title: Building on safety, feasibility, and acceptability: the impact and cost of community health worker provision of injectable contraception.
abstract: BACKGROUND
  A critical shortage of doctors, nurses, and midwives in many sub-Saharan African countries inhibits efforts to expand access to family planning services, especially in rural areas. One way to fill this gap is for community health workers (CHWs) to provide injectable contraceptives, an intervention for which there is growing evidence and international support. In 2009, with approval from the Government of Zambia (GoZ), FHI 360 collaborated with ChildFund Zambia to design and implement such an intervention as part of its existing CHW family planning program.
  
  
  METHODS
  The safety of CHW provision of injectable DMPA (depot medroxyprogesterone acetate) was measured by client reports and by a 21-item structured observation checklist. Feasibility and acceptability were measured by interviews with CHWs and a subset of DMPA clients. The impact of adding DMPA to pill and condom provision was assessed by family planning uptake among the clients of trained CHWs from February 2010 to February 2011. Costs were documented using spreadsheets over the period November 2009 to February 2011.
  
  
  RESULTS
  Scores were high on all measures of safety, feasibility, and acceptability. Couple-years of protection (CYP, protection from pregnancy for 1 year) was provided to 51 condom clients, 391 pill clients, and 2,206 DMPA clients. Of the 1,739 clients new to family planning, 85% chose injectable DMPA, while 13% chose pills and 2% chose condoms. Continuation rates were also high, at 63% after 1 year as compared with 47% for pill users. Incremental costs per couple-year were US$21.24 if 50% of users continue with CHW-provided DMPA.
  
  
  CONCLUSIONS
  The study affirms that the provision of injectable contraceptives by CHWs is safe, acceptable, and feasible in the Zambian context, with very high rates of uptake in hard-to-reach areas. High continuation rates among clients mean that costs of the intervention can be low when added to an existing community-based distribution program-a finding that is relevant to program replication (now underway in Zambia).
authors.affiliation: FHI 360, Division of Health Services Research , Research Triangle Park, NC , USA.
authors.forename: Dawn
authors.initials: D
authors.lastname: Chin-Quee
authors.affiliation: FHI 360, Division of Health Services Research , Research Triangle Park, NC , USA.
authors.forename: John
authors.initials: J
authors.lastname: Bratt
authors.affiliation: FHI 360, Division of Research Utilization , Research Triangle Park, NC , USA.
authors.forename: Morrisa
authors.initials: M
authors.lastname: Malkin
authors.affiliation: FHI 360, TB CARE I , Lusaka , Zambia.
authors.forename: Mavis Mwale
authors.initials: MM
authors.lastname: Nduna
authors.affiliation: FHI 360, Division of Health Services Research , Research Triangle Park, NC , USA.
authors.forename: Conrad
authors.initials: C
authors.lastname: Otterness
authors.affiliation: ChildFund Zambia , Lusaka , Zambia.
authors.forename: Lydia
authors.initials: L
authors.lastname: Jumbe
authors.affiliation: Republic of Zambia Ministry of Health , Lusaka , Zambia.
authors.forename: Reuben Kamoto
authors.initials: RK
authors.lastname: Mbewe