Say hello to three people you do not work with on a daily basis

Say hello to three people you do not work with on a daily basis
Before we begin… Say hello to three people you do not work with on a daily basis Have this slide showing already when the Px are starting to arrive. June 19, Depo for CBDs – Family Planning Training Resource Package

Welcome, opening remarks and introductions of trainers

Community-based provision of Depo-Provera
CBD Training in Mumbwa and Luangwa districts

Session 1 Introduction to pilot project: CBD provision of Depo and overview of week’s training agenda

By the end of this session, participants will have learned:
Basic background of CBD of Depo Introduction to this pilot project Training objectives Overview of materials for this training What to expect in the upcoming training (administrative, logistics, etc.)

Background on CBD of Depo

Why CBD of Depo? Depo is most popular choice for family planning in Africa. Family planning use in rural areas is low. CBDs live in rural areas, so they can provide family planning to women who have difficulty reaching a clinic. CBDs are people the women already know and trust. Family planning can be provided in comfortable, private setting.

Experience with CBDs giving Depo elsewhere
Asia (1970s, 2000) Latin America (1990s) Uganda (2005) Madagascar (2006) Kenya, Nigeria (2009) Household delivery of family planning methods began in Bangladesh about 30 years ago. At its peak, these field workers provided up to 80% of contraception in some areas..this distribution included depo. In the 90’s a series of studies were carried out in Latin America to examine DEPO provision by CRHW workers. All three studies demonstrated the ability of CRHW workers to deliver depo and reach new FP users mainly among rural and indigenous women. And finally, all three of these efforts were scaled up. Today I will be sharing with you findings from a study in Uganda that demonstrated how community-based distribution of Depo is safe and acceptable. Uganda being closer to home has similar demographic and programmatic characteristics to Kenya. KEY POINT – COMMUNITY HEALTH WORKERS HAVE PROVIDED FP METHODS IN ASIA, LATIN AMERICA AND PART OF AFRICA AND HAVE BEEN SUCCESSFUL IN REACHING CLIENTS Source: Population Council, Family Health International June 19, Depo for CBDs – Family Planning Training Resource Package

Research and experience tells us…
…with proper training and support, CBD provision of injectable contraception is: Safe Feasible Acceptable From the Uganda case study, we have seen that …. June 19, Depo for CBDs – Family Planning Training Resource Package

Pilot project in Mumbwa and Luangwa
Government of Zambia would like to know whether CBD of Depo works in Zambia. Family Health International (FHI), Zambia Prevention, Care and Treatment (ZPCT) and ChildFund Zambia (CFZ) are working together to find out whether CBD of Depo works in Mumbwa and Luangwa. After a year of research, we will know how CBD of Depo works in these two districts. If it works well, the government may want to use CBD of Depo in more districts in Zambia.

Training objectives By the end of training, participants will have learned: Definition of family planning Benefits of family planning for the community and the country of Zambia Four groups of women who are at high risk should they become pregnant How to provide counseling on the full range of family planning (FP) methods How to use screening checklists to decide if a woman can safely use her family planning method When to initiate injectables (e.g., postpartum, breastfeeding or non-breastfeeding, switching from other methods). Review of the parts and function of the male and female reproductive systems Reviewed all of the family planning methods (what they are, how they work, how effective each one is, how each is used, advantages and disadvantages)

Training objectives – Cont’d
What is Depo and how does it work What is the effectiveness of injectables What are the common, non-harmful side effects of injectables How to safely give a Depo injection How to counsel the client about Depo (benefits and side effects, how it works in the body, etc.) How to use the Counseling Flipbook with their clients How to explain to client how to use injectables, including describing how the injection is administered and what to do post injection. How to address common concerns, misconceptions, and myths clients may have Prevent infection (washing hands and safely disposing of needles) What to do in the event of a needle-stick injury or other unexpected event How to locate the correct Depo injection site on the arm Proper injection technique by having practiced on fruits or vegetables

Training objectives – cont’d
How to refer clients to health centers for any services they cannot provide How to calculate a 13-week re-injection date and safe re-injection window. How to make follow-up visits to their clients How to track services they provide using the FP register and other forms What are the roles of data retrievers and what to expect When they should visit the district clinic and their supervisor What their supervisor’s role will be in their work How to order and store contraceptives and injection supplies How to dispose of their boxes at the district clinic What to expect during the clinical practicum About the supplies in the CBD kits they will receive after graduation

Which ones are you most excited about?
Pick five Put colored dots next to your top five on flipcharts Trainer Tip: Before this session, prepare flip charts listing learning objectives for this training. Post the pre-prepared flipcharts around the room. Hand out colored dot stickers so that there at least enough so that each gets five dots. Instruct them to read through the learning objectives and indicate the five that they are most excited about learning in this training. Allow three or four minutes for this. Then ask them to come up to the front of the room and place the stickers next to the learning objectives that they have selected. Look at where the clusters appear on the flipcharts. Take note of the sessions that people are most excited about and discuss your observations with the group. June 19, Depo for CBDs – Family Planning Training Resource Package

Session 2: Benefits of Family Planning
infants and children women Photo credit: ©2001 Moctar Ouedraogo/courtesy of Photoshare families communities June 19, Depo for CBDs – Family Planning Training Resource Package

What is the definition of family planning?
Group Activity What is the definition of family planning? Family planning implies the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility. – Working definition, WHO Department of Reproductive Health and Research June 19, Depo for CBDs – Family Planning Training Resource Package

Brainstorm benefits of FP for:
Questions to Consider Brainstorm benefits of FP for: women children men communities Note to facilitator: Ask participants to brainstorm about the benefits of family planning for each of the groups. Some possible examples for each group are outlined below. Family planning benefits for women: Lower risk of maternal death; lower risk of poor pregnancy outcomes and complications including a reduction in vaginal fistulas that result from prolonged labor; lower risk of anemia; lower risk of complications related to miscarriage or unsafe abortion; additional health benefits related directly to a contraceptive method (i.e., cancer protection). █ Family planning benefits for children: Longer breastfeeding, provides optimal nutrition, protects from childhood diseases, improves mother/child bonding; reductions in child morbidity and mortality; allows more time for parents to meet the needs of each child. █ Family planning benefits for men: Allows men to decide when and if they become fathers; allows men, in conjunction with their partners, to have the number of children which they desire and can afford. █ Family planning benefits for families and communities: Families can devote more resources to providing for each child; reductions in maternal and child illness can reduce economic strain on family; reductions in maternal deaths due to pregnancy and delivery strengthens families and communities; relieves economic, social, and environmental pressures. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Health benefits of family planning for women
Lower risk of dying from pregnancy Lower risk of poor pregnancy outcomes and complications Lower risk of anemia Lower risk of problems from miscarriage or unsafe abortion Some contraceptive methods offer protection from disease certain cancers and other women’s health problems June 19, Depo for CBDs – Family Planning Training Resource Package

Benefits for children Longer breastfeeding:
provides nutrition protects from childhood diseases improves mother/child bonding Reduces child illness and death Allows more time for parents to meet the needs of each child When women and couples use family planning to space and time their pregnancies, their children also benefit. Properly spaced pregnancies allow for longer periods of breastfeeding which give infants and young children the chance to derive the maximum benefits from the practice of breastfeeding including protection from childhood diseases and opportunities for mother and child bonding. Children who are exclusively breastfed are at lower risk of disease, especially diarrhea and respiratory infections. █ Children born to women who practice healthy timing and spacing of pregnancies are more likely to survive and less likely to be sick. █ Family planning gives parents the option to have the number of children they want when they want them which allows them to meet the varied needs of each individual child. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Family planning benefits for men
Allows men to decide when and if they become fathers Allows men, in conjunction with their partners, to have the number of children they desire and can afford.

Benefits for Families and Communities
Families can devote more resources to providing for each child Reduced maternal and child illness reduces economic strain on family Reduced maternal deaths strengthen families and communities Relieves economic, social, and environmental pressures Family planning allows families to devote more resources to providing their children with food, clothing, housing, and education. █ The reduced risk of death and illnesses among mothers, newborns, infants, and children achieved by healthy timing and spacing of pregnancies can contribute to reducing the economic strain on a family. █ Reductions in maternal mortality mean that more women are able to care for their children and families thus improving the quality of life for the entire community. █ When entire communities carefully plan their families, it may relieve the economic, social and environmental pressures from rapidly growing populations. Smaller and healthier families and communities may enhance opportunities for better planning and development and facilitate preservation of natural resources like forests, water, and land. █ June 19, Depo for CBDs – Family Planning Training Resource Package

too young (younger than 18) too old (more than 35)
4 groups of women at high risk for health problems if they become pregnant: too young (younger than 18) too old (more than 35) too many (more than 5 births) too close together (less than 2 years between births) Women who space births have time to recover between births and have more time to take care of the new baby. June 19, Depo for CBDs – Family Planning Training Resource Package

Group Activity Are family planning services accessible to everyone in your community who may need them? June 19, Depo for CBDs – Family Planning Training Resource Package

Review of basics about the reproductive system
Session 3 Review of basics about the reproductive system Male reproductive organs play an important role in reproduction - releases sperm, which fertilizes the egg. The parts of a male that are involved in sexual activities are called are called male reproductive organs. The organs are divided into external and internal parts June 19, Depo for CBDs – Family Planning Training Resource Package

Parts on the outside of the man
Penis The organ that carries the man’s seeds into the vagina. At the end of the penis there are folds of skin called foreskin that covers uncircumcised penis. Scrotum A sac where the testes are stored.

Parts on the outside of the man
Testes Produces sperms which fertilize the eggs Release the male hormone responsible for making a boy develop male characteristics such as Beards Deep voice Broadened shoulders

Male reproductive parts

Female reproductive parts
Parts of the female that are involved in sexual activity, pregnancy and child bearing are called the female reproductive organs or parts These consist of: Parts on the outside (vulva, breast) Parts on the inside (ovaries, fallopian tubes, uterus, vagina) These organs lie inside the lower part of the abdomen, called the pelvis, and are protected by bones and muscles. June 19, Depo for CBDs – Family Planning Training Resource Package

Female reproductive parts
June 19, Depo for CBDs – Family Planning Training Resource Package

Overview of all family planning methods
Session 4 Overview of all family planning methods

Session 5: Overview of Depo learning objectives, Characteristics of Depo, and Why Women Like/Dislike Depo Progestin-only injectable contraceptives are safe and highly effective and many women find that they are convenient to use. Depo is the most popular progestin-only injectable. Use of Depo is increasing rapidly. Depo can be provided in different settings by a wide range of providers – with community health workers (CBDs) playing an increasingly important role in offering this method. █ Note to facilitator: If there is no equipment available for projecting PowerPoint images, the participants can refer to the corresponding pages in the flip book to review technical information during the presentation/discussion. Regardless of how the technical information is presented, ask participants to open their flip books and look at the pages related to the topics under discussion so that they become familiar how the information is presented in the flip book and comfortable using the flip book with clients. When conducting training activities, refer to the “Notes to facilitator” embedded in the speaker notes of the presentation and the “Facilitator Instructions for Conducting Learning Activities” included in the session plan. Photo credit: FHI (packaging from socially marketed Depo in Kenya and Uganda) June 19, Depo for CBDs – Family Planning Training Resource Package

Objectives Describe the characteristics of Depo including common side effects. Describe what makes women ineligible for Depo use and how the checklist is used to determine eligibility. Describe when to initiate Depo. Describe (and demonstrate) how to give an injection. Describe key counseling topics. Describe how to conduct initial and re-injection visits. Identify clients in need of referral for Depo-related complications. Note to facilitator: Review the objectives of the session and related activities with the participants. The presentation and activities are designed to address these specific Depo-related objectives: 3.1 Describe the characteristics of injectables in a manner that clients can understand including: 3.1.1 what are injectables and how do they work 3.1.2 effectiveness 3.1.3 common side effects (NB: no health risks for women who are properly screened) 3.1.4 other characteristics (e.g., absence of STI/HIV protection, ease of use, return to fertility, when to initiate and discontinue) 3.2 Demonstrate the ability to: 3.2.1 screen clients for medical eligibility for injectables using a checklist for initiation and a job aid for re-injection. 3.2.2 explain to client how to use injectables, including describing how the injection is administered and what to do post injection. administer an intramuscular injection on model in compliance with standard guidelines (NB: arrangements for six supervised injections on clients must be made). describe and demonstrate appropriate infection prevention practices while providing injectables (i.e., hand washing, sharps disposal) and what to do in the event of a needle-stick injury or other unexpected event. 3.2.5 calculate a 13 week re-injection date and safe re-injection window. 3.2.6 explain when to seek medical care from a skilled provider (e.g., client feels something is seriously wrong with her health). 3.2.7 address common concerns, misconceptions, and myths. 3.2.8 conduct routine follow-up for Depo re-injection clients in a way that enhances continuing satisfaction and acceptance. 3.3 Describe when to initiate injectables (e.g., postpartum, breastfeeding or non-breastfeeding, switching from other methods). 3.4 Describe the process for re-ordering supplies, tracking clients, making referrals, and disposing of sharps and waste materials. June 19, Depo for CBDs – Family Planning Training Resource Package

What is Depo? Contraceptive method given by injection
Contains progestin (scientific name: Depo) Similar to natural hormone made by woman’s body Slowly released into blood from injection site Providers find that injectables are easy to administer, and many women find that they are convenient to use. Contains the synthetic hormone, called progestin, the scientific name is Depo. Each dose contains 150 mg of Depo. The hormone in Depo is similar to a natural hormone made by a woman’s body. The Depo is slowly released into blood from the injection site.1 Note to facilitator: Show the flip book and ask participants to consider how they can use this page when talking with their clients about Depo. Illustration credit: Ambrose Hoona-Kab Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007, updated 2008. June 19, Depo for CBDs – Family Planning Training Resource Package

How is Depo Provided? (part 1)
The injection is given in the upper arm: Depo is given as intramuscular injection in one of two sites; either the deltoid muscle of the arm or the ventrogluteal muscle the hip. A woman can decide where she prefers to receive the injection.1 █ Note to facilitator: Show the flip book and ask participants to consider how they can use this page when talking with their clients about where they prefer to have their Depo injection. Illustration credits: Ambrose Hoona-Kab. Ohio State University Medical Center. Giving Medicine By Intramuscular Injection. Columbus, Ohio: General Clinical Research Center, Ohio State University Medical Center. Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007, updated 2008. June 19, Depo for CBDs – Family Planning Training Resource Package

How is Depo Provided? (part 2)
Injection Schedule: Every 13 weeks (3 months) Can be up to 2 weeks early or 4 weeks late Schedule A woman should receive an injection of Depo once every three months or 13 weeks. The window for subsequent injections – how early or late the injection can be given while maintaining effective contraception – is up to two weeks early or four weeks late. If a woman returns more than four weeks late, she can receive an injection if the CBD is reasonably sure she is not pregnant. The use of backup contraception for seven days should be considered, and the woman should be counseled that delaying injections increases the risk of pregnancy.1 Women on ARV therapy should be encouraged to receive the next injection by the end of the three-month period. █ Reference: 1. World Health Organization (WHO). Selected Practice Recommendations for Contraceptive Use. Second Edition. Geneva: WHO, 2004; updated 2008. March April June September December June 19, Depo for CBDs – Family Planning Training Resource Package

How does Depo work? Prevents eggs from getting ripe and leaving the ovaries The hormones in Depo prevent pregnancy mainly by keeping the eggs from becoming ripe and leaving the ovary – a process known as ovulation. When there is no ovulation, there is no egg to be fertilized.1 █ Illustration credit: Ambrose Hoona-Kab Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007, updated 2008. June 19, Depo for CBDs – Family Planning Training Resource Package

Questions to Consider In your community, what do women believe about how injectables work? Explain how injectables work. Note to facilitator: Ask participants to share the common beliefs they may have heard about how injectables work. █ In the event that participants share misinformation or misconceptions about how injectables work, challenge them to explain the mechanism of action in simple terms. Ask how they might use their flip book to explain this information to their clients. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Depo Is Popular Among Women
Used: by millions of women worldwide in more than countries for almost 50 years In 2005 over 32 million couples throughout the world were using some type of injectable contraceptive.1 By 2006, Depo was registered in 179 countries. 1 It was first made available during the 1960s.2 Illustration credit: Ambrose Hoona-Kab References: 1. Lande, R. and Richey, C. Expanding services for injectables. Population Reports, Series K, No. 6. Baltimore, INFO Project, Johns Hopkins Bloomberg School of Public Health, December 2006. 2. Lande, R. E. New era for injectables. Population Reports, Series K, No. 5. Baltimore, Johns Hopkins School of Public Health, Population Information Program, August 1995. June 19, Depo for CBDs – Family Planning Training Resource Package

Depo Is Safe Most women can use Depo safely
A few women with certain conditions should not use Depo these women can be identified by asking a few simple questions Depo does not cause any serious health problems, cancer, or infertility Most women can use Depo safely. However, there are a few women with certain conditions who should not use Depo. Most women with these conditions can be identified by asking a few simple questions. Depo does not cause any serious health problems, cancer, or infertility; nor does it produce any significant change in blood pressure.1 Note to facilitator: Show flip book and ask participants to consider how they can use this page when talking with their clients about Depo. Illustration credit: Ambrose Hoona-Kab Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007, updated 2008. June 19, Depo for CBDs – Family Planning Training Resource Package

Depo Is Very Effective Women who have injections on time have very small risk of pregnancy (about one in 300 women) Women who have injections on time have very small risk of pregnancy (about one in 300 women). Even in typical use, when some women may be late for injection, only 9 of every 300 women become pregnant (or 3 in 100). Note to facilitator: Show flip book and ask participants to consider how they can use this page when talking with their clients about Depo. How does this page compare with the other pages in the flip book that describe method effectiveness (e.g., the Comparing Effectiveness of Family Planning Methods from the Global Handbook and alternative version, If 100 women use a method for one year, how many will become pregnant?, which compares numbers of women out of 100 that may become pregnant in one year. Illustration credit: Ambrose Hoona-Kab Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007, updated 2008. June 19, Depo for CBDs – Family Planning Training Resource Package

Question to Consider Why do women like Depo? Note to facilitator:
Ask participants to share the common beliefs among women in their community about why Depo is appealing. For example, available from community health workers, safe and effective, recommended by other women who are injectable users, best method for women in certain situations, able to use during breastfeeding, and nothing to remember at time of intercourse. Remind participants that women with similar characteristics in similar situations may have very different reasons for making choices about contraceptive methods. When counseling women it is important to help clients consider how these method characteristics fit into their lifestyles and reproductive health goals and desires. █ Illustration credit: Ambrose Hoona-Kab June 19, Depo for CBDs – Family Planning Training Resource Package

Why Women May Like Depo Easy to use Long acting Reversible
Can be discontinued without a provider’s help Does not interfere with sex Use can be private Has no effect on breastfeeding Eventually most women stop having monthly bleeding In addition to being safe and effective, Depo offers a number of other advantages. It is easy to use correctly and consistently, in part because it requires no daily routine. Depo is long acting. It is a reversible method of contraception, and it can be discontinued without the provider’s help. To discontinue, a woman simply stops receiving injections, and the level of Depo in her blood gradually decreases. Use of Depo requires no action at the time of sexual intercourse. Because no supplies are kept at home, its use can be private. Depo has no effect on lactation, so it can be used by women who are breastfeeding. Eventually most users stop having monthly bleeding which some women find very appealing. █ Question for reviewers: We have NOT included non-contraceptive health benefits. Options: 1- take out topic completely (as in this draft) 2- include only most straightforward (e.g., prevention of endometrial cancer and anemia), or 3- include all benefits and try to explain them. Ultimately, the decision should be based on what we expect CBDs to do and it would seem that non-contraceptive health benefits is something that CBDs cannot effectively explain to clients. June 19, Depo for CBDs – Family Planning Training Resource Package

Why Women May Not Like Depo
Causes side effects, particularly menstrual changes Action cannot be stopped immediately May take more time to become pregnant after stopping Depo Provides no protection against STIs/HIV As much as some women like Depo, others find that they dislike it. The main disadvantage of Depo is that it has common side effects – in particular, it causes menstrual changes in most users. These changes include prolonged or irregular bleeding or amenorrhea, which is the absence of menses. Because Depo is long acting, its action cannot be stopped immediately if side effects develop or if the user wishes to become pregnant. After a woman’s last injection of Depo, its level in the blood decreases gradually. For this reason, it takes longer for fertility to return after discontinuation of Depo than after discontinuation of other contraceptive methods. The length of time a woman has used Depo makes no difference in return to fertility. On average, women can become pregnant nine to ten months after the last Depo injection. Some women may become pregnant as soon as four months after the last injection, but a small percentage may take as long as 18 months. Because of the delay in return to fertility, women should be counseled to consider discontinuing Depo several months before the time they want to conceive. They should be reassured that Depo does not cause permanent infertility.1, 2 Like other hormonal methods, Depo offers no protection against sexually transmitted diseases, including HIV infection. █ References: 1. Pardthaisong T. Return of fertility after use of the injectable contraceptive Depo Provera: Up-dated data analysis. J Biosocial Science 1984;16(1):23-34. 2. SCBDallie PC, Assenzo JR. The effect of depot-medroxyprogesterone acetate on pituitary and ovarian function, and the return of fertility following its discontinuation: a review. Contraception 1974;10(2): June 19, Depo for CBDs – Family Planning Training Resource Package

Common Side Effects of Depo
prolonged or heavy bleeding irregular bleeding or spotting headaches and dizziness amenorrhea (no menses) The most commonly reported side effects of Depo are menstrual changes, including prolonged, heavy, or irregular bleeding, spotting, and amenorrhea. █ Depo users also commonly report weight gain. █ Less commonly reported side effects are headaches; dizziness; abdominal bloating and discomfort, mood changes, such as anxiety; and changes in sex drive.1 Typically, over 90 percent of Depo users report at least one side effect during the first year of use. In most cases, none of these side effects result in health risks. Nonetheless, some side effects, such as changes in bleeding, may have serious practical and social consequences for women.2 █ Illustration credit: Ambrose Hoona-Kab Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007, updated 2008. 2. World Health Organization (WHO). Multinational comparative clinical trial of long-acting injectable contraceptives: norethisterone enanthate given in two dosage regimens and depot-medroxyprogesterone acetate. Final report. Contraception 1983;28(1):1-20. abdominal bloating and discomfort weight gain changes in mood and sex drive June 19, Depo for CBDs – Family Planning Training Resource Package

Questions to Consider Which side effects do you think women in your community find most important when making a choice to use Depo? Why do you think those are the most significant? Note to facilitator: Ask participants to think about the side effects of Depo and describe how certain side effects may impact a woman’s life. For example, what might be the consequences for a woman if she experiences prolonged, heavy, or irregular bleeding? What if the woman experiences amenorrhea? Ask participants to consider how they can help women think about what it would be like to experience side effects. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Who Can Use and Who Should Not Use DMPA
Session 6 Who Can Use and Who Should Not Use DMPA

Who Can Use Depo Any woman of reproductive age who desires an effective, reversible, and long-acting method who: is breastfeeding a baby who is at least six weeks old has or has not had children cannot or does not want to use other methods (i.e., those containing estrogen) has a sexually transmitted infection including HIV is taking medications to treat AIDS or other diseases Depo can be used freely by women of reproductive age who desire an effective, reversible, and long-acting method to prevent pregnancy. A woman may be breastfeeding a baby older than six weeks; have no children, want to space her next pregnancy, or have all the children she desires but does not want permanent contraception; cannot or does not want to use other methods such as those containing estrogen; have a sexually transmitted infection, including HIV; or be taking medications such as ARV drugs or drugs to treat other infections such as TB.1 █ Illustration credit: Ambrose Hoona-Kab Reference: 1. World Health Organization (WHO). Medical Eligibility Criteria for Contraceptive Use. Third Edition. Geneva: WHO, 2004; updated 2008. June 19, Depo for CBDs – Family Planning Training Resource Package

Who Cannot Use Depo (part 1)
My period is late… have abnormal vaginal bleeding think they may be pregnant While Depo is safe for the majority of women, a small number of women with certain characteristics or medical conditions should not use Depo. Women who are pregnant or think they may be pregnant do not need contraception. Depo is not recommended for women who are breastfeeding a baby less that six weeks old; have abnormal vaginal bleeding that may indicate a serious condition; or have severe hypertension with blood pressure of 160/100 mm Hg or higher.1 █ Illustration credit: Ambrose Hoona-Kab Reference: 1. World Health Organization (WHO). Medical Eligibility Criteria for Contraceptive Use. Third Edition. Geneva: WHO, 2004; updated 2008. are pregnant Hmm… that is high. are breastfeeding a baby less than six weeks old have very high blood pressure Source: WHO, 2004; updated 2008. June 19, Depo for CBDs – Family Planning Training Resource Package

Who Cannot Use Depo (part 2)
I cannot eat sweets. have diabetes Depo is also not recommended for women who have breast cancer or have been treated for breast cancer in the past; have complicated diabetes, severe cirrhosis, malignant liver tumors, or systemic lupus; or had a heart attack or stroke or have blood clots.1 █ Illustration credit: Ambrose Hoona-Kab Reference: 1. World Health Organization (WHO). Medical Eligibility Criteria for Contraceptive Use. Third Edition. Geneva: WHO, 2004; updated 2008. have breast cancer have serious liver disease or lupus had a heart attack or stroke or have blood clots Source: WHO, 2004; updated 2008. June 19, Depo for CBDs – Family Planning Training Resource Package

Group Activity Understanding the Checklist
Read each question in the checklist and match them with the pictures in your flip book. This set of questions identifies women who should not use Depo. This set of questions identifies women who are not pregnant. Note to facilitator: Introduce the Depo checklist and highlight how the questions on the checklist can be used to identify women who should not use Depo. Ask participants to take turns reading the questions on the checklist and identifying which picture in their flip book addresses the question in the checklist. Draw attention to questions 9–13 and emphasize that CBDs must follow the instructions for this set of questions to identify women who are not pregnant or those who might be pregnant and should be referred to a higher level provider to rule out pregnancy. Tell CBDs that they will learn how to use the checklist to ensure that they do not provide Depo to women who should not use it. █ In addition to helping decide who can use Depo, the checklist gives instructions about starting Depo. June 19, Depo for CBDs – Family Planning Training Resource Package

When Can A Woman Start Depo (part 1)
Anytime – if you are sure woman is not pregnant. During the first seven days after your client’s period starts you can assume that she is not pregnant. You can give an injection now. There is no need for her to abstain or use condoms. After day eight of her cycle, you must rule out pregnancy before giving an injection. If she is not pregnant, give the injection and tell her to abstain from sex or use condoms for the next seven days. Depo can be initiated anytime during the menstrual cycle as long as the CBD can be reasonably sure the woman is not pregnant. If a woman wishes to initiate Depo during the first seven days of her menstrual cycle – where day one is the first day of bleeding, CBDs can assume that she is not pregnant. Notice how question #9 in the checklist addresses this issue. As shown on the checklist, women who answer NO to questions 1–8 and YES to question #9 can be given an injection immediately and do not need to abstain or use condoms. If a woman answers NO to question #9, the CBD should keep asking questions 10–14, until she answers YES. Questions 10–14 are designed to help rule out pregnancy for women who are not in the first 7 days of their menstrual cycle. If the woman answers YES to one of the questions 10–14, the woman can receive an injection immediately but should be encouraged to abstain or use condoms for 7 days. If a woman answers NO to all of questions 9–14, the CBD cannot be sure that she is not pregnant. She should be referred to a higher level provider for a pregnancy test and given condoms to use in the meantime.1 █ Note to facilitator: While describing when a woman can start Depo, ask participants to find and read the related questions on the Checklist for Screening Clients Who Want to Initiate Depo or NET-EN. Reference: 1. World Health Organization (WHO). Selected Practice Recommendations for Contraceptive Use. Second Edition. Geneva: WHO, 2004; updated 2008. June 19, Depo for CBDs – Family Planning Training Resource Package

When Can A Woman Start Depo (part 2)
Postpartum and breastfeeding: delay 6 weeks (follow checklist instructions) Postpartum and not breastfeeding: anytime within 4 weeks after delivery (after 4 weeks, rule out pregnancy) Ideally, women who are breastfeeding should not start using Depo until six weeks postpartum, because of the theoretical concern that newborn infants may not be able to metabolize the Depo received in breast milk. Notice how question #8 in the checklist addresses this issue. As shown on the checklist, women who answer YES to question #8 should not initiate Depo until the baby is at least six weeks old. Instruct the woman to return for an injection as soon as possible after the baby is six weeks old. Depo can be initiated immediately postpartum if the woman is not breastfeeding. If the woman had her baby in the past 4 weeks, she can be given a Depo injection immediately. Notice how question #12 in the checklist addresses this issue. Depo can be initiated immediately after a miscarriage or abortion. Notice how question #13 in the checklist addresses this issue. Women who have been using other contraceptive methods can switch to Depo immediately. If a woman is switching from another injectable, she can start the new injectable when the repeat injection would have been given. For women who are more than 4 weeks postpartum and not breastfeeding or women who are more than 7 days postabortion or miscarriage, pregnancy can be ruled out by the other questions in the checklist – such as question #11, has abstained from sex since last menstrual period, or question #14, has been using a contraceptive method – or by other means, such as a referral to a higher level provider for a pregnancy test. Women who are exclusively breastfeeding a baby less than six months old and whose menses have not returned are protected from pregnancy by the lactational amenorrhea method (LAM). Notice that both question #10 and question #14 on the checklist address this issue.1 █ Note to facilitator: While describing when a woman can start Depo, ask participants to find and read the related questions on the Checklist for Screening Clients Who Want to Initiate Depo or NET-EN. Illustration credits: Ambrose Hoona-Kab, Salim Khalaf, Institute for Reproductive Health Reference: 1. World Health Organization (WHO). Selected Practice Recommendations for Contraceptive Use. Second Edition. Geneva: WHO, 2004; updated 2008. Miscarriage or abortion: anytime within 7 days (after day 7 rule out pregnancy) Switching from another method: start immediately June 19, Depo for CBDs – Family Planning Training Resource Package

Group Activity Using the Checklist
Describe how the checklist helps you decide whether these women can use Depo. has malaria, finished her pack of COCs yesterday, and started her period 8 days ago is fully breastfeeding an eight week old baby and has not resumed menstrual bleeding had a blood clot in her leg after surgery 5 years ago but is now healthy and started her period 6 days ago Note to facilitator: Read the description of the first client and discuss how the checklist helps determine whether the woman has a condition that will prevent her from using Depo. Ask participants to describe how they would use the checklist to determine whether the woman was eligible to receive a Depo injection. Repeat the same process for client #2 and client #3. Client #1 – has malaria, finished her pack of COCs yesterday, and wishes to switch to Depo. She started her period 8 days ago. Malaria is not a condition that prohibits someone from using Depo – it’s not mentioned in questions #1–8 of the Depo checklist so she will answer NO to all those questions. Since the woman finished her pack of COCs yesterday, she will answer YES to question 14, making her eligible to have a Depo injection. However, since she started her period more than 7 days ago, she should abstain or use condoms for 7 days. █ Client #2 – is fully breastfeeding an eight week old baby and has not resumed menstrual bleeding since giving birth. When asked, the client will answer NO to all of questions # 1–8 and YES to question #10 which means she can have a Depo injection immediately because she is protected from pregnancy by the lactational amenorrhea method. However, as mentioned in the instructions on the checklist, she should abstain or use condoms for the next 7 days. █ Client #3 – had a blood clot in her leg after surgery 5 years ago but is now healthy. She started her period 6 days ago. When asked, the client will answer NO to all of questions # 1–8; although she had a blood clot several years ago she does not currently have a problem with blood clots. She will also answer YES to question #9 which means she can have a Depo injection immediately and does not need to abstain or use condoms. Tell participants that they will have more opportunities later to use the checklist during practice role plays. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Injection Demonstration
Session 7 Injection Demonstration

How to Give the Injection (part 1)
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, dry your hands with a clean towel or let them air dry.1 █ Note to facilitator: Ask participants to follow along in their flip book during the discussion about how to give Depo injections. 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 Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007, updated 2008. 1. Wash your hands well with soap and water. 2. Dry your hands with a clean towel or let them air dry. June 19, Depo for CBDs – Family Planning Training Resource Package

3. Locate the injection site and clean the site with cotton wool soaked in clean water. Wash your hands again, if needed. If the skin around the injection site is dirty, wash it with soap and water or wipe 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. █ Illustration credit: Ambrose Hoona-Kab Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007, updated 2008. 4. Double-check the bottle for content, dose, and expiration date. 5. Roll the bottle between the palms of your hands or shake it gently. June 19, Depo for CBDs – Family Planning Training Resource Package

6. Hold the bottle of Depo and remove the plastic cap. 8. Insert the needle into the rubber cover and empty the entire contents into the syringe. Hold the bottle of Depo 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 from the package. 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 Depo solution on the tip of the needle. Be careful not to contaminate the needle.1, 2 █ Illustration credit: Ambrose Hoona-Kab Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007, updated 2008. 2. Program for Appropriate Technology in Health (PATH). Introducing Auto-Disable Syringes and Sharps Disposal Containers with Depo. Seattle, WA: PATH, 2001. 9. Hold the syringe upright and tap on the barrel to remove air. Expel the air from the syringe gently. 7. Open the sterile package containing the syringe. June 19, Depo for CBDs – Family Planning Training Resource Package

10. Locate the exact site to insert the needle. the upper arm knobby part of arm injection site crease at arm pit Depo is given as an intramuscular injection in the deltoid muscle of the arm. To locate the injection site in the deltoid 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. Note to facilitator: Tell participants that they will have an opportunity to practice locating the injection sites on the arm 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. Reference: 1. Malkin B. Are techniques used for intramuscular injection based on research evidence? Nursing Times 2008;104(50/51):48-51. 2. Small SP. Preventing sciatic nerve injury from intramuscular injections: Literature review. J Adv Nursing 2004;47(3): June 19, Depo for CBDs – Family Planning Training Resource Package

Hold the syringe like a dart. Use a dart-like motion to insert the needle. 11. Insert needle straight into the muscle. Depo must be injected into the muscle Syringe must enter the skin straight – not at an angle Insert the needle deep into the muscle so that the Depo 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. June 19, Depo for CBDs – Family Planning Training Resource Package

Inject Depo emptying all the contents of the syringe. After injecting the Depo, gently press the injection site (do not rub or massage) with clean cotton wool. Remind the client NOT to massage the site after the injection as this can cause the Depo to be absorbed more quickly and make it less effective. █ Illustration credit: Ambrose Hoona-Kab Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007, updated 2008. 12. Inject Depo emptying all the contents of the syringe. 13. Gently press the injection site with clean cotton wool. Instruct the client not to rub or massage the site. June 19, Depo for CBDs – Family Planning Training Resource Package

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 Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007, updated 2008. 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. June 19, Depo for CBDs – Family Planning Training Resource Package

Safe disposal of syringes and other used injection supplies
Session 8 Safe disposal of syringes and other used injection supplies

Practice Safe Handling of Sharps
Do not recap the needle. Do not touch the needle. Do not leave the needle inside the vial. Safe handling of sharps is an important CBD responsibility – so prior to 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 box. 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. Do not overfill the sharps box. When the sharps box is 3/4 full, return the sharps box to your supervisor and get a new one. Replacing a sharps’ box before it gets too full prevents needle sticks that occur when a provider stuffs a needle and syringe into the box and pricks him/herself on a dirty needle that is already in the box. Always place used needles and syringes in the sharps container. Do not put anything into the sharps box other than needles and syringes. When the sharps container is 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 box and show how full it should get before the CBDs return the bow for a new one. Program administrators must consider what type and size puncture-proof container is appropriate for CBDs to use when disposing of used syringes. If CBDs 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 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. Reference: 1. Program for Appropriate Technology in Health (PATH). Introducing Auto-Disable Syringes and Sharps Disposal Containers with Depo. Seattle, WA: PATH, 2001. Do not overfill the sharps box. Do not dispose of used needles in anything other than a sharps box. Return the used sharps container to your supervisor or the health care facility. June 19, Depo for CBDs – Family Planning Training Resource Package

Needle Safety and Accidental Needle Stick
Session 9 Needle Safety and Accidental Needle Stick

Risk of HIV Infection after a Needle Stick
If 300 people injured themselves with a needle or other sharp instrument after using it on someone with HIV, how many do you think might get HIV? 1 in 300 10 in 300 100 in 300 The chance of getting HIV is even lower if the injury is from a needle used for a Depo injection. Discussion question: [Ask for participant responses to the following question before clicking the mouse to reveal the correct information.] If 300 people injured themselves with a needle or other sharp instrument after using it on someone with HIV, how many of those people do you think might get HIV? █ Answer: The risk of becoming infected with HIV following a needle-stick or sharp- instrument injury is about 1 in 300. Most injuries do not result in infection. The chance of getting HIV is even lower if the injury is from a needle used for a Depo injection. This is because the needles used for Depo injections are inserted into a muscle rather than directly into a blood vessel, making the exposure to infected blood minimal.1 █ Reference: 1. Bell DM. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. Am J Med 1997;102(5B):9-15. Source: Bell, 1997. June 19, Depo for CBDs – Family Planning Training Resource Package

Caring for a Needle-Stick Injury
Wash injured area with soap and water as soon as possible Do not apply caustic agents like bleach Tell your supervisor what happened Seek counseling and care at the health center 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 CBD should: Flush the injured area with running water and wash it with soap and water immediately.1 Avoid applying caustic agents, such as bleach, to the wound. This is not recommended because it may cause inflammation and potentially facilitate the entry of the organism. Contact the supervisor of community-based activities and inform him/her about the injury. Check with with the supervisor about what to do next or follow the instructions for needle-stick injuries shared during the CBD 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: Show appendix in the flip book that describes what to do in the event of a needle stick injury. Prior to the initiation of the CBA program, stakeholders must make decisions about what protocols will be followed for accidental sharps injuries. For example: 1- immediately wash affected area, 2- contact a supervisor, 3- complete a needle-stick report, 4- encourage CBD to attend counseling, 5- request that the CBD get tested, and 6- begin treatment if indicated. Add country-specific information to this presentation and to the CBD’s flip book 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 the CBDs. Reference: 1. U.S. Centers for Disease Control and Prevention (CDC). Updated U.S. public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 2001;50(RR11). Source: CDC, 2001. June 19, Depo for CBDs – Family Planning Training Resource Package

Finding the Injection Site on the Arm
Session 10 Finding the Injection Site on the Arm

Group Activity Practice Finding the Injection Site
Follow the instructions in your flip book to locate the injection sites on your partner’s arm. the upper arm knobby part of arm injection site crease at arm pit Note to facilitator: Tell the participants that during this activity they will be observing the facilitator as he/she explains and demonstrates how to locate the injection site and then practicing it themselves with a partner. Tell the participants to look in their flip books for the part that which describes how to how to locate the injection site and to follow along during the demonstration and practice. 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. June 19, Depo for CBDs – Family Planning Training Resource Package

Giving Practice Injections (to fruits and vegetables)
Session 11 Giving Practice Injections (to fruits and vegetables)

Group Activity Practice Giving Injections
Check the photo files to locate a better photo – one where the fruit is properly positioned over the injection site and the syringe is at a 90 degree angle to the fruit and the CBD is holding the syrince like a dart (not touching the needle as it appears might be happening in this photo) Group Activity Practice Giving Injections Follow the instructions in your Counseling Flipbook: Locate the expiration date on the bottle. Roll or shake the bottle gently. Remove the plastic cap from the bottle. Open the sterile package containing the syringe and the needle and if necessary, attach needle to syringe. Insert the needle into the rubber cover and empty the entire contents into the syringe. Hold the syringe upright and tap on the barrel to remove air. Expel the air from the syringe gently. Insert needle straight into the fruit. Inject Depo emptying all the contents of the syringe. Gently press the injection site (on the fruit) with a clean cotton ball. Note to facilitator: Tell the participants that during this activity they will be observing each step of the injection process and then practicing it themselves with a partner. Tell the participants to locate injection instructions in their job aids which describe how to give an injection, and to follow along in during the demonstration and practice. Give each participant, a vial of Depo, a syringe (non-anti-block syringes can be used for practice sessions), a piece of fruit, and a cotton ball. Demonstrate how to: – locate the expiration date on the bottle. Ensure that participants know where to look for the date and how to interpret the format (e.g., which number represents the day, month, year). – roll the bottle between the palms or shake it gently until the solids are mixed with the liquid. Remind participants as they roll or shake their bottles that the contents should not become frothy. – remove the plastic cap from the bottle and ask the participants to do the same. – open the sterile packaging for the syringe and needle and attach the needle to the syringe. Lay the open packaging flat on the table so that there is a sterile surface upon which the rest the syringe. Ask the participants to do the same. – remove the needle cover and insert the needle into the rubber cover ensuring that it is placed at the lowest corner of the vial. Draw up the entire contents of the vial into the syringe – without drawing in air. Ask the participants to do the same. – remove the syringe from the bottle and hold it upright while tapping on the barrel to move any trapped air to the tip of the syringe. Gently push the plunger to expel any air trapped in the syringe. Ask the participants to do the same. – insert the needle straight into the fruit (not at an angle) and inject the contents of the syringe. Ask the participants to do the same (partners can take turns holding the fruit for each other). – press the injection site with a clean cotton ball. Ask the participants to do the same. Remind participants that normally they would be disposing of the syringe immediately after giving the injection but since these are just practice injections, they can be used another time. █ Photo credit: Angela Akol June 19, Depo for CBDs – Family Planning Training Resource Package

Family Planning Counseling and Informed Choice
Session 12 Family Planning Counseling and Informed Choice

Review of making referrals to health facilities
Session 13 Review of making referrals to health facilities

Session 14 Counseling about Depo

Counseling about Depo Factors for clients to consider:
Other available contraceptive options Characteristics (advantages and disadvantages) Side effects, including menstrual bleeding changes Timing of return to fertility Need for regular, timely injections Although knowing how to give an injection safely is very important skill – knowing how to counsel your clients appropriately is equally important. A client’s satisfaction with any contraceptive method depends greatly on counseling. This is especially true with injectables. When a woman chooses an injectable contraceptive, the CBD must be sure that she has carefully considered these factors: All available contraceptive options The characteristics of the injectable and how its use may affect her lifestyle Anticipated menstrual bleeding changes and other potential side effects The timing of return to fertility after injections are discontinued The need for regular, timely injections. █ Illustration credit: Ambrose Hoona-Kab June 19, Depo for CBDs – Family Planning Training Resource Package

Counseling about Depo Tell the woman after she chooses Depo:
Do not massage injection site You can expect some spotting. However, some women will have bleeding while others will not. Seek help for problems or concerns at health center No protection from STIs/HIV Once a woman has decided to use an injectable contraceptive, it is important that she be counseled on these points: She should not massage the injection site after the injection as that can cause the Depo to be absorbed too quickly. She should expect menstrual bleeding or spotting after the injection. She should seek help from a provider at a health care facility if she is concerned that there is something seriously wrong with her health, for example if she has severe headaches; severe abdominal pain, or unusually heavy or long bleeding – bleeding that is more than eight days long or twice as heavy as usual; or yellow skin or eyes that may indicate a serious liver condition. She should keep in mind that injectables do not protect against STIs including HIV and should therefore consider using condoms to avoid infection. █ Illustration credit: Ambrose Hoona-Kab June 19, Depo for CBDs – Family Planning Training Resource Package

Counseling Helps Depo Users Continue
Bleeding changes is the most common reason for discontinuation Women receiving counseling about bleeding changes before they start Depo are more likely to continue Clients with concerns or with severe bleeding should be referred to a higher level provider for treatment or a decision about whether to continue the method Seems like my period just ended and now I’m spotting… With injectable contraceptives, the quality of counseling has a large effect on whether women discontinue the method because of side effects. Changes in menstrual bleeding – such as prolonged, irregular, or frequent bleeding resulting from Depo use – are the most common reason for discontinuation. Women who are considering using Depo should be counseled that such changes in bleeding are normal and expected and that they are not signs of disease or health problems. After injections begin, counseling and reassurance should be provided as needed. Women are much more likely to continue using Depo if they have received adequate counseling about the possibility and meaning of side effects. For example, in one study of Depo, women who had been counseled about side effects were more than three times as likely to continue using the method as women who had not been counseled. The sites that provided better counseling had lower discontinuation rates.1 Women’s concerns over prolonged or heavy bleeding should never be disregarded or considered unimportant. CBD should refer the woman to a higher level provider. If a Depo user is experiencing severe bleeding, the CBD should refer the woman to a higher level provider. Medical treatment or discontinuation of Depo may be necessary, especially in cases where the woman has pre-existing anemia. █ Illustration credit: Ambrose Hoona-Kab Reference: 1. Lei Z-W, Wu SC, Garceau RJ, et al. Effect of pretreatment counseling on discontinuation rates in Chinese women given depot-medroxyprogesterone acetate for contraception. Contraception 1996;53(6): June 19, Depo for CBDs – Family Planning Training Resource Package

Question to Consider What can you do to ensure that your clients are prepared to deal with bleeding changes? Note to facilitator: Ask participants to think about how they can help to make sure that their clients are prepared to deal with bleeding changes. For example, they may ask a client to think how their day-to-day activities might be disrupted by breakthrough or prolonged bleeding. After the client mentions how things might be disrupted, the CBD may be able to make suggestions about how to cope with irregular bleeding.█ June 19, Depo for CBDs – Family Planning Training Resource Package

Question to Consider What have you heard women say about Depo that you know is not true? Note to facilitator: Ask participants to think about things they have heard women in the community say about Depo that they know is not true. Compare what they mention with the items listed on the next slide. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Replace Myths with Facts
Does not cause cancer Does not cause infertility Does not cause abortion Can be used by women with HIV Not having monthly bleeding is not harmful Does not interfere with breastfeeding Does not cause deformed babies if accidentally given to pregnant woman Counseling provides an opportunity to replace a client’s misunderstandings about Depo with facts. In addition to the things that you just mentioned about what women in your community have said about Depo, some common myths and misunderstandings that you may need to correct during counseling include: Depo does not cause cancer. In fact, it has been shown that Depo protects against cancer of the lining of the uterus, also known as endometrial cancer. Depo does not cause infertility. Although it may take an average of nine to ten months for a woman to become pregnant after her last Depo injection, Depo does not cause a woman to become permanently infertile. The bleeding pattern that a woman had before she used Depo generally returns several months after the last injection. Depo does not cause abortion. Research on progestin-only injectables finds that they do not disrupt an existing pregnancy. Depo can be used by women with HIV. Depo can be used safely by women with HIV, including women who are on antiretroviral treatment. Not having monthly bleeding is not harmful. Some women may erroneously believe that if they do not have monthly bleeding they are either pregnant or that menstrual blood is collecting in their bodies. Depo causes the lining of the uterus to become thin and over time many women stop having menstrual bleeding. If a woman is concerned that she may be pregnant, refer her to a higher level provider for a pregnancy test. Some women prefer Depo because they like not having monthly bleeding. Depo does not interfere with breastfeeding. Unlike combined contraceptives which impact the amount of breast milk produced, Depo has no effect on breastfeeding. However, it is recommended that breastfeeding women wait until six weeks postpartum before using Depo due to a concern that an infant’s liver cannot properly get rid of the hormone in Depo which they receive in breast milk. Depo does not cause deformed babies if accidentally given to pregnant woman. There is no evidence that Depo causes abnormalities in children who were accidentally exposed to Depo while in the uterus. Note to facilitator: Compare the participants’ responses to the question on the previous slide to the information shared on this slide. Encourage the participants to note commonalities and any differences. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Group Activity Counseling about Depo
Use your flip book to counsel about: What is Depo and how does it work? How safe and effective is it? What are some advantages and disadvantages? What are the common side effects? When should Depo be initiated? What is the period of time in between injections? Who can use or who is eligible to use Depo-Provera? Who cannot use or is not eligible to use Depo-Provera? Note to facilitator: Tell participants that they will now have the opportunity to use what they have learned about Depo. In this activity they will practice telling each other about Depo using the pages from their flip book. Demonstrate how to use the flip book to explain what is Depo. For example: “As you can see in this picture, Depo is a method used to prevent pregnancy that is given by injection. It contains a synthetic hormone called progestin. The hormone in Depo is similar to a natural hormone made by a woman’s body. The Depo is slowly released into blood from the injection site. What else can I tell you about Depo?” Ask participants to split up into pairs and take turns using the appropriate pages from their flip book to practice counseling and sharing information about the topics listed on the slide. Remind them to ask open-ended questions, paraphrase client responses, and use other techniques that they learned. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Determining the Re-injection Date
Session 15 Determining the Re-injection Date

Decide Next Injection Date
Use a calendar to count 13 weeks from today Client may receive next injection 2 weeks early or 4 weeks late An important benefit of providing Depo injections in the community is that you can help ensure that women receive their next injections on time. After giving the injection, use your calendar to count 13 weeks from today. Make arrangements with the woman for a follow-up appointment around that time. A woman can receive a re-injection up to two weeks early or four weeks late. This time period is shaded in the example calendar and is sometimes called the re-injection window. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Group Activity Deciding Next Injection Date
If a woman receives an injection today, what day would she be due for her next injection? What is the earliest date that you could give her another injection? What is the latest date that the injection can be given without ruling out pregnancy? Note to facilitator: Calculate the answers to the questions in advance. Ask participants to look at their calendars. Ask the first question and tell the participants to write that date on a piece of paper. Ask one of the participants to share the date with the group. Confirm that the response is correct, or ask for other responses, and if necessary, demonstrate how to use the calendar to count 13 weeks and arrive at the re-injection date. █ Ask the second question and tell the participants to write that date on a piece of paper. Ask one of the participants to share the date with the group. Confirm that the response is correct, or ask for other responses, and if necessary, demonstrate how to use the calendar to count two weeks prior to the scheduled re-injection date to arrive at the earliest re-injection date. █ Ask the third question and tell the participants to write that date on a piece of paper. Ask one of the participants to share the date with the group. Confirm that the response is correct, or ask for other responses, and if necessary, demonstrate how to use the calendar to count four weeks past the scheduled re-injection date to arrive at the latest date that a re-injection can be given without needing to rule out pregnancy.█ June 19, Depo for CBDs – Family Planning Training Resource Package

Conducting Client Re-injection Visits
Session 16 Conducting Client Re-injection Visits

Group Activity Conducting Client Visit
Describe how to conduct visits with clients. Note to facilitator: Review with the participants the general structure of a client visit using the steps in their Job Aids. Ask participants to consider how they can use this list of steps as a job aid to remind themselves about how to conduct visits with clients. While reviewing the steps, encourage participants to think about how they can use the information from the various parts of their flip book (see specific suggestions in the session plan).† Remind the participants that during visits with clients, they should reassure the client as appropriate and try to answer questions raised by the client. Remind them that if they don’t know an answer, they should tell the client that they do not know but can refer her to a provider who can address her questions and concerns. It is not expected that that CBDs will be able to answer all client questions.‡█ † ‡ Participants may not be able to adequately understand step 2 and step 5 if they have not achieved the pre-requisite core objectives. Conduct the activities designed to allow participants to master these skills before proceeding with other activities. Illustration credit: Ambrose Hoona-Kab June 19, Depo for CBDs – Family Planning Training Resource Package

Preparing for Visits with Clients
Make sure that you have all the supplies and equipment you need. Question: Given what we have reviewed thus far, what supplies and equipment do you need to have available in your CBD Kit during client visits? █ [Ask for participant responses to the question before clicking the mouse to reveal the correct information.] Answer: When preparing to visit a client, the supplies and equipment you need include the eligibility checklist, the re-injection tool, a calendar for calculating re-injection dates, the counseling flipbook, reporting forms, client reminder cards, a single- or multi-dose vial of Depo (150 mg/dose), a 2ml syringe, a 21–23 gauge intramuscular needle, a puncture- proof sharps container, soap and clean water for hand washing, and cotton balls for pressing over the injection site or for cleaning the injection site if dirty. █ Note to facilitator: Show page in flip book entitled “Steps to Follow for Client Visit” and ask participants to think about how they will remember to gather all the things they need for doing a client visit. For, example, they could look at this page and check the items shown on the page against the items in their bag to make sure that they have everything in order. Illustration credit: Ambrose Hoona-Kab Balls Cotton June 19, Depo for CBDs – Family Planning Training Resource Package

Group Activity Conducting Re-injection Visits
Follow the instructions on the job aid to figure out if clients are eligible to receive another injection. Note to facilitator: Review with the participants the general structure of a re-injection visit using the steps outlined in the Reinjection Job Aid, in the flipbook (see the session plan for suggestions about how to conduct the review of the job aid). Ask participants to consider how they can use the job aid to remind themselves about how to conduct re-injection visits with clients. June 19, Depo for CBDs – Family Planning Training Resource Package

Group Activity Using the Re-injection Job Aid
Note to facilitator: Read the description of the first client and discuss how the job aid helps determine whether the woman is eligible to receive a Depo re-injection (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 Depo). Ask participants to describe how they would use the job aid to make the decision. Repeat the same process for client #2 and client #3. Describe how the job aid helps you decide whether these women can receive their next injection. Had initial injection on 16 Jan 09. Has returned for re-injection on 16 Mar 09. Mentions light bleeding and spotting but no other health problems. Wishes to continue Depo. Had her previous injection on 04 Feb 09. Has returned for re-injection on 01 Jun 09. Mentions minor complaints about feeling moody and bloated but no other health problems. Wishes to continue Depo. Had previous injection on 13 Jan 09. Has returned for re-injection on 03 Jun 09 because her husband who has been gone the past month is due home. She would like to continue using Depo. She has developed no other health problems since her previous injection. Client #1 – Following the guidance provided in the job aid, the facilitator should walk the participants through these steps: count the number of weeks that have elapsed since the previous injection conclude that only ~8 weeks have passed since the previous injection which is prior to the start of the re-injection window inform the client that she is outside the re-injection window and it is too early for her to receive another injection remind the client that side effects – especially bleeding changes – are possible and reassure the client as appropriate use the calendar to explain to the client when she should return for re-injection (her scheduled re-injection date is April 17th – so she should return as close to that date as possible, but not before April 3rd or after May 15th) remind the client that if she cannot return before May 15th she should use a back-up method such as condoms until she can come back for re-injection █ Client #2 – Following the guidance provided in the job aid, the facilitator should walk the participants through these steps: conclude that ~17 weeks have elapsed since the previous injection – which is later than the planned re-injection date of May 6th but within the re-injection window which does not close until June 3rd inform the client that although she has arrived late for her re-injection, it is within the re-injection window so she may receive another injection if she has not developed any conditions that would make her medically ineligible reassure the client that moodiness and bloating are common side effects experienced by Depo users and present no health risk; ensure that the client has not developed any of the other health problems mentioned on the screening checklist; determine that the client can continue to use Depo since in this case the client has opted to continue the method, give the re-injection and remind the client that Depo does not protect against STIs/HIV use the calendar to determine that the client’s re-injection date is August 31, 2009 encourage the client to respect her new re-injection date – if she cannot make it on her scheduled day, returning up to two weeks early or four weeks late is acceptable; she should come back regardless of how late she might be – remind her that if she is more than four weeks late for the next injection she should use a back-up method such as condoms or abstinence to avoid unintended pregnancy. █ Client #3 – Following the guidance provided in the job aid, the facilitator should walk the participants through these steps: conclude that ~20 weeks have elapsed since the previous injection – which is later than the planned re-injection date of April 14th and outside the re-injection window which closed on May 12th inform the client that she is outside the re-injection window and you would like to ask her a series of questions to determine if there is any chance that she may be pregnant use the pregnancy checklist on page 2 of the job aid to determine that the client is not pregnant as she has been abstaining since the previous injection expired (during the time that her husband was away) ask the client if she is experiencing any new health problems to ensure that the client is still medically eligible remind the client that side effects are possible and reassure the client as appropriate give the re-injection and tell the client to use a back-up method for the next 7 days; remind the client that Depo does not protect against STIs/HIV use the calendar to determine that the client’s next re-injection date is September 2 encourage the client to respect her new re-injection date – if she cannot make it on her scheduled day, returning up to two weeks early or four weeks late is acceptable; she should come back regardless of how late she might be – if she is more than four weeks late for the next injection encourage the client to use a back-up method such as condoms or abstain. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Session 17 Record keeping

Session 18 CBD relationship with district clinic: Safe disposal, re-supply, supportive supervision

What does your supervisor do?
Participate in 1-day training this week Observe CBDs during 2-week clinical practicum to practice counseling clients and giving injections Attend CBD graduation ceremony, if possible Manage CBD sharps disposal at the clinic Re-supply CBDs with contraceptives Manage supply logistics between DHMT and the health centre (including Medical Stores) Review of CBD service delivery data, if needed Provide supportive supervision throughout project

Group Activity Play the Depo Fun Facts Game
Be the first team to completely fill your pie! Fill a segment of the pie each time your team gets a correct answer in one of five categories: general Information about Depo who can use Depo and when can they start giving an injection conducting a re-injection visit practicing safe disposal of needles and other safety concerns Note to facilitator: Detailed instructions for conducting the Depo Fun Facts Game are included in the session plan. The participant question/answer sheets, the score sheet and answer key for Depo Fun Facts Game. June 19, Depo for CBDs – Family Planning Training Resource Package

Session 19 Role Playing

Group Activity Practice Client Visits Using Role Plays
Use the Counseling Flipbook, checklists, job aids, and forms to practice doing client visits. Each participant will have a chance to be a client, a CBD, and an observer. Discuss these questions after each role play: What was going on between the CBD and the client? What did the CBD do that was effective in this situation? What might the CBD consider doing differently if this situation were to happen again? How did the CBD attend to the items on the counseling observation checklist and the case-specific observations included in the role-play description? Note to facilitator: Inform participants that they will now have an opportunity to practice applying their new knowledge and using their job aids as they take turns playing the roles of clients and CBDs in a series of real-life simulations. Following the General Guidance for Facilitating Role Plays, instruct the participants about how the role plays will be conducted. Encourage the participants to challenge themselves and each other to use the job aids and techniques reviewed during previous activities and provide each other with constructive feedback about their performance. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Orientation to the Clinical Practicum
Session 20 Orientation to the Clinical Practicum

Group Activity Practicum Objectives
To complete the practicum participants must show they are able to: Explain to clients key facts about Depo how to use it. Screen clients for medical eligibility. Administer an intramuscular injection for six clients. Demonstrate appropriate infection prevention practices. Calculate a 13 week re-injection date for each client. Explain to each client when to seek medical care from a skilled provider. Address concerns, misconceptions, and myths raised by each client. Conduct routine follow-up for Depo re-injection clients in a way that enhances continuing satisfaction and acceptance. Note to facilitator: Review with participants the objectives of the practicum. Inform the participants that they must successfully complete the objectives described above and demonstrate competency for (# of) injections under the supervision of a trained clinician. Tell participants that practicum supervisors will provide careful oversight for each CBD during the practicum period. Supervisors will use an observation checklist to evaluate the performance of each participant during their interactions with clients. Supervisors will provide constructive feedback to the participant after each observation and will intervene in an interaction if there is any risk posed to a client. Conduct a careful review of the checklist that the practicum supervisors will use during their observations of the client interactions. Ensure that participants understand what is expected of them to successfully complete the practicum. █ June 19, Depo for CBDs – Family Planning Training Resource Package

Say hello to three people you do not work with on a daily basis

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Say hello to three people you do not work with on a daily basis

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