regardless of the training approach and is therefore dominant. From the health system perspective, self-injection is dominant compared to health worker administration if a one-page instruction sheet is used and one additional DMPA-SC unit is used for training and is cost-effective at $208 per DALY averted when two additional DMPA-SC units are used. Sensitivity analysis showed estimates were robust. CONCLUSIONS: Self-injected DMPA-SC averted more pregnancies and DALYs and cost less from the societal perspective compared to health-worker-administered DMPA-IM and hence is dominant. Using fewer DMPA-SC units for practice or demonstration improves cost-effectiveness of self-injection from the health system perspective. IMPLICATIONS: Evidence from Senegal shows that self-injection of DMPA-SC can be dominant or cost-effective from both health system and societal perspectives relative to DMPA-IM from health workers even if women practice injecting or health workers demonstrate with one or two DMPA-SC units. Evidence on whether practice or demonstration is required for client training would be useful.

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 women's time and travel costs, under a societal perspective, self-injection could save approximately US$1 million or $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 $15 and per maternal DALY averted of $98. Sensitivity analysis showed that the estimates were robust. The one-way and probabilistic sensitivity analyses showed that the costs of the first visit for self-injection (which include training costs) were an important variable impacting the cost-effectiveness estimates. CONCLUSIONS: Under a societal perspective, self-injected DMPA-SC averted more pregnancies and cost less compared to health-worker-administered DMPA-IM. Under a health system perspective, self-injected DMPA-SC can be cost-effective relative to DMPA-IM when a lower-cost visual aid for client training is used. IMPLICATIONS: Self-injection has economic benefits for women through savings in time and travel costs, and it averts additional pregnancies and maternal disability-adjusted life years compared to health-worker-administered injectable DMPA-IM. Implementing lower-cost approaches to client training can help ensure that self-injection is also cost-effective from a health system perspective.

Costs of administering injectable contraceptives through health workers and self-injection: evidence from Burkina Faso, Uganda, and Senegal.

OBJECTIVE: To evaluate the 12-month total direct costs (medical and nonmedical) of delivering subcutaneous depot medroxyprogesterone acetate (DMPA-SC) under three strategies - facility-based administration, community-based administration and self-injection - compared to the costs of delivering intramuscular DMPA (DMPA-IM) via facility- and community-based administration. STUDY DESIGN: We conducted four cross-sectional microcosting studies in three countries from December 2015 to January 2017. We estimated direct medical costs (i.e., costs to health systems) using primary data collected from 95 health facilities on the resources used for injectable contraceptive service delivery. For self-injection, we included both costs of the actual research intervention and adjusted programmatic costs reflecting a lower-cost training aid. Direct nonmedical costs (i.e., client travel and time costs) came from client interviews conducted during injectable continuation studies. All costs were estimated for one couple year of protection. One-way sensitivity analyses identified the largest cost drivers. RESULTS: Total costs were lowest for community-based distribution of DMPA-SC (US$7.69) and DMPA-IM ($7.71) in Uganda. Total costs for self-injection before adjustment of the training aid were $9.73 (Uganda) and $10.28 (Senegal). After adjustment, costs decreased to $7.83 (Uganda) and $8.38 (Senegal) and were lower than the costs of facility-based administration of DMPA-IM ($10.12 Uganda, $9.46 Senegal). Costs were highest for facility-based administration of DMPA-SC ($12.14) and DMPA-IM ($11.60) in Burkina Faso. Across all studies, direct nonmedical costs were lowest for self-injecting women. CONCLUSIONS: Community-based distribution and self-injection may be promising channels for reducing injectable contraception delivery costs. We observed no major differences in costs when administering DMPA-SC and DMPA-IM under the same strategy. IMPLICATIONS: Designing interventions to bring contraceptive service delivery closer to women may reduce barriers to contraceptive access. Community-based distribution of injectable contraception reduces direct costs of service delivery. Compared to facility-based health worker administration, self-injection brings economic benefits for women and health systems, especially with a lower-cost client training aid.

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.

Acceptability of Contraceptive Self-Injection with DMPA-SC Among Adolescents in Gulu District, Uganda.

CONTEXT: In Uganda, an estimated one in four adolescent women have begun childbearing. Many adolescent pregnancies are unintended because of substantial barriers to contraceptive access. The injectable contraceptive is the most commonly used method in Uganda, and a new subcutaneous version offers the possibility of reducing access barriers by offering a self-injection option. However, more information about adolescent attitudes toward and interest in self-injection is needed. METHODS: In 2015, in-depth interviews were conducted with a purposive sample of 46 adolescent women aged 15-19 from rural and urban areas of Gulu District. Respondents were asked about their demographic characteristics, experience with contraceptives and opinions about injectable contraception, then introduced to subcutaneous depot medroxyprogesterone acetate (DMPA-SC) and trained in how to give an injection using a model. They were then asked their opinion about contraceptive self-injection. The interviews were transcribed and analyzed qualitatively to identify key themes. RESULTS: Although the injectable was generally viewed favorably, some adolescents expressed reservations about the suitability of injectable contraception for adolescents. The most common concern was fear of infertility. The majority felt self-injection would be an appealing option to adolescents because of the time and money saved and the discreet nature of injecting at home. Barriers to self-injection included fear of needles, the potential of making a mistake and lack of privacy at home. CONCLUSIONS: Contraceptive self-injection has the potential to increase contraceptive access and use for adolescents in Uganda, and should be considered as a delivery modality in the context of adolescent-friendly contraceptive services.

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

OBJECTIVES: Evidence on contraceptive self-injection from the United States and similar settings is promising, and the practice may increase access. There are no published studies on the feasibility of contraceptive self-injection in sub-Saharan Africa to date. The purpose of this study was to assess feasibility of subcutaneous depot medroxyprogesterone acetate self-injection in Uganda, with specific objectives to (a) measure the proportion of participants who self-injected competently, (b) measure the proportion who self-injected on time 3 months after training (defined conservatively as within 7 days of their reinjection date) and (c) assess acceptability. STUDY DESIGN: In this prospective cohort study, 380 18-45-year-old participants completed self-injection training by licensed study nurses, guided by a client instruction booklet, and practiced injection on prosthetics until achieving competence. Nurses supervised participants' self-injection and evaluated injection technique using an observation checklist. Those judged competent were given a Sayana® Press unit, instruction booklet and reinjection calendar for self-injection at home 3 months later. Participants completed an interview before and after self-injection. Nurses visited participants at home following reinjection dates; during the follow-up visit, participants demonstrated self-injection on a prosthetic, injection technique was reevaluated, and a postreinjection interview was completed. RESULTS: Of 368 participants followed up 3 months posttraining, 88% [95% confidence interval (CI)=84-91] demonstrated injection competence, and 95% (95% CI=92-97) reinjected on time, while 87% (95% CI=84-90) were both on time and competent. Nearly all (98%) expressed a desire to continue. CONCLUSIONS: Self-injection is feasible and highly acceptable among most study participants in Uganda. IMPLICATIONS: The first research results on contraceptive self-injection in sub-Saharan Africa indicate initial feasibility and acceptability of the practice 3 months after women received one-on-one training and a highly visual training and memory aid. Results can inform self-injection programs which aim to increase women's autonomy and access to injectable contraception.

What some women want? On-demand oral contraception.

OBJECTIVE: To summarize evidence regarding current demand for on-demand oral contraception. STUDY DESIGN: We used Medline and collegial contacts to find published and unpublished studies conducted or reported in the past 15 years with information assessing women's interest in using any oral drug preparation, including emergency contraceptive pills, in a coitus-dependent manner either repeatedly or as a primary or planned pregnancy prevention method. RESULTS: We found 19 studies with relevant information. The studies were conducted in 16 countries. Eight studies provided data on women's attitudes regarding a coitus-dependent oral contraceptive; all suggested substantial interest in using it. Nine studies assessed actual use of oral tablets on demand for primary contraception. In these studies, 9-97% of women in the analysis populations reported using the pills on demand as main method, although frequency and consistency of use varied. Reported reasons for interest in or use of this contraceptive approach included convenience, ease of remembering, ability to conceal use, lack of coital interruption, and infrequent sexual activity. Three studies were clinical trials of investigational on-demand oral contraceptives which reported Pearl indices ranging from 6.8 to 53 pregnancies per 100 woman-years. CONCLUSION: Data from a variety of settings suggest that demand for an on-demand oral contraceptive may be widespread. The effectiveness of this potential method is not established, however. Considering the seriousness of the unmet need for contraception, further development research into the public health benefits and risks of such a method would be worthwhile. IMPLICATIONS: Demand for an on-demand oral contraceptive may be widespread. Efforts should be made to further explore the possibility of developing such a method.

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

The development of pericoital contraceptive pills is under consideration to address unmet need for family planning, especially among women who have infrequent sexual intercourse. Pericoital pills, an oral contraceptive taken 24 hours before or after intercourse, would be a potentially desirable contraceptive option because it could provide convenience, discretion, and female control over contraceptive use. To gauge receptivity to pericoital contraception, a total of 49 in-depth interviews and 5 focus group discussions were conducted in India and Uganda with family planning providers and stakeholders. In India, the method was seen as filling a demonstrated need, based on perceived widespread and/or repeat use of emergency contraceptives. In Uganda, where emergency contraception has met strong opposition from conservative and religious leaders, respondents were more skeptical about the merits of the product. In both settings, using condoms consistently and taking oral contraceptives daily present challenges for consistent use, thus a new contraceptive method that is easy to use and under female control is likely to be appealing.

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 partner's 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.

Pilot randomized, controlled trial of pramipexole to augment antipsychotic treatment.

The preferential dopamine D(3)-agonist pramipexole (4.25±0.38 mg/day) or placebo were added for up to 12 weeks to ongoing antipsychotic treatment for 24 adult patients with DSM-IV schizophrenia or schizoaffective disorder. Pramipexole was generally well-tolerated (82% trial-completion), and yielded greater decreases in PANSS-total scores (drug/placebo=2.1; p=0.04), with similar decreases in PANSS positive and negative scores and 6.7-fold greater reduction of serum prolactin concentrations compared to placebo. There were no differences in ratings of mood, cognition or extrapyramidal symptoms, all of which were low at intake.

Stakeholder perceptions of a total market approach to family planning in Nicaragua.

OBJECTIVE: To assess private-sector stakeholders' and donors' perceptions of a total market approach (TMA) to family planning in Nicaragua in the context of decreased funding; to build evidence for potential strategies and mechanisms for TMA implementation (including public-private partnerships (PPPs)); and to identify information gaps and future priorities for related research and advocacy. METHODS: A descriptive exploratory study was conducted in various locations in Nicaragua from March to April 2010. A total of 24 key private-sector stakeholders and donors were interviewed and their responses analyzed using two questionnaires and a stakeholder analysis tool (PolicyMakerTM software). RESULTS: All survey participants supported a TMA, and public-private collaboration, in family planning in Nicaragua. Based on the survey responses, opportunities for further developing PPPs for family planning include building on and expanding existing governmental frameworks, such as Nicaragua's current coordination mechanism for contraceptive security. Obstacles include the lack of ongoing government engagement with the commercial (for-profit) sector and confusion about regulations for its involvement in family planning. Strategies for strengthening existing PPPs include establishing a coordination mechanism specifically for the commercial sector and collecting and disseminating evidence supporting public-private collaboration in family planning. CONCLUSIONS: There was no formal or absolute opposition to a TMA or PPPs in family planning in Nicaragua among a group of diverse nongovernmental stakeholders and donors. This type of study can help identify strategies to mobilize existing and potential advocates in achieving articulated policy goals, including diversification of funding sources for family planning to achieve contraceptive security.

Stakeholder perceptions of a total market approach to family planning in Nicaragua / Percepciones de grupos interesados sobre la aplicación de un enfoque de mercado total a la planificación familiar en Nicaragua

OBJECTIVE: To assess private-sector stakeholders' and donors' perceptions of a total market approach (TMA) to family planning in Nicaragua in the context of decreased funding; to build evidence for potential strategies and mechanisms for TMA implementation (including public-private partnerships (PPPs)); and to identify information gaps and future priorities for related research and advocacy. METHODS: A descriptive exploratory study was conducted in various locations in Nicaragua from March to April 2010. A total of 24 key private-sector stakeholders and donors were interviewed and their responses analyzed using two questionnaires and a stakeholder analysis tool (PolicyMakerTM software). RESULTS: All survey participants supported a TMA, and public-private collaboration, in family planning in Nicaragua. Based on the survey responses, opportunities for further developing PPPs for family planning include building on and expanding existing governmental frameworks, such as Nicaragua's current coordination mechanism for contraceptive security. Obstacles include the lack of ongoing government engagement with the commercial (for-profit) sector and confusion about regulations for its involvement in family planning. Strategies for strengthening existing PPPs include establishing a coordination mechanism specifically for the commercial sector and collecting and disseminating evidence supporting public-private collaboration in family planning. CONCLUSIONS: There was no formal or absolute opposition to a TMA or PPPs in family planning in Nicaragua among a group of diverse nongovernmental stakeholders and donors. This type of study can help identify strategies to mobilize existing and potential advocates in achieving articulated policy goals, including diversification of funding sources for family planning to achieve contraceptive security.

OBJETIVO: Evaluar las percepciones de los grupos interesados y de los donantes del sector privado sobre la aplicación de un enfoque de mercado total a la planificación familiar en Nicaragua en el contexto de una reducción del financiamiento; establecer datos científicos que avalen posibles estrategias y mecanismos para ejecutar este tipo de enfoque (lo que incluye alianzas entre los sectores público y privado); y determinar las brechas de información y las prioridades futuras en la investigación y la promoción de este enfoque. MÉTODOS: Entre marzo y abril del 2010 se llevó a cabo un estudio exploratorio descriptivo en varios lugares de Nicaragua. Se entrevistaron 24 personas de varios grupos interesados y de donantes clave del sector privado y se analizaron sus respuestas mediante dos cuestionarios y una herramienta de análisis específica (programa informático PolicyMakerTM). RESULTADOS: Todos los encuestados respaldaron la aplicación de un enfoque de mercado total y la colaboración entre los sectores público y privado respecto de la planificación familiar en Nicaragua. Según las respuestas obtenidas en la encuesta, las oportunidades para desarrollar alianzas adicionales entre los dos sectores respecto de la planificación familiar incluyen mejorar y ampliar los marcos gubernamentales existentes, como el actual mecanismo de coordinación de Nicaragua para la seguridad anticonceptiva. Los obstáculos son la falta de colaboración actual del gobierno con el sector comercial (con fines de lucro) y la confusión acerca de la reglamentación para participar en la planificación familiar. Las estrategias para fortalecer las alianzas existentes entre los sectores público y privado comprenden el establecimiento de un mecanismo de coordinación específico para el sector comercial, y la recolección y difusión de datos que avalen la colaboración entre los dos sectores respecto de la planificación familiar. CONCLUSIONES: En la evaluación de varios grupos interesados y de donantes del sector no gubernamental no se encontró ninguna oposición formal o absoluta a un enfoque de mercado total o a la conformación de alianzas entre los sectores público y privado respecto de la planificación familiar en Nicaragua. Este tipo de estudio puede ayudar a identificar estrategias que motiven a los promotores de la causa actuales y potenciales a alcanzar las metas políticas enunciadas, lo que incluye la diversificación de las fuentes de financiamiento para la planificación familiar a fin de alcanzar la seguridad anticonceptiva.

The role of interpersonal communication in preventing unsafe abortion in communities: the dialogues for life project in Nepal.

Legal, procedural, and institutional restrictions on safe abortion services-such as laws forbidding the practice or policies preventing donors from supporting groups who provide legal services-remain a major access barrier for women worldwide. However, even when abortion services are legal, women face social and cultural barriers to accessing safe abortion services and preventing unwanted pregnancy. Interpersonal communication interventions play an important role in overcoming these obstacles, including as part of broad educational- and behavioral-change efforts. This article presents results from an interpersonal communication behavior change pilot intervention, Dialogues for Life, undertaken in Nepal from 2004 to 2006, after abortion was legalized in 2002. The project aimed to encourage and enable women to prevent unplanned pregnancies and unsafe abortions and was driven by dialogue groups and select community events. The authors' results confirm that a dialogue-based interpersonal communication intervention can help change behavior and that this method is feasible in a low-resource, low-literacy setting. Dialogue groups play a key role in addressing sensitive and stigmatizing health issues such as unsafe abortion and in empowering women to negotiate for the social support they need when making decisions about their health.

Stakeholder perceptions of a total market approach to family planning in Viet Nam.

Viet Nam has high modern contraceptive prevalence (68%), with most services received through the public sector. As the country transitions to middle-income status, Viet Nam's donors have ceased donations of contraceptive supplies, causing a large projected shortfall in the family planning budget. In response, the Ministry of Health has decided to prioritize free or subsidized contraceptives for poor and vulnerable groups, while enhancing social marketing and sales of contraceptives in the free market. To support planning for this "total market approach", a descriptive exploratory study was conducted with 38 public and private sector family planning stakeholders to gain their perceptions of the proposals. There was a high level of support for government leadership of public-private coordination and stewardship of the entire family planning system. Key information gaps were identified regarding how the reforms can promote equitable access to family planning and financial sustainability in pricing. The government's experience with this transition may yield valuable guidance for other settings.

Making evidence work for communities: the role of nongovernmental organizations in translating science to programs.

Evidence-informed public health refers to the process of applying proven interventions within the context of community preferences in order to achieve positive health impacts. A key role for nongovernmental organizations (NGOs) in evidence-informed public health is to use and expand on research to help shape appropriate interventions for diverse communities. This article suggests that NGOs are particularly well positioned for this role for a number of reasons, including their geographic reach, their engagement with diverse stakeholders, and their extragovernmental position, which enables them to develop and advocate for innovative, scientifically sound solutions to long-standing health challenges. Three case studies are presented that highlight how NGOs can harness these advantages to shape evidence-informed policies and programs to improve women's health: PATH's multicountry HPV Vaccines project, the International Consortium for Emergency Contraception, and a collaborative effort to combat maternal mortality in Mali.

Formative research to shape HPV vaccine introduction strategies in Peru / Investigación formativa relacionada con el diseño de estrategias para introducir la vacuna contra el VPH en Perú

OBJECTIVE: To understand the sociocultural environment, health systems' capacities, and policy processes related to cervical cancer and HPV vaccines in order to inform HPV vaccine introduction. MATERIAL AND METHODS: Mixed-method formative research using qualitative and quantitative data collection techniques. Participants included girls, parents, community leaders, health and education officials, and policymakers. RESULTS: Respondents, including policymakers, generally supported HPV vaccine introduction, due partly to appreciation for the benefits of vaccination and the desire to prevent cancer. Community-level concerns regarding safety and quality of services will need to be addressed. The immunization system in Peru is strong and has capacity for including the HPV vaccine. CONCLUSION: Formative research provides key insights to help shape an effective program for HPV vaccine introduction.

OBJETIVO: Comprender el contexto sociocultural, las capacidades del sistema de salud y las condiciones políticas vinculadas al cáncer cervical y a la vacuna contra el VPH para diseñar una estrategia apropiada de introducción de la vacuna contra el VPH. MATERIAL Y MÉTODOS: Investigación formativa usando técnicas cualitativas y cuantitativas. Los participantes incluyeron niños, padres, líderes, funcionarios del sector salud y educación, y diseñadores de políticas. RESULTADOS: Generalmente se apoya la introducción de la vacuna contra el VPH, dado que se aprecian los beneficios de la vacunación y se desea prevenir el cáncer. En la comunidad se encontraron preocupaciones sobre seguridad, confianza y calidad de atención. El sistema de inmunizaciones en el Perú es eficiente y tiene la capacidad para incluir la vacuna contra el VPH. CONCLUSIONES: La investigación formativa permite comprender elementos clave que ayudan a diseñar un programa efectivo para la introducción de la vacuna contra el VPH.