Project design
In order to measure changes over time, the study used a single arm (intervention only) pre-test and post-test study design that involved comparing the baseline and endline indicators. The overall approach entailed developing a proof of concept that combined provision of sexual and reproductive health and rights (SRHR) information and services including medical abortion to women and girls by using pharmacy outlets, community health volunteers (CHVs) and local youth peer providers’ (YPP) networks. The study was conducted over a period of 23 months (from February 2021 December 2022).
Study site and population
The project was undertaken in one of the sub-counties in Homa Bay County, Kenya. The selection of the project site was based on the high number of functional pharmacy outlets in the area. A total of 9 pharmacy outlets, 10 pharmacy staff and 20 CHVs selected randomly from community health units in the Sub-County. With support from the Homa Bay County Health Management Team (CHMT) and Kenya Pharmaceutical Association Nyanza Region chapter, the project team conducted a mapping exercise in which all functional pharmacy outlets were listed. The selection criteria included whether the outlet dispensed MA drugs and services, sold contraceptives, had more than 1 pharmacy staff, and whether the staff were willing to participate in the study.
Data collection, analysis and management procedures
The study utilized a mixed methods approach comprising quantitative interviews and records review. Baseline and endline interviews were conducted with 10 pharmacy staff and 20 CHVs using semi-structured questionnaires, while program data was extracted from pharmacy sales records and CHVs activity registers in order to track the project indicators. Baseline and endline data collection activities were conducted using structured paper-based questionnaires. Upon completion of fieldwork, the data was exported to Stata® software program for analysis. Analysis involved pairing of baseline and endline data by each pharmacy outlet and generating simple frequencies. The tool for documenting the purchase of MA products and contraceptives was programmed in Open Data Kit (ODK) software for use in tablets. Each participating pharmacy outlet had 1 tablet for transmitting the monthly sales data to the server.
Ethical considerations
Ethical approval for the Tembe Mkononi project was obtained from AMREF Ethics and Scientific Review Committee vide letter Ref: ESRC/P995/2021 dated 18th June 2021. A research license for the project was obtained in December 2021 from the National Commission for Science, Technology and Innovation (License number NACOSTI/P/22/15033). Written consent was sought and obtained from all the participating pharmacy staff and CHVs prior to conducting interviews. Before consenting, data collectors emphasized to participants that the study was voluntary, the reason they were participating and risks and benefits of participating.
Intervention activities
Intervention activities were conducted with a view to addressing the barriers to accessing medical abortion information, products and services by women and girls in the project sites. Key intervention activities undertaken between April 2021 and November 2022 are outlined below.
i. National and county level consultations:
Consultative and project inception meetings were held in March-April 2021 with Kisumu Medical and Educational Trust (KMET) who were the project’s implementing partners. In May 2021, the project team held a consultative meeting with the leadership of the Division of Reproductive and Maternal Health (Ministry of Health) and the National Reproductive Health Network. County level meetings were held in June 2021 and comprised of representatives of the Kenya Pharmaceutical Association (KPA) Nyanza Region, Homa Bay CHMT and KMET.
ii. Training of pharmacy staff, CHVs and YPPs:
Participating pharmacy staff were trained for 5 days on counselling, determination of pregnancy gestation period, provision of information on pregnancy management, offering MA products and services including contraception, post-MA follow up, referral and values clarification and attitude transformation. CHVs and YPPs were trained for 3 days on sensitisation and demand creation activities, identifying and counselling clients, referral and linkage of clients to pharmacy outlets, post MA follow-up, documentation and values clarification and attitude transformation.
iii. Deployment of online pharmacy platform:
A tool in Open Data Kit (ODK) was programmed to collect, store and report data on online sales of MA products and contraceptives by the pharmacy outlets. Information from the online sales data included client’s age, gestation period, MA services and drugs offered, and FP methods provided. A 24-hour hotline was established to give clients information and referral to the nearest pharmacy outlet. All pharmacy staff in the outlets were trained on utilization of the online platform. Figure 2 presents a summary of the flow of services through the online platform.
iv. Strengthening of referral activities:
The project in collaboration with the Ministry of Health linked 20 trained Community Health Volunteers (CHVs) to 9 participating pharmacy outlets with the help of 4 Community Health Assistants (CHAs). A group of 15 youth peer providers (YPPs) were also deployed by the Ministry of Health to reach out, counsel, and refer adolescent girls 19 years and below who required SRHR services. The linked CHVs and YPPs referred adolescent girls and women seeking SRHR services to the pharmacy outlets from their respective communities. Whenever pharmacy staff received clients referred from CHVs, they counselled and advised the clients on available contraceptive methods to use after undergoing MA. After providing the MA and FP services, pharmacy providers gave their contacts and that of the CHVs to the clients so that the clients could call in case they experienced any complications. Figure 3 summarizes the typical journey through which girls seeking SRHR information, services and products went through in order to access services.
v. Demand creation activities: Demand creation for SRHR information, services and products involved advocacy with the County Health Management Team (CHMT) and community health committees within units linked to selected pharmacy outlets and Community Health Assistants (CHAs). In order to create awareness on SRHR services, CHVs and YPPs conducted community dialogue meetings in villages, undertook routine home visits, and disseminated information pamphlets on where and how to access MA products and services.
vi. Monitoring and support supervision: Monitoring visits by the project team to participating pharmacy outlets were conducted monthly for data verification and audit as well as vendor support on utilization of the online pharmacy platform. The project team also monitored the quality of education sessions delivered to clients by CHVs as well as referrals made. Data on the sale of MA products was collected and compiled by the project team on a monthly basis from the participating pharmacy outlets. A joint review meeting involving the project team, pharmacy staff, CHVs and CHAs was held in October 2022 to share and strengthen working relationships, explore ways of documenting project achievements, identify challenges and ways of addressing them.