Empowering women one page at a time

“Does this mean I need to give the injection while standing up? And this woman is not wearing clothing—this is indecent.”

We leaned in to see where the woman was looking on the page. She was pointing to a drawing in an early draft of a Sayana® Press booklet designed for client self-injection counseling. Sayana Press is a simple, prefilled contraceptive device that is easy to use and is newly available through health workers in Senegal, Uganda, and several other countries.

Soon, for the first time in a low-resource setting, more than 700 women in Senegal and Uganda will have the option to self-inject Sayana Press at home, unsupervised, through ongoing PATH and Ministry of Health research studies.

The woman asking questions was one of 29 family planning clients our team met with in Senegal and Uganda who practiced using the booklet in a pretest in preparation for PATH’s Sayana Press self-injection research studies. As we talked further, we realized that our participant was interpreting the drawing literally—because the injection site options were depicted on a woman who was standing and wearing no clothes, she thought she should do so as well.

When we asked how to make this page clearer, she suggested indicating the injection site on the abdomen or thighs of seated and clothed women.

It was valuable feedback. We noted this change for the next iteration of the booklet, and moved on.

Figure 1: During pretesting, the injection site illustration depicted an unclothed woman standing.

Figure 2: After pretesting, the version used in self-injection studies depicts a clothed and seated woman.

In Africa, injectable contraceptives are popular because they are safe, effective, and discreet. One shot provides protection for three months. However, it is often difficult for women to get to health centers with staff qualified to give the injections. And often, after a woman arrives at the center, the staff may be too busy to administer the contraceptive.

PATH’s Sayana Press team is conducting research to find out the most effective approach to train women to self-inject independently without direct supervision of a trained health provider. What ongoing support will they need? Can well-designed self-injection programs improve family planning outcomes in countries like Uganda and Senegal?

In public health, task-shifting—or moving specific tasks from trained medical providers to community health workers—is a low-cost, effective way to improve access to more health services. The self-injection approach takes this concept a step further: to train women how to self-inject outside clinics in the privacy of their own homes, giving them even more autonomy. But for Sayana Press to be provided as a safe self-injection contraceptive option, women must learn how to correctly administer an injection and accurately calculate their reinjection date.

How-to booklets and instructional materials may not be the first thing people think of when new innovations are introduced, but often a solution’s success hinges on the development and design of these guides.

This process involves both listening to users’ feedback and observing how they use, and interpret, the materials and device.

For instance, take the woman who misunderstood the injection site illustrations—training materials must account for more than differences in language. To provide truly transformative solutions that empower women, PATH considers local conventions, customs, and religions, and incorporates the unique perspectives of the people living in these communities.

Pretesting the Sayana Press self-injection instruction materials in Senegal and Uganda was an important step in creating usable and acceptable country-specific booklets.

Most of the women who participated in the instruction booklet exercise were already using a family planning method such as Depo-Provera®. They provided the PATH team with invaluable guidance on how women might use self-guided instruction and reminder materials at home, and they also provided critical feedback to help women calculate and remember reinjection dates.

For instance, they preferred to remember reinjection dates by counting three months rather than 13 weeks, and that they had multiple ways to track important dates—a calendar, writing the date, asking a family member to help, committing it to memory, or by using a cell phone.

Based on this feedback, PATH revised the booklets prior to heading into self-injection research studies in the field. These studies (243 KB PDF) will assess the feasibility and acceptability, and ultimately the impact of self-injection.

In low-resource regions, self-injection of Sayana Press has the potential to empower low-literate women by providing them with another family planning option. And, like many more skilled health providers, several of our pretest participants required practice in order to master the key steps in using the injection device but were able to use it correctly after a short in-person training and the chance to practice.

By providing both clear visual instructions and comprehensive client counseling, we’re poised for success with self-injection in the future.

• Sayana Press self-injection studies (243 KB PDF).
• Sayana Press Pilot Introduction and Research website.
• Sayana Press Update newsletter (July 2015 edition).

Sayana® Press and Depo-Provera® are registered trademarks of Pfizer Inc. and/or its affiliates. Uniject is a trademark of BD.