Injection Technique ImportantCareful injection technique ensures that the full dose is absorbed at the right rate and thus is fully effective.
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The User's Perspective on InjectablesWomen's attitudes toward progestin-only injectables largely reflect their feelings about the privacy and convenience of injections and menstrual bleeding disruptions. These feelings in turn reflect not only the attributes and physiological effects of the method but also women's knowledge and understanding of the method, personal needs, contraceptive experience, partners' attitudes, and cultural norms. Family planning providers can better counsel and advise clients if they are aware of these differing attitudes and physiological responses. Similarly, communication programs must understand people's attitudes and reactions in order to devise effective messages.
The New UserWomen choose injectables because:
"One of my husband's relatives once said to me, `Injectables
are good. I've been using them for three years. Come with me and
you'll be able to get an injection, too. There won't be any
trouble.' So I talked to my husband and after he agreed, I began
using injectables. Many others have followed me. Even my
sister-in-law uses injectables now.
"I started using injectables after I had two children in
quick succession."
"I decided to use the Depo shot because it was very easy.
You just come back every three months. I didn't decide to take
the Pill because I am on medication for seizures. I thought I
would forget to take the pills.
"I was a poor pill taker. I thought barrier methods were
inconvenient and messy."
The Continuing UserUsers' attitudes toward injectables are reflected in discontinuation rates. The most common reason for stopping injectables is side effects. In a WHO trial of DMPA, for example, half of users discontinued after one year: about one-third stopped because of side effects—for example, menstrual disruption, headaches, dizziness, or weight gain—and the rest stopped for personal reasons or were lost to follow-up (342).Women's attitudes toward side effects, particularly menstrual disruption, are varied and complex (111, 115, 278, 324, 327). Irregular bleeding is inconvenient for many women who do not have sexual relations while menstruating (327). Muslim women often discontinue injectables because their religion forbids them to pray, fast, read from the Koran, or have sexual relations during vaginal bleeding. Amenorrhea may make some women think that they are pregnant or that a drug powerful enough to take away monthly bleeding is unhealthy in other ways. Many people have the false idea that, if a woman does not menstruate, poisonous blood collects in her body (327). Such attitudes are not universal. Many users in Jamaica, Indonesia, and Thailand, for example, accept menstrual disruption (115). For many users the benefits of effective contraception clearly outweigh the disadvantages of side effects. A Bangladeshi woman commented:
For some women amenorrhea and weight gain are advantages of injectables. A US woman using DMPA commented:
Women in Egypt, Nepal, the Philippines, Sierra Leone, and Thailand have reported that they like weight gain experienced with progestin-only injectables (11, 117, 241, 270, 298). Counseling can help women who choose injectables to adapt to the side effects. Counseling may be so important to clients, in fact, that they are willing to pay for it. In the 1970s the McCormick Family Planning Program, which pioneered use of DMPA in Thailand, offered the injectable for a small fee, while the public family planning program in the same area offered free services. Program staff observed that many DMPA users preferred to pay the small fee because of the good counseling that they received with each injection in the McCormick program (20).
Survey of Service ProvidersService providers in 10 countries responded to a Population Reports questionnaire asking about their perception of injectables, their clients' perceptions, difficulties and benefits of providing injectable services, medical eligibility requirements for the use of injectables, and lessons learned. Their answers have been used extensively in this report, particularly in "The User's Perspective."
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| WHO Eligibility
Criteria: Differences Between Progestin-Only Injectables and Combined Oral Contraceptives The recommendations of eligibility criteria for progestin-only injectables and combined oral contraceptives (OCs), formulated by the WHO scientific working group on improving access to quality care in family planning, are similar for most conditions. For some, however, the estrogen in combined OCs makes a difference. Thus the working group made important distinctions between DMPA/NET EN and combined OCs for women with the following conditions:
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Five Basic Steps of
Infection Prevention: | ||||||||||||||||||||||||||||||||||||||||||
| CLEANING HANDS | Reusable needles and syringes should be sterilized by autoclaving (steam sterilization) or dry heat.
Steam sterilization:
Dry heat:
Storage: If sterilization is not possible, reusable needles and syringes should be high-level disinfected by boiling or steaming for 20 minutes and then allowed to dry. They can be used immediately or stored for up to one week in a clean, high-level disinfection of needles and syringes should be avoided. A high-level disinfected container is prepared by boiling, if it is small enough, or soaking for 20 minutes in a plastic container filled with 0.5% chlorine solution. The chlorine solution can then be transferred to another container and reused. The container should be rinsed thoroughly with boiled water and allowed to air dry. Sources: Lubis et al. 1995 (188), POGI et al. 1995 (132), Schaefer (273), Tietjen et al. 1992 (305), WHO 1990 (333). | ||
| 1 | DO wash hands before each injection. This is one of the most important steps in infection prevention. | PREPARING THE INJECTION SITE | |
| 2 | DO make sure the site of
the injection is clean and disinfected. DO swab the site with a new piece of cotton for each client. DO wipe from the injection site outwards in a circular motion. | ||
| DO NOT use the same piece of cotton repeatedly to clean the injection sites of several clients. | |||
| USING STERILE NEEDLES AND EQUIPMENT | |||
| 3 | DO use a new disposable
needle and syringe for each injection. OR DO make sure that reusable needles and syringes are sterilized or high-level disinfected before each use. DO use single-dose vials of injectable. If using multidose vials, keep the unused portions sterile. | ||
| DO
NOT use the same needle and syringe for more than one client without processing
the equipment. DO NOT change the needle but still use the same syringe for several clients. DO NOT leave a needle in the stopper of a multidose vial to withdraw the fluid. | |||
| PROCESSING USED INJECTION EQUIPMENT | |||
| 4 | Processing Disposable
Equipment DO decontaminate disposable needles and syringes by flushing them with 0.5% chlorine solution 3 times or soaking them in the chlorine solution for 10 minutes. DO dispose of disposable needles and syringes by placing them in a puncture-proof container and then burning and/or burying the container when three-quarters full. |
Processing Reusable
Equipment DO process reusable needles and syringes appropriately:
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| DO
NOT put disposable needles in the trash, even after they have been
decontaminated. DO NOT recap disposable needles before disposal. DO NOT bend or break needles before disposal. |
DO
NOT high-level disinfect or sterilize equipment without decontaminating and
cleaning it first. DO NOT clean needles and syringes without taking them apart. DO NOT use needles and syringes that have been cleaned only with alcohol or other disinfectant or antiseptic. DO NOT reuse disposable needles and syringes. If they must be reused, it is recommended that only the syringe be reprocessed and reused, after decontaminating both the needle and syringe. DO NOT store sterilized or high-level disinfected needles and syringes in a container that has not been sterilized or high-level disinfected. | PREPARING THE INJECTION SITE | |
| 5 | DO dispose of waste such as cotton and gauze that are contaminated with blood or other body fluids in a leak-proof container with a lid or in a plastic bag. | ||
| DO NOT throw contaminated materials into the general trash. | |||