# Understanding clients’ and providers’ perspectives on the implementation of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) for self-injection programming in Nigeria

## TL;DR

This study explores how clients and providers in Nigeria experience using a self-injectable contraceptive method, highlighting factors that could improve its adoption and effectiveness.

## Contribution

The paper provides new insights into the implementation challenges and facilitators of DMPA-SC self-injection programming in Nigeria using an implementation science framework.

## Key findings

- Clients found peer and social network support helpful in adopting DMPA-SC for self-injection.
- Providers need better training and resources to maintain protocol fidelity and improve outreach feasibility.
- Proactive provider follow-up is desired by clients to manage side effects and encourage continued use.

## Abstract

Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is an injectable contraceptive method with a small needle and prefilled syringe system that has been approved for self-injection (SI) by clients. As DMPA-SC for SI programmes are being scaled, employing an implementation science lens is critical to understanding what works. This study explored providers’ and clients’ experiences with providing and receiving services, respectively, for DMPA-SC for SI in Nigeria, using an implementation science framework.

Between 2021 and 2023, we conducted N=141 interviews with providers offering DMPA-SC for SI, and N=129 interviews with their clients using DMPA-SC for SI in Lagos, Enugu and Plateau States. Using Proctor et al’s implementation science framework, we noted observations for each interview question, extracted related quotes, and coded observations and quotes by implementation outcome (acceptability, appropriateness, feasibility, fidelity, cost, efficiency, safety, client-centredness and adoption).

Among clients, learning about DMPA-SC and SI from social network members facilitated acceptability and adoption of the method. Clients reported that provider outreach was appropriate for contraceptive information. However, providers desired support to mitigate their own out-of-pocket costs and enhance the feasibility of outreach. Occasionally, providers used clients’ age or education to decide whether they could self-inject independently, rather than clients’ ability to perform SI procedures, limiting client-centredness. Many providers felt their fidelity to SI provision protocols could improve with refresher trainings on the latest guidelines around offering SI. Clients indicated that proactive follow-up support from providers for continued SI and side effect management was appropriate and desired; providers concurred with offering such support.

Findings suggest that programme scale-up efforts should prioritise: (1) leveraging peer support or social networks to facilitate acceptability of DMPA-SC for SI among clients, (2) improving access to training aids to ensure fidelity to protocols and facilitate adoption among clients and providers, (3) emphasising shared decision-making in judgement-free client trainings to encourage client-centredness, and (4) investing in models for proactive follow-up support to improve feasibility of continuation for clients’ desired length of time.