Session IV: Practicing Provision of Progestin-Only Injectables Progestin-Only Injectable Contraceptives: DMPA and NET-EN Session IV: Practicing Provision of Progestin-Only Injectables Using a Conventional Syringe Photo credit: FHI (packaging from socially marketed DMPA in Kenya and Uganda) DMPA and NET-EN are given as intramuscular injections in one of three sites: the muscle of the upper arm, the muscle of the hip, or in the buttock. A woman can decide where she prefers to receive the injection. If one of your clients would prefer to receive her injection in a site where you have not been trained to give injections, refer her to a clinical provider that is trained accordingly. This session describes the steps for injecting and re-injecting progestin-only injectables and for preventing infection during injection. The information on slides #3-9 describes a 15-step process for giving injections. This practice can be greatly reduced for experienced clinicians who are used to giving injections in these injection sites. Extensive practice on fruits or vegetables, observations of master clinicians, and supervised practice are necessary for the provider to be skillful in the injectable insertion and removal procedures. During this session, we will first review the steps of injection, using the slides. This will be followed by a demonstration and return demonstration and practice by participants on fruits or vegetables, using competency-based checklists to monitor progress. Most community health workers (CHWs) are only trained to provide injections in the arm. If a woman wishes to receive an injection in the hip or buttock and the CHW has not been trained to provide injections in this location, the woman should be referred. Note to Facilitator: this session is focused solely on the mechanics of the clinical procedures in insertion and reinsertion of progestin-only injectables and prevention infection during injection.. Refer to Session III for guidance about counseling users and other injectable-related issues.

Overview The injection can be given in: the hip or buttock DMPA and NET-EN are given as intramuscular injections in one of three sites: the muscle of the upper arm, the muscle of the hip, or in the buttock. A woman can decide where she prefers to receive the injection. If one of your clients would prefer to receive her injection in a site where you have not been trained to give injections, refer her to a clinical provider who is trained accordingly. Illustration credits: Ambrose Hoona-Kab. X the upper arm

How to Give the Injection: Steps 1-2 1. Wash your hands well with soap and water. 2. Let your hands dry in the air After counseling the client and determining her eligibility, it is then time to give the client the injection. The information on the next several slides, describes a 15-step process for giving injections. First, if possible, wash your hands well with soap and water. Then, let your hands dry in the air. Note to facilitator: Demonstrate each of the steps as you review them. Inform the participants to pay close attention as they will be expected to demonstrate these steps during practice. Ensure that participants can see the demonstration and encourage them to ask questions. Illustration credit: Ambrose Hoona-Kab

How to Give the Injection: Steps 3-5 3. If the skin around the injection site is dirty, clean the site with a cotton ball soaked in clean water. 4. Double-check the bottle for content, dose, and expiration date. 5. Roll the bottle gently between the palms of your hands. If the skin around the injection site is dirty, wash it with a cotton ball soaked in clean water. If the skin is not visibly dirty, there is no need to clean it before giving the injection. Next, double-check the bottle for content and dose and make sure that it is not past the expiration date. Roll the bottle between the palms of your hands to mix the solution, or shake it gently. Do not shake it too vigorously or the contents will become frothy making it difficult to extract the entire contents of the bottle. NET-EN does not need to be mixed but rolling the bottle in the palms will warm the solution, making it easier to extract. Illustration credit: Ambrose Hoona-Kab

How to Give the Injection: Steps 6–9 6. Hold the bottle of DMPA or NET-EN and remove the plastic cap. 8. Insert the needle into the rubber cover and empty the entire contents into the syringe. 7. Open the sterile package containing the syringe and the needle (if necessary attach needle to syringe). 9. Hold the syringe upright and tap on the barrel to move the air into the tip. Expel the air from the syringe gently. Hold the bottle of DMPA or NET-EN and remove the plastic cap to expose the rubber cover. There is no need to wipe top of vial with antiseptic. If vial is cold, warm to skin temperature before giving the injection. Carefully open the sterile package containing the syringe and the needle and remove the syringe and needle from the package. If necessary, attach the needle to the syringe. Remove the needle shield from the needle. Insert the needle into the bottle’s rubber cover, and empty the entire contents of the bottle into the syringe. Remove the needle from the bottle. Hold the syringe upright and tap on the barrel to move any air into the tip. Expel the air from the syringe gently until you can see a drop of DMPA or NET-EN solution on the tip of the needle. Be careful not to contaminate the needle. Illustration credit: Ambrose Hoona-Kab

How to Give the Injection: Step 10 knobby top part of long bone in leg edge of hip bone (pelvis) injection site 10. Locate the exact site to insert the needle. the upper arm knobby part of arm injection site crease at arm pit the hip DMPA and NET-EN are given as an intramuscular injection in one of three sites; either the muscle of the upper arm (deltoid) or the muscle of the hip (ventrogluteal) or the buttocks (upper outer portion. A woman can decide where she prefers to receive the injection. To locate the injection site in the muscle of the upper arm, imagine drawing a box on the upper arm. Find the knobby top of the arm (acromion process) marked with a red dot in the illustration. Place two fingers under the knobby top to locate the top of the imaginary box. The bottom of the box is an imaginary line that runs from the crease of the armpit from front to back. The sides of the box are imaginary lines that are formed when dividing the arm into three equal sections from front to back. The middle of the imaginary box marks the injection site. To locate the injection site in the muscle of the hip, find the knobby top of the long bone of the leg (femur) marked with a red dot in the illustration. Place the palm of your hand over the knobby top of the femur with your index finger pointed toward the front of the hip bone. The thumb should be pointed toward the front of the leg. Spread your second finger toward the back, making a V-shape. The middle of the V-shape marks the injection site. Note to facilitator: Tell participants that they will have an opportunity to practice locating the injection sites on the arm and the hip on each other. Illustration credits: Ohio State University Medical Center. Giving Medicine By Intramuscular Injection. Columbus, Ohio: General Clinical Research Center, Ohio State University Medical Center. the buttock pelvic bone upper outer quadrant sciatic nerve injection site X

How to Give the Injection: Step 11 11. Insert needle straight into the muscle. DMPA or NET-EN must be injected into the muscle Syringe must enter the skin straight―not at an angle Hold the syringe like a dart. Use a dart-like motion to insert the needle. Insert the needle deep into the muscle so that the DMPA or NET-EN will be injected into the muscle – not into the skin or just under the skin. Study these drawings to make sure that you understand how to place the needle and hold the syringe. The needle should go into the muscle straight – not at an angle. When inserting the needle, spread the skin with your fingers, hold the syringe like a dart, and use a dart-like motion to insert the needle at the injection site. Note to facilitator: Tell participants that they will have an opportunity to practice holding the syringe properly and piercing the skin of fruit during their practice injections to get a better feel for things before beginning to inject humans. Illustration credits: World Health Organization (WHO). Ensuring safe injections. In WHO, Immunization in Practice: A practical resource guide, 2004 update. Geneva: WHO, 2004. Ohio State University Medical Center. Giving Medicine By Intramuscular Injection. Columbus, Ohio: General Clinical Research Center, Ohio State University Medical Center.

How to Give the Injection: Steps 12-13 12. Inject DMPA or NET-EN, emptying all of the contents of the syringe, then pull the needle out of the muscle. 13. Gently press the injection site with a clean cotton ball or cloth. Instruct the client not to rub or massage the site. Inject DMPA or NET-EN emptying all the contents of the syringe. Pull the needle out of the injection site. After injecting the DMPA or NET-EN, gently press the injection site (do not rub or massage) with a clean cotton ball or cloth. Remind the client NOT to massage the site after the injection as this can cause the DMPA or NET-EN to be absorbed more quickly and make it less effective. Illustration credit: Ambrose Hoona-Kab

How to Give the Injection: Steps 14-15 14. Place the used syringe in a puncture-proof container. Use great care to avoid a needle-stick injury to yourself or others. 15. Wash hands again with soap and water. Place the used syringe in a puncture-proof container. Use great care to avoid a needle- stick injury to yourself or others (see next slide for detailed information regarding safe handling of sharps). Wash hands again with soap and water. Note to facilitator: Ask participants if they have questions about any of the steps for giving an injection. Illustration credit: Ambrose Hoona-Kab

Practice Safe Handling of Needles Do not overfill the sharps container. Do not leave the needle inside the vial. Do not dispose of used needles in anything other than a sharps container. Do not re-cap the needle. Do not touch the needle. Ask participants: There are very specific rules for how to handle needles. In particular there are five DON’Ts for handling needles. What do you think are the five things that you should not do when handling needles? [Ask for participant responses to the question before clicking the mouse to reveal the correct information.] Answer: Safe handling and disposal of needles, is an important CHW responsibility so before practicing with needles, it is important to learn how to handle them safely. To avoid accidental needle-stick injuries, do not re-cap the needle after use. Immediately after use, place the used syringe in the sharps container. Do not touch a needle. If you accidentally touch a needle or stick yourself with a needle, do not use the needle on a client. Simply discard the needle and use a fresh one. Do not leave a needle inside the vial to avoid contaminating both the needle and the contents of the vial. Needles are also known as sharps. Sharps are objects that need to be placed in hard-walled container before disposal to protect garbage handlers and others from injury. The box where used needles are placed for disposal is called a sharps container. Do not overfill the sharps container. When the sharps container is 2/3 to 3/4 full, return the container to your supervisor and get a new one. Replacing a sharps’ container before it gets too full prevents needle sticks that occur when a provider stuffs a needle and syringe into the container and pricks him/herself on a dirty needle that is already in the container. Always place used needles and syringes in the sharps container. Do not put anything into the sharps container other than needles and syringes. When the sharps container is 2/3 to 3/4 full return it to your supervisor or the health care facility and get a new sharps container. Local regulations on disposal of sharps containers should be followed to ensure the health and safety of all the members of the community. Note to facilitator: Demonstrate for participants how to assemble a sharps container and show how full it should get before the CHWs return the box for a new one. Program administrators must consider what type and size puncture-proof container is appropriate for CHWs to use when disposing of used syringes. If CHWs are moving from place-to-place to provide services they must be issued portable sharps containers. Home-made portable sharps containers can be crafted from sturdy plastic bottles with wide mouths covered by tight-fitting caps or sturdy cardboard boxes. It is essential that home-made containers share the same safety features as the commercial grade containers (e.g., the container walls are sturdy to prevent needles from poking through, the syringes can be deposited in the container without forcing them, the needles/syringes cannot fall out after they are in the container, the entire container can be disposed of when it is 2/3 to 3/4 full ). Illustration credit: World Health Organization (WHO). Ensuring safe injections. In WHO, Immunization in Practice: A practical resource guide, 2004 update. Geneva: WHO, 2004. Destroy full sharps container by burning or burying.

Caring for a Needle-Stick Injury Wash injured area with soap and water as soon as possible. Do not apply anything to the site. Contact your supervisor. Seek counseling and care at a health facility. In addition to HIV exposure, needle stick injuries can result in exposure to other harmful viruses and bacteria. In the event of an injury with a needle that was used for injection, a provider should: Flush the injured area with running water and wash it with soap and water immediately. Avoid applying caustic agents, such as bleach, to the wound. This is not recommended because it may cause inflammation and potentially facilitate infection. Contact the supervisor and inform him/her about the injury. Check with the supervisor about what to do next or follow the instructions for needle-stick injuries shared during the provider training. If you cannot reach the supervisor or if you have concerns that you would like to discuss with a health care provider, seek counseling and care at a health facility. Note to facilitator: If no standard protocols are available. Use the following instructions: : 1- immediately wash affected area, 2- contact a supervisor, 3- complete a needle-stick report, 4- encourage provider to attend counseling, 5- request that the provider get tested, and 6- begin treatment if indicated. Add country-specific information to this presentation on what to do in case of occupational exposure to HIV or other pathogens. Typically this information would be based on the protocols used in health facilities but simplified to ensure understanding among providers. Source: CDC, 2001.

Finding the Injection Site Upper arm knobby part of arm injection site crease at arm pit Demonstrate that to locate the injection site in the deltoid muscle of the upper arm, participants should imagine drawing a box on their client’s upper arm. Find the knobby top of the arm (acromion process) marked with a red dot in the illustration. Place two fingers under the knobby top to locate the top of the imaginary box. The bottom of the box is an imaginary line that runs from the crease of the armpit from front to back. The sides of the box are imaginary lines that are formed when dividing the arm into three equal sections from front to back. The middle of the imaginary box marks the injection site. Ask participants to take turns finding the injection site on their partner’s arm. Observe whether the participants are accurately finding the correct site. Illustration credits: Ohio State University Medical Center. Giving Medicine By Intramuscular Injection. Columbus, Ohio: General Clinical Research Center, Ohio State University Medical Center.

Practice Finding the Injection Site Hip knobby top part of long bone in leg edge of hip bone (pelvis) injection site upper outer quadrant sciatic nerve X Demonstrate that to locate the injection site in the ventrogluteal muscle of the hip, participants should find the knobby top of the long bone of the leg (femur) marked with a red dot in the illustration. Place the palm of their hand over the knobby top of the femur with their index finger pointed toward the front of the hip bone. Their thumb should be pointed toward the front of the leg and they should spread their second finger toward the back, making a V-shape. The middle of the V-shape marks the injection site. Ask participants to take turns finding the injection site on their partner’s hip. Observe whether the participants are accurately finding the correct site. Illustration credits: Ohio State University Medical Center. Giving Medicine By Intramuscular Injection. Columbus, Ohio: General Clinical Research Center, Ohio State University Medical Center. Buttock

Using the DMPA Reinjection Job Aid Describe how the job aid helps you decide whether these women can receive their next injection. Had initial injection on 15 Jan. Has returned for reinjection on 15 Mar. Mentions light bleeding and spotting but no other health problems. Wishes to continue DMPA. Had her previous injection on 04 Feb. Has returned for reinjection on 01 Jun. Mentions minor complaints about feeling moody and bloated but no other health problems. Wishes to continue DMPA. Had previous injection on 13 Jan. Has returned for reinjection on 03 Jun because her husband who has been gone the past month is due home. She would like to continue using DMPA. She has developed no other health problems since her previous injection. Instructions for the facilitator: The purpose of this activity is to give participants an opportunity to use the reinjection job aid. Read the description of the first client and discuss how the job aid helps determine if the woman is eligible to receive a DMPA reinjection (e.g., based on the timing of the previous injection and whether she has developed a medical condition that prevents her from continuing to use DMPA). Ask participants to describe how they would use the job aid to make the decision. Repeat the same process for clients 2 and 3.

Using the NET-EN Reinjection Job Aid Describe how the job aid helps you decide whether these women can receive their next injection. Had initial injection on 15 Jan. Has returned for reinjection on 19 Feb. Mentions light bleeding and spotting but no other health problems. Wishes to continue NET-EN. Had her previous injection on 04 Feb. Has returned for reinjection on 13 Apr. Mentions minor complaints about feeling moody and bloated but no other health problems. Wishes to continue NET-EN. Had previous injection on 13 Jan. Has returned for reinjection on 16 Apr because her husband who has been gone the past month is due home. She would like to continue using NET-EN. She has developed no other health problems since her previous injection. Instructions for the facilitator: The purpose of this activity is to give participants an opportunity to use the reinjection job aid. Read the description of the first client and discuss how the job aid helps determine if the woman is eligible to receive a DMPA reinjection (e.g., based on the timing of the previous injection and whether she has developed a medical condition that prevents her from continuing to use DMPA). Ask participants to describe how they would use the job aid to make the decision. Repeat the same process for clients 2 and 3.