Accessing DMPA-SC through the public and private sectors in Nigeria: users’ characteristics and their experiences

Data collection

We calculated KPIs related to user experience from responses to a phone survey conducted with a subset of DMPA-SC clients who had consented to be contacted after their encounter with the provider. Our recruitment flow chart is illustrated in Figure 1.

Figure 1. Recruitment flow chart.

During training, participating public sector providers and volunteers (N=3,912), including facility-based clinicians, CHEWs, and community health volunteers, were instructed to screen all clients acquiring DMPA-SC for their willingness to be contacted. Of 144,505 clients receiving services through UNFPA, 116,614 received DMPA-SC, of whom a total of 1,156 clients consented to be contacted during their encounter with their provider. After internal data transfer, validation checks, and quality screening, register information with phone numbers were transferred to the M&E survey team in three tranches: August 2017, November 2017, and January 2018.

For private sector providers supplied by DKT Nigeria, DKT outreach personnel distributed a client register to each selected facility to collect potential survey participants. A standardized register was distributed because private facilities do not follow standardized procedures or forms for collecting patient information, if at all; the practice is rare among drug shop providers. In two, one-day sessions, DKT Nigeria outreach personnel were trained on explaining the purpose of the research to providers, instructing providers on how to complete the registers and seek consent for research from eligible clients. To maximize the number of potential respondents, only high-volume facilities were targeted for client register data collection. DKT Nigeria provided a list of 250 DMPA-SC participating providers, of which 187 were excluded due to duplicate records, incorrect data, and missing contact information. Of 63 providers who filled in information on the client registers, 555 clients received DMPA-SC and 532 consented to be contacted. We periodically contacted participating private providers (every 4–6 weeks) to extract information on eligible clients and their contact information from the registers. The sample size was one of convenience, and no attempt was made to control for bias during recruitment and enrollment.

Trained phone interviewers contacted all clients who had provided verbal consent and phone numbers for survey purposes. Phone interviewers were bilingual in English and one other language relevant to program geography (e.g. Yoruba, Hausa, Pidgin, Ibo, Ibibio) and received three days of training on contraceptive methods, survey procedures, how to obtain informed consent, tips for administering questionnaires, and guidance on completing the data collection tool. We adapted the survey instrument from a previous version used as part of the M&E for the DMPA-SC introductory (2015-2016) phase^14,15. Changes were made to incorporate public sector program features and adjustments made to the private sector program (e.g. the cessation of the private-sector CBD program). The questionnaire²² collected information on user characteristics (e.g., age, marital status, wealth), past contraceptive use, the quality of counseling, and other aspects of the care-seeking experience. The instrument was pre-tested in May 2017 among a small set of clients across different states (Abia, Cross River, and Kaduna) and revised before being encoded in Open Data Kit for electronic data capture on the SurveyCTO mobile application. The survey was conducted on a rolling basis from October 2017 to February 2018. Up to five attempts were made to contact each potential respondent before the survey was deemed incomplete. Interviews lasted about 15 minutes and respondents received compensation of 200 Naira (~$US 0.55) of mobile phone credits upon completion.

In total, 459 clients completed a survey. Among public sector program clients, 235 (25.8% of 912 contacted) completed a survey, ranging from one to five months following the time of injection (median=three months); the remaining clients did not complete a survey due to being unreachable (n=488; 53.5%; e.g., incorrect phone number, did not pick up), ineligible (n=124; 13.6%; e.g., did not obtain DMPA-SC), or refused to participate (n=32; 3.5%). Among private sector program clients, 224 (42.1% of 532 contacted) completed a survey, with a median follow-up at two months from the time of injection; 308 did not complete a survey for similar reasons as public sector counterparts.

Data analysis

From the phone survey data, we first described our sample of 459 DMPA-SC users’ sociodemographic backgrounds (age, marital status, education, wealth, past modern contraceptive use, and region) by program sector (i.e., public vs. private). We coded past modern contraceptive use based on answers to the question, “Before using the Sayana Press injection, have you ever used a modern contraceptive to delay or avoid getting pregnant?” State of residence was grouped into region categories—North, Central, and South—based on respondent confirmation of their location during the interview. Using multivariate logistic regression, we examined the sociodemographic predictors of accessing DMPA-SC from a public provider (relative to a private provider) among survey respondents.

We then examined outcomes related to four steps in the care-seeking process: (1) becoming aware of DMPA-SC, (2) choosing a provider, (3) choosing DMPA-SC from among method options, and (4) the quality of care experienced. Survey responses for the questions, “How did you hear about the Sayana Press injection,” “What is the main reason why you receive the contraceptive from this place or person,” and “What made you interested in switching to Sayana Press?” were graphed to visualize differences in responses across sectors and formally tested with chi-square tests. All statistical analyses were conducted in Stata (v14.2, College Station, TX).

We measured quality of care through 14 questions related to information offered by providers, interpersonal experience, and method choice. We analyzed individual question responses and as a summary measure aggregating all items. Most quality of care questions were based on previous frameworks for measuring contraceptive service quality^23,24, and had been tested for validity and reliability during the DMPA-SC introductory phase¹⁵. Following methods we previously used to create summary quality measures for contraceptive counseling, we coded responses corresponding to the higher-quality outcome for each component item with a “1”; for two interpersonal measures, the higher-quality outcome was considered to be a response of “no” for feeling treated differently because of one’s age or marital status. A “high quality” indicator was then constructed from the summary quality score to identify scores equal to the median (score of 12) or higher. We tested differences in responses across sectors using logistic regressions controlling for age, marital status, education, wealth, past modern contraceptive use, and region of residence.

Ethical approval

The Institutional Review Boards at the University of California, San Francisco (IRB# 15-18353) and the Nigeria Health Research Ethics Committee (NHREC/01/01/2007-06/01/2016 and NHREC/01/01/2007-16th/02/2017) approved this research.

Sample characteristics

A full dataset is available on Harvard Dataverse²². Demographic characteristics for survey respondents are described in Table 1. Compared to survey respondents who obtained DMPA-SC from a private provider, those who saw a public provider were more likely to be under age 25 (18.3% vs. 6.7%; OR=2.93, 95% CI 1.36-6.35, p = 0.006) and less likely to have either completed secondary school or have some college/university education (OR=0.46, 95% CI 0.23-0.96, p=0.037 and OR=0.44, 95% CI 0.20-0.94, p=0.035, respectively). Although a larger percentage of public sector respondents were unmarried and from poorer wealth quintiles compared to private sector respondents, these differences were not statistically significant. Both programs had similar percentages of respondents who had never used modern contraception prior to DMPA-SC: 60.3% among private sector respondents and 58.7% among public sector respondents. Nearly all private sector respondents (92.0%) were from the South (primarily Oyo and Lagos); approximately half (51.9%) of public sector respondents were from the North (nearly equal numbers from Kaduna and Kebbi) with 38.7% from the South (N_Abia=53, N_{Akwa Ibom}=29); only 9.4% were from Central states (nearly equal numbers from Benue and Abuja). Among public sector respondents, fewer respondents in the North were married (76.2% vs. 82.4% in South and 50% in Central; p=0.006), were new users of modern contraception (50% in North vs. 73.6% in South and 45.5% in Central; p=0.001), and from the richest wealth quintile (72.1% vs. 94.5% in South and 86.4% in Central; p=0.000); no differences were found by age or education categories.

Becoming aware of DMPA-SC

The source of awareness about DMPA-SC is displayed in Figure 2. Overall, 43.1% of respondents had heard of DMPA-SC through a friend or family member and 41.5% through a provider, followed by 14.6% at outreaches in the community and 1.8% from a media source. Higher percentages of respondents attending public providers heard about DMPA-SC through a friend or family member and outreaches in the community (50.9% and 15.6%, respectively) compared to their private sector counterparts (36.8% and 3.7%, respectively). In contrast, higher percentages of respondents attending private providers heard about DMPA-SC directly from their provider or through different media outlets (48.5% and 11.0%, respectively) than among public sector respondents (32.7% and 1.8%, respectively).

Figure 2. Source of awareness about DMPA-SC.

Chi-square test p-values: *p<0.05, **p<0.01; ***p<0.001.

Choosing a provider

Convenience was the most common reason for choosing a provider among all respondents (43.8%; see Figure 3), with more public sector respondents (53.6%) citing this reason than private sector respondents (33.5%). Going to a usual or previously-visited provider was the second most common reason given (22.8%), followed by recommendation from friends/family (15.1%). Private sector respondents were more likely to choose the provider whom they usually go to or had gone to before (32.1%) or for quality-related reasons (15.2%) than their public sector counterparts (13.7% and 8.2%, respectively). However, more public sector respondents stated that the provider came to their house (5.6%), which was minimal among private sector respondents (0.4%) and which reflected the proactive CBD model used by CHEWs and community health volunteers.

Figure 3. Reasons for choosing their provider.

Quality-related reasons include: treats me well, respects me, I trust this provider, the quality is good, they keep my info confidential, experts in family planning. Chi-square test p-values: *p<0.05, **p<0.01; ***p<0.001.

Choosing DMPA-SC from among method options

Providers’ recommendation was the most common reason given for choosing DMPA-SC (41.0% among all respondents), with more private sector respondents giving this reason (51.8%) than public sector respondents (30.8% Figure 4). Ease of use was also the reason for uptake among 32.2% of all respondents, followed by effectiveness (16.9%), potential for fewer side effects (13.8%), among others. More public sector respondents cited reasons related to specific DMPA-SC features than among private sector respondents: ease of use (38.0% and 26.1%, respectively), ease of access (10.7% and 4.5%, respectively), and longer duration (7.3% and 1.4%, respectively); no differences in responses were found for features related to side effects, effectiveness, or the smaller needle.

Figure 4. Reasons for choosing DMPA-SC.

Chi-square test p-values: *p<0.05, **p<0.01; ***p<0.001.

Quality of care experienced

More private sector respondents reported an overall high-quality summary score (62.9%) than public sector respondents (56.4%), but this difference was not significant (Table 2). Across items measuring information given, more private sector respondents than public sector respondents reported that the provider had asked about past experiences of side effects associated with another contraceptive method (77.9% vs. 63.0%), if she had any health issues (88.3% vs. 78.6%), and described possible side effects of DMPA-SC (79.6% vs. 71.9%). For both interpersonal measure items, more respondents attended by private providers reported being treated differently because of their marital status (13.9%) and their age (14.8%) than among those attended by public providers (6.4% and 10.4%, respectively). For method choice, private sector respondents were more likely to report that the provider had a moderate-to-strong preference on which method to choose (73.1% vs. 51.1%), but also more likely to describe a contraceptive method other than DMPA-SC (82.1% vs. 72.1%).

Limitations

Our results should be interpreted cautiously and in light of several contextual factors. It is unknown how generalizable survey results are beyond the users completing the survey or how different women not responding to the survey were distributed across implementing partners. Among private sector providers approached to participate in recruiting respondents, no registration database or standardized reporting formats existed previously from which a representative sample could be readily drawn. The resulting sample of providers and clients was highly skewed towards those in large urban areas in the South West, namely Oyo and Lagos, where contraceptive use is more prevalent and private sector providers relatively more abundant^26,27. In addition, young or unmarried women disproportionately declined to participate in the survey based on a comparison of the age profiles between survey respondents and the full client database available from the public sector program. All data collection activities excluded women without access to a telephone, who are likely to be poorer and from more rural locations.

Thus, quantitative survey results are unlikely to be representative and results should be cautiously interpreted. Experiences of survey respondents may not reflect more typical experiences of women reached through either the public or private sector programs. However, as the emphasis on CBD delivery of contraceptive services through the public sector departs from the usual mode of facility-based service provision, no pre-existing data exists to assess the representativeness of the resulting clientele served. Within the private sector sample, the general direction of biases is largely consistent with those documented in the Nigeria DMPA-SC private sector introductory phase, which showed that, in general, Nigerian women using longer-acting contraceptive methods are similarly older and wealthier than those not using contraception or using shorter-acting methods¹⁴.

Underlying data

Primary data used in this article are available from the Harvard Dataverse, DOI: https://doi.org/10.7910/DVN/XCLNIS²². The phone survey questionnaire, codebook, and dataset can be found within the folder “Phone survey 2017–2018.”

Extended data

The questionnaire used to guide the participant interviews is available from the Harvard Dataverse, DOI: https://doi.org/10.7910/DVN/XCLNIS²².

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).