Assessing Feasibility and Acceptability of Increasing Access to Sexual and Reproductive Health and Rights through Pharmacies: Lessons from Pilot Study in Kenya

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The World Health Organization recommends the use of medical abortion to stop unwanted pregnancies. However, the extent of provision and uptake of medical abortion through private pharmacies in Kenya is not well known. This study assessed the feasibility and acceptability of utilizing pharmacy outlets and community health volunteers to increase women’s and girls’ access to information, medical abortion and other sexual and reproductive health services and rights. Methods The study utilized a single arm (intervention only) pre-test and post-test design that involved implementing a set of interventions and comparing the baseline and endline indicators. The study, referred to as Tembe Mkononi project, was conducted from 1st February 2021 to 31st December 2022, in Homa Bay County. Data collection involved baseline and endline interviews with 10 pharmacy staff (drawn from 9 pharmacy outlets) and 20 community health volunteers while program data was extracted from pharmacy sales records. Results A total of 527 clients obtained medical abortion drugs from the 9 participating pharmacy outlets between April and December 2022. There was a steady increase in the number of clients served from 15 clients in April 2022 to 112 clients in December 2022. Out of the 527 clients, 523 of them obtained family planning methods. All the pharmacy staff and community health volunteers expressed satisfaction and positive attitude towards the services provided to clients. Conclusion Results of the study show that the provision of medical abortion and other sexual and reproductive health services such as contraceptives to women and girls through private pharmacy outlets was feasible and acceptable. Building the capacity of community health volunteers to create awareness, strengthen referral and follow-up activities increased demand and uptake of sexual and reproductive health services including medical abortion over the project period. Overall, the interventions implemented in a rural county in Western Kenya have potential in addressing the problem of unsafe abortion which is one of the leading causes of maternal morbidity and mortality in Kenya and other developing countries. Sexual & Reproductive Medicine Sexual and reproductive health and rights medical abortion pharmacy community health volunteer Homa Bay County Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Introduction Background Unsafe abortion is a major public health problem globally. According to the World Health Organization, 73.3 million induced abortions occurred worldwide each year between 2015 and 2019 (WHO, 2020). The 2020 WHO report indicates that 3 out of 10 (29%) pregnancies, and 6 out of 10 (61%) unintended pregnancies, ended in an induced abortion. Among these, 1 out of 3 were carried out in the least safe or dangerous conditions, and 3 out of 4 abortions that occurred in Africa and Latin America were unsafe. The risk of dying from an unsafe abortion was highest in Africa, and each year 4.7% - 13.2% of maternal deaths can be attributed to unsafe abortion. Recent evidence from work conducted by Guttmacher Institute shows that sub-Saharan Africa (SSA) has the highest unintended pregnancy rate and the highest estimated proportion of unsafe abortions in the world. It is estimated that unsafe abortion is responsible for approximately 7% of maternal mortality in the region. As of 2019, SSA had the highest annual case-fatality rate of any world region, at roughly 185 deaths per 100,000 abortions. These deaths are preventable and point to an urgent need for comprehensive and quality post-abortion care to prevent more women from dying from severe consequences of unsafe abortion (Bankole A et al , 2020). In Kenya, 35% of maternal deaths are attributable to unsafe abortion (Center for Reproductive Rights, 2010; MOH Kenya, 2003). Over 2,600 women die annually in Kenya from complications of unsafe abortion and over a third of the women admitted with abortion complications were in the second trimester of pregnancy when risks of severe complications and mortality are substantially higher (Center for Reproductive Rights, 2010). In a 2002 study conducted at Provincial General Hospital in Kakamega, abortion was found to be the most common acute gynecological ailment with its complications accounting for the longest hospital stay (Wamwana, E.B. et al , 2006). Yet, one-half of unmarried women and more than 4 in 10 of married women in Kenya who are pregnant report their current pregnancies as mistimed or unintended (APHRC, 2019; APHRC, 2013). Unintended pregnancy is a major contributor to girls leaving school, with an estimated 13,000 girls dropping out of school every year in Kenya (Undie, C. et al , 2015). In Homa Bay County of Kenya, 70% of adolescent girls aged 13-19 years are out of school due to unintended pregnancy (Undie, C. et al , 2015). These girls have limited access to sexual and reproductive health information and services and face stigma at health facilities. The World Health Organization (WHO) recommends the use of medical abortion (Mifepristone and Misoprostol) as a safe and effective method of stopping unwanted pregnancies (Bankole A et al , 2020). The two drugs are registered in Kenya for various indications including treatment of incomplete abortion and miscarriage, treatment and prevention of post-partum haemorrhage (PPH), treatment of missed abortion in first trimester, treatment of intrauterine foetal death and cervical ripening. However, a large proportion of women and girls are not aware of medical abortion (MA) products and where to access these services. Similarly, the extent of provision and uptake of MA drugs in private pharmacies in Kenya is not well known. A study conducted among private pharmacies in three major urban centers in Kenya found that 32% of the pharmacies stocked MA drugs while mystery clients who were sent to the pharmacies as part of the study to assess the quality of care provided were offered the drugs in 54% of the encounters at the outlets (Liambila W et al. , 2015; Reiss K et al ., 2016). Research problem Based on the foregoing background, the following problems were identified, namely, high rate of unintended pregnancy among women and girls; high rate of unsafe abortion among women and girls; limited access to sexual and reproductive health information, products and services; and high prevalence of stigma associated with pregnancy termination. The study sought to address these problems by equipping pharmacy staff and CHVs with appropriate knowledge and counseling skills. Research goal and objectives The overall goal of the project was to reduce unsafe abortion among women and girls in Kenya by increasing access to medical abortion information, products and services. The objectives of the study were to i) Assess the feasibility of increasing access to medical abortion information and products by women and girls through pharmacy-based provision; ii) Test the feasibility of using community health volunteers and local peer networks to increase demand for and referral to medical abortion information, products and services and ii) Assess the acceptability of pharmacy-based and community-based approaches in increasing uptake and utilization of medical abortion products by women and girls with unintended pregnancy in the context of choice. Conceptual framework The study team developed a conceptual framework to guide the implementation of the study and assist in clarifying the relationship between the problem, intervention strategies or inputs and expected outcomes (Figure 1). Methods 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 18 th 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. Results Background characteristics of study respondents Study respondents comprised of 4 female and 6 male pharmacy staff as well as 17 female and 3 male CHVs. The mean age of participating pharmacy staff was 31 years with an average of 6 years’ experience in the pharmacy field, while the mean age of CHVs was 40 years and almost all of them had worked as CHVs for 10 years. In terms of level of schooling, all the 10 pharmacy staff had attained college/university level education, while 3 out of the 20 CHVs had primary school level education, 9 had secondary school education, while 8 had attended college. Number of MA clients served by participating pharmacy outlets We obtained MA products sales data from each of the participating pharmacy outlets on monthly basis from April to December 2022. A total of 527 medical abortion clients were served at the participating pharmacy outlets, increasing from 15 clients in April 2022 to 112 in December 2022 (Fig. 4 ). Out of the 527 clients, the largest proportion (248 clients or 47%) was of women aged 20–24 while girls aged 15–19 years were fewer (134 clients accounting for 25%) of the total. There was variation in the workload between pharmacy outlets (Fig. 5 ), with pharmacies A, F and I having higher workload at 94 clients, 82 clients and 86 clients respectively, while pharmacies D, E and H had the least workload at 12 clients, 9 clients and 13 clients respectively. Sources of information on MA for clients Clients who sought services from pharmacy outlets were asked to state the source of their information on SRHR services including MA. Analysis of the data revealed that a large proportion of clients who received MA services (308 clients) got information about accessing the products at pharmacy outlets from community outreach meetings, while 194 clients had been referred to the pharmacy outlets by CHVs (Fig. 6 ). Majority of clients seeking MA services were in the 20–24 years age group. Screening of clients seeking MA services Pharmacy staff were asked to state the type of screening they conducted on clients in order to determine their eligibility for obtaining MA services from the pharmacy outlets. All the 10 pharmacy staff reported that they asked clients about gestation period and reasons for wanting to terminate pregnancy before providing MA services, while 9 out of 10 pharmacy staff asked about the client’s age and requested clients to conduct a rapid pregnancy test before providing any further services (Fig. 7 ). A comparison of baseline and endline results showed that certain screening procedures either reduced or increased at the endline. For instance, asking clients whether they had referral forms, their medical history or whether they had prescription from medical practitioners reduced at the endline. On the other hand, certain screening questions including knowing the client’s age and asking for reasons for wanting to terminate the pregnancy increased at the endline. There were no major differences in the results of the other screening questions between baseline and endline. Counseling and information provision to MA clients Pharmacy staff were asked to state the type of SRHR information and advice they provided to clients who came to them seeking pregnancy termination. At endline, all the 10 pharmacy staff reported advising clients on the side effects of MA drugs as well as on post-abortion family planning (Fig. 8 ). The number of pharmacy staff who informed clients on how to confirm whether the MA process was successful increased from 4 at baseline to 9 at endline. Similarly, the number of pharmacy staff who mentioned to clients about complications that may arise from MA use increased from 7 at baseline to 9 at endline. The number of pharmacy staff who counseled clients on other available options for pregnancy termination, risk of failure of MA, and when and how to use MA drugs appears to have reduced at endline. Community health volunteers were asked to state the nature of counseling, advice and information they provided to clients who sought pregnancy termination services. Marked improvements occurred regarding the number of CHVs who informed clients on how to confirm that the MA process was successful from 2 at baseline to 7 at endline. The number of CHVs who informed clients on when and where to seek help increased from 9 at baseline to 16 at endline, and those who informed clients on the side effects of MA drugs increased from 7 at baseline to 10 at endline (Fig. 9 ). It should be noted that key tasks for CHVs involved creating awareness on availability of MA services and referring potential clients to pharmacy outlets. CHVs also worked in partnership with pharmacy staff to follow up post-MA clients to ensure that the MA process was successful. Overall trend in client utilization of SRHR services at pharmacy outlets Data from the online pharmacy platform showed a steady increase in the number of clients who obtained SRHR information, services and products from 14 clients in April to 112 clients in December 2022 (Fig. 10 ). The decline in number of clients served between August and September 2022 could be attributed to the general elections held in Kenya during that period. Provision of post-MA family planning methods to clients Monthly sales data from the online pharmacy platform showed that pharmacy staff were able to provide a variety of short-term contraceptive methods. For instance, the 3-months injectable contraceptive (DMPA) was the most commonly dispensed method (205 clients), followed by oral contraceptive pills (121 clients), while the emergency pill (5 clients) was the least FP method obtained (Table 1 ). Table 1 Post-MA FP sales to clients by age category April-Dec 2022 Contraceptive Method 15–19 years 20–24 years 25 + years Grand Total 3 Month Injectable 49 100 56 205 Condoms 12 10 12 34 Emergency contraception 2 3 5 Implant 3 2 2 7 Method desired but no method received 5 14 12 31 No method desired 48 45 17 110 Oral Contraceptives 15 70 36 121 Referred for contraception (PAFP) 1 3 6 10 Grand Total 133 246 144 523 Follow-up referral for post-MA clients Both pharmacy staff and CHVs were trained on the importance of conducting follow-up to post-MA clients. At endline, all the 10-pharmacy staff reported that they offered counseling and verbal reassurance to post-MA clients, provided pain medication, and referred the clients to CHVs for home support. Majority of CHVs also indicated that pharmacy staff referred women and girls who had undergone pregnancy termination to them for follow-up. All the 20 CHVs at endline indicated that they provided counseling and verbal reassurance to clients who came back or called in for post-abortion follow-up compared to 9 at baseline (Fig. 11 ). There was also an increase in number of CHVs who referred post-abortion clients back to pharmacy outlets for further review from 3 at baseline to 6 at endline. Similarly, 17 CHVs advised post-abortion clients on available FP options at endline up from none at baseline. Community level demand creation activities According to the Government of Kenya Community Health Strategy, community dialogue days provide a useful platform and forum for CHVs and community health committees to interact with members of the public to discuss priority public health issues affecting them. CHVs were asked whether they had conducted community dialogue forums in the past 6 months prior to the baseline and endline surveys at which SRHR issues were discussed. The number of CHVs who organized community forums to discuss SRHR issues including MA increased from 18 at baseline to 20 at endline. The number of CHVs who conducted 7–9 meetings in the 6 months period preceding the baseline and endline surveys increased from 2 CHVs at baseline to 4 CHVs at endline, while the number of CHVs who had organized 10 meetings and above increased from 1 CHV at baseline to 5 CHVs at endline (Fig. 12 ). The rest of the CHVs indicated having organized between 1 and 6 community dialogue forums in the 6 months preceding the baseline and endline surveys. Pharmacy staff and CHV satisfaction with provision of SRHR services In order to assess the acceptability of providing SRHR services and products through pharmacy outlets, both pharmacy staff and CHVs were asked a number of questions. Pharmacy staff were asked whether they were satisfied with their role in providing counseling, information and services to MA clients including utilization of the online platform. All the 10 pharmacy staff indicated satisfaction with provision of MA products and services to clients. Key reasons for satisfaction mentioned by pharmacy staff were: privacy and confidentiality of service provision; accurate MA sales data capture and verification through online platform; and fast retrieval of records and tracing of clients. Similarly, CHVs were asked how satisfied they were with referring SRHR clients to pharmacy outlets for services. Eighteen out of 20 CHVs at baseline and all the 20 CHVs at endline indicated that they were satisfied with how they referred and linked clients to pharmacy outlets for MA services and products. Reasons provided by CHVs in support of their satisfaction with referral of clients to pharmacy outlets included positive feedback from clients as well as the pharmacy outlets on their performance, pharmacy outlets offering privacy and confidentiality to clients, friendly pharmacy staff and cooperative service providers, and proximity of pharmacy outlets to clients hence facilitating effective referrals. Dissemination of preliminary findings A forum for disseminating preliminary findings from the project was undertaken in December 2022 and attended by key national and county level stakeholders. Priority themes in the dissemination forum were: Strategies for scaling up utilization of pharmacy outlets in the provision of SRHR services, particularly medical abortion, to women and girls; Opportunities for institutionalizing provision of SRHR services including MA within Homa Bay County reproductive health agenda, work plans and budgets; and Role of Ministry of Health and Kenya Pharmaceutical Association in capacity building for pharmacy staff, CHVs and YPPs to strengthen provision of MA services, MA task-sharing and commodity security, and routine data collection and utilization. Stakeholders acknowledged the potential role played by pharmacy outlets in reaching more girls and women who require SRHR services. They explained that at present CHVs do refer clients to pharmacy outlets for counseling services and to obtain MA products. Once a client has been attended to, she is referred back to the CHV for follow up at the community level. To facilitate effective follow up, pharmacy staff agreed amongst themselves to be providing their telephone contacts and those of the CHVs to the clients. Participants at the dissemination meeting said that this referral model is easily scalable because it links the pharmacy outlets with the CHVs and clients. At the meeting, Kenya Pharmaceutical Association (KPA) indicated that with collaboration from other partners including Pharmacy and Poisons Board and Ministry of Health, it is able to advocate for scale up and utilization of pharmacy outlets as service points for MA services. Majority of stakeholders noted that through the project, pharmacies are now able to counsel, advice clients, dispense MA drugs and contraceptives and conduct telephone-based follow-ups. Given that in the past, the primary role of pharmacies was to dispense drugs, the additional activities benefit clients by bringing SRHR services closer to them, making them available and within reach. From the findings, stakeholders indicated that utilizing pharmacy outlets is a sustainable avenue for girls and women to access and utilize SRHR services including MA. Stakeholders also pointed out the importance of linking data from pharmacy outlets to the national District Health Information System (DHIS). They expressed the need to advocate for linking of data from private sector health providers such as pharmacy outlets and health centres to the Ministry’s health management information system. Lastly, stakeholders recommended that findings and lessons from the project be integrated into the Homa Bay County work plans and budget. They pointed out that this would ensure sustainability of the interventions and the model. Discussion Number of MA clients served According to the project’s proof of concept, it was expected that 300 girls aged 15–19 years and 900 women aged 20–49 years would be reached during the project period. The set targets were exceeded whereby 1,025 girls aged 15–19 years and 1,389 women aged 20–49 years were reached. In addition, CHVs also reached 526 men through community sensitization. At the end of the project period, a total of 527 MA clients were served at the participating pharmacy outlets, increasing from 15 clients in April 2022 to 112 in December 2022. The large number of women and girls who received MA information and services could be attributed to increased awareness created by CHVs through community outreach forums. Previous studies have provided evidence that community health cadres are effective in making safe abortion information and services accessible to women to facilitate decision-making in the context of choice (Gupta P, et al, 2017 ; Rishita N, 2018; Olaniran A, et al, 2019 ). The increased utilization of pharmacy outlets could also be attributed to the confidence the target population had in getting services from community pharmacy outlets, which offer privacy and confidential care. Similar studies have observed that the choice of service delivery points by clients seeking abortion services depends on waiting time, distance to access points, need for privacy and control (Newton D, et al, 2016 ; Ho P., 2006 ; Aiken A., et al, 2018 ; Kanstrup C., et al, 2018 ). These studies argue that providing choices to consumers is an integral part of service delivery. In addition, the studies point out that health systems which do not provide options limit individuals’ likelihood of opting for a safe method that meets their needs. Counseling and information provision by pharmacy staff The project’s training activities for pharmacy staff aimed to build their capacity to deliver accurate information on medical abortion to prospective clients, conduct screening and counseling, dispense correct dosage of MA medication, and provide quality post-MA services. As shown in the results section of this paper, all the participating pharmacy staff were able to provide information and counsel clients on all critical aspects of MA services, thereby enabling clients to make informed decisions. These results demonstrate that pharmacy staff are strategically placed to increase access to and utilization of MA services even in contexts where provision of abortion and contraceptive services to adolescents is stigmatized. Previous studies have shown that pharmacy staff are often the first-line healthcare providers hence they have the responsibility of delivering accurate information and increasing access to interventions for unintended pregnancy. Training of pharmacy staff enables them to successfully provide information, conduct counseling and deliver healthcare related to stigmatized conditions including STIs, HIV & AIDS and pregnancy termination (Sneeringer R.K, et al, 2012 ). Further, studies have shown that pharmacy outlets are often the most available healthcare outlets in communities, with short waiting time and less costly services. Their success has been due to their ability to facilitate rapid access to medications, supplies, medical information, and advice while maintaining client confidentiality (Lara D, et al, 2011 ; Billings D.L., et al, 2009 ). Linkage with wider health system Throughout the various project phases, it was evident that involvement of the county government and the leadership of the county and sub-county health management teams was critical to proper functioning of the health system including the provision of SRHR services. The issue of embracing a health system approach was also discussed during the dissemination meeting held in December 2022. Both the public and private sector representatives at the dissemination meeting acknowledged that through the project, pharmacy staff are now able to counsel, advise clients, dispense MA drugs and contraceptive methods, and conduct follow-up of clients after service provision. Participants also advocated for the linking of service data collected at pharmacy outlets to the national District Health Information System (DHIS 2) to be utilized for policy and programming on medical abortion. Participants pointed out the need to involve private sector providers, including pharmacy staff in update trainings on SRHR service provision organized by the public sector. They pointed out that the private sector is often left out during refresher trainings. They argued that task-shifting allows clinical staff to focus on clinical procedures whilst leaving pharmacy staff to focus on provision of MA services so long as it is undertaken within the recommended gestation period. Similar studies have emphasized the need for refresher trainings for all service cadres, both in public and private sectors, in order to guarantee the quality of services provision (Elul B., 2011 ). Other studies have also emphasized the need for service providers to be competent in pregnancy determination, pre and post abortion counseling, gestation assessment, knowledge on need for referral and procedures involved, dispensing MA pills, patient monitoring, and follow-up assessment and care (Puri M.C. et al , 2018; Samari G. et al, 2018 ; WHO, 2014; National Academy of Sciences, 2018). The involvement of pharmacy staff in the provision of MA services was viewed as strengthening the task-shifting approach. The approach allows medical staff with clinical skills such as doctors, nurses and clinical officers to focus on provision of surgical methods such as manual vacuum aspiration and dilation and curettage (D&C). Implication of study findings on maternal morbidity and mortality Morbidity and mortality related to unsafe abortion are major public health problems not only in Kenya but globally. Reducing maternal morbidity and mortality is a priority for low-and-middle-income countries. According to the World Health Organization, countries wanting to reduce maternal mortality but reluctant to address abortion, need to resolve their internal incoherence (Shukla, et al., 2022 ). Furthermore, the rollout of universal health coverage (UHC) provides the opportunity to integrate abortion services more meaningfully with relevant reproductive health programs given that unsafe abortion is one of the leading causes of preventable maternal mortality in Kenya. Findings from this project showed that it is feasible and acceptable to utilize pharmacy outlets to increase access to MA services by women and girls. Pharmacy outlets were found to be closest to women and girls in the communities where they reside and are the preferred first points of contact for MA and post-abortion contraceptive services. Further, it emerged from the findings that pharmacy outlets have MA drugs and contraceptives in stock all the time, a finding that guarantees uninterrupted availability of services. Therefore, attempts to reduce morbidity and mortality related to unsafe abortion have to consider involving the pharmacy outlets given the potential they have as the preferred first point of contact for MA and post-abortion services. Overall, the findings demonstrate that providing MA information and services to women and girls at pharmacy outlets is a promising strategy for increasing access. It is anticipated that improving access to MA would reduce unsafe abortions and ultimately maternal morbidity and mortality associated with such abortions. Study Limitations The main limitation of this study was the short time frame within which the project team was expected to implement activities. Initial requirements including obtaining ethical approval, contracting obligations with implementing partners and the COVID-19 situation prevailing at the time contributed to delays in the commencement of project activities. Another limitation is that the baseline survey was conducted a few months after commencement of project interventions including training of pharmacy staff and CHVs. The project team delayed collection of baseline data in order to give room for setting up of a functional online pharmacy platform, which was one of the main project interventions. This could explain the marginal differences between baseline and endline findings since the study participants had already been exposed to some aspects of the project interventions by the time of conducting the baseline survey, and also the interval between baseline and endline data collection was short. Conclusions One, findings from the study showed that it is feasible and acceptable to increase access to SRHR information and services, including MA, through pharmacy provision and community health volunteers. Two, the steady increase in the number of clients who sought MA services during the project period could be attributed to increased awareness on availability of MA services by clients, as well as increased knowledge, skills and confidence of the pharmacy staff after undergoing training. Three, the support provided by the County Government of Homa Bay contributed to creating demand for SRHR services among the target population including MA information and products. Recommendations One, there is need to scale up the provision of MA information, products and services through pharmacy outlets given its potential to reach the target population, and to deliver services in a private and confidential manner. Two, the Pharmacy and Poisons Board, Pharmaceutical Association of Kenya, the Division of Reproductive and Maternal Health (Ministry of Health), and County Governments should prioritize training of pharmacy staff in SRHR information, products and services through on-the-job training or continuous medical education. For sustainability purposes, such training could be undertaken as part of continuous professional development (CPD). Three, findings and lessons learned from the study point to the need for incorporating capacity building of health providers particularly pharmacy staff and CHVs as well as commodity security for SRHR into county annual work plans and budgets to ensure sustained service provision. Abbreviations CHA Community Health Assistant CHMT County Health Management Team CHV Community Health Volunteer DHS Demographic and Health Survey EML National Emergency Medicines List FGDs Focus Group Discussions FP Family Planning GBV Gender-Based Violence IDIs In-Depth Interviews IRB Institutional Review Board KDHS Kenya Demographic and Health Survey KMET Kisumu Medical and Educational Trust PPB Pharmacy and Poisons Board MA Medical Abortion MOH Ministry of Health PI Principal Investigator PC-Kenya Population Council Kenya RA Research Assistant RCC Referral Care Centre SCHMT Sub-County Health Management Team SRHR Sexual and Reproductive Health and Rights WHO World Health Organisation YPP Youth Peer Provider Declarations Ethics approval and consent to participate Ethical approval for the Tembe Mkononi project was obtained from AMREF Ethics and Scientific Review Committee vide letter Ref: ESRC/P995/2021 dated 18 th June 2021. A research license for the project was obtained in December 2021 from the National Commission for Science, Technology and Innovation (NACOSTI) under license number NACOSTI/P/22/15033. Written consent was sought and obtained from all the participating pharmacy staff and CHVs prior to conducting interviews. Consent for publication The authors hereby give consent for the publication of the manuscript. Availability of data and materials The datasets generated and analyzed during this study are in the possession of the authors and are available for sharing. Competing interests The authors declare that they have no competing interests. Funding Funding for this study was provided by Grand Challenges Canada under the OPTions Initiative Grant Number R-POC-OPT-2104-38141. Authors’ contributions WL conceptualized the overall study; FO wrote the study design and methodology; MO, CN and BD interpreted data for accuracy; SR and ZW reviewed the article for intellectual content. Acknowledgements We would like to appreciate the roles played by a team of research assistants, pharmacy staff, community health volunteers and youth peer providers who participated in the study. We acknowledge with thanks the contribution of Stephen Kizito of Population Council’s Data Management Unit in data analysis. We would also like to single out two KMET Staff, namely Griffin Odindo and Maureen Mobasi for having played important roles in project implementation and in coordinating data collection activities during baseline and endline phases of the project. Suggested citation Wilson Liambila, Francis Onyango, Saumya RamaRao, Monica Oguttu, Carol Nyandat, Benedict Denga and Zeka Wekesa (2023): Assessing Feasibility and Acceptability of Increasing Access to Sexual and Reproductive Health and Rights through Pharmacies: Lessons from Pilot Study in Kenya. Population Council Kenya; Nairobi. References World Health Organization (WHO) Factsheet. 2020. Preventing unsafe abortion . Geneva https://www.who.int/news-room/fact-sheets/detail/preventing-unsafe-abortion Bankole A et al ., From Unsafe to Safe Abortion in Sub-Saharan Africa: Slow but Steady Progress , New York: Guttmacher Institute, 2020, https://www.guttmacher.org/report/from-unsafe-to-safe-abortion-in-sub-Saharan-Africa Center for Reproductive Rights. 2010. The impact of Kenya’s Restrictive Abortion Law .New York: Center for Reproductive Rights. Accessed at: [email protected] . Ministry of Health [Kenya]. 2003. Kenya National Post Abortion Care Curriculum: Trainer’s Manual . Nairobi: Ministry of Health. Wamwana, E.B., P.M. Ndavi, P.B. Gichangi, J.G. Karanja, E.G. Muia, and G.W. Jaldesa. 2006. “Socio-demographic characteristics of patients admitted with gynaecological emergency conditions at the provincial general hospital, Kakamega, Kenya.” East African Medical Journal 83(12):659-665. African Population and Health Research Center (APHRC), Ministry of Health [Kenya], Ipas, and Guttmacher Institute. 2013. Incidence and Complications of Unsafe Abortion in Kenya: Key Findings of a National Study . Nairobi: APHRC, Ministry of Health [Kenya], Ipas, and Guttmacher Institute. African Population and Health Research Center (APHRC). 2019. Understanding Contraceptive Uptake after Medical Abortion among Women and Adolescent Girls in Kenya: Formative Research Report . Nairobi: APHRC. Undie, C, Birungi, H, Odwe, G. and Obare, F. 2015. Expanding Access to Secondary School Education for Teenage Mothers in Kenya: A Baseline Study Report . STEP UP Technical Report. Nairobi. Liambila, Wilson, Francis Obare, Edward Ikiugu, Vitalis Akora, Jesee Njunguru, Michael Njuma, Kate Reiss, and Harriet Birungi. 2015. Availability, use and quality of care for medical abortion services in private facilities in Kenya . Nairobi: Population Council and Marie Stopes International. Reiss, Kate, Katharine Footman, Vitalis Akora, Wilson Liambila, and Thoai D. Ngo. 2016. Pharmacy workers’ knowledge and provision of medication for termination of pregnancy in Kenya. Journal of Family Planning and Reproductive Health Care 42:2018-212. Gupta, P., Iyengar, S.D., Ganatra, B. et al. Can community health workers play a greater role in increasing access to medical abortion services ? A qualitative study. BMC Women's Health 17 , 37 (2017). https://doi.org/10.1186/s12905-017-0391-1 Nandagiri, Rishita (2018) “They know everything”: the role of Community Health Workers in Abortion Access. In: Abortion and reproductive justice: the unfinished revolution III, 2018-07-08 - 2018-07-12, Rhodes University in Grahamstown (Makanda), South Africa. http://eprints.lse.ac.uk/id/eprint/89378 Olaniran A, Madaj B, Bar-Zev S , et al. 2019. The roles of community health workers who provide maternal and newborn health services: case studies from Africa and Asia . BMJ Global Health 2019; 4: e001388. Newton D, et al . 2016. How do women seeking abortion choose between surgical and medical abortion? Perspectives from abortion service providers . Aust N Z J Obstet Gynaecol. 2016;56(5):523–9. Ho P. Women’s perceptions on medical abortion. Contraception. 2006;74(1):11–5. Aiken A, et al . 2018. Barriers to accessing abortion services and perspectives on using mifepristone and misoprostol at home in Great Britain . Contraception. 2018;97(2):177–83. Kanstrup C, Makela M, Hauskov GA. 2018. Women’s reasons for choosing abortion method: a systematic literature review . Scand J Public Health. 2018;46(8):835–45. Sneeringer, R. K., Billings, D. L., Ganatra, B., & Baird, T. L. (2012). Roles of pharmacists in expanding access to safe and effective medical abortion in developing countries: a review of the literature . Journal of public health policy, 33(2), 218–229. https://doi.org/10.1057/jphp.2012.11 Lara, D., García, S. G., Wilson, K. S., & Paz, F. (2011). How often and under which circumstances do Mexican pharmacy vendors recommend misoprostol to induce an abortion? International perspectives on sexual and reproductive health, 37(2), 75–83. https://doi.org/10.1363/3707511 Billings, D. L., Walker, D., Mainero del Paso, G., Clark, K. A., & Dayananda, I. (2009). Pharmacy worker practices related to use of misoprostol for abortion in one Mexican state . Contraception, 79(6), 445–451. https://doi.org/10.1016/j.contraception.2008.12.011 Elul B. 2011. Assessments of the importance of provider characteristics for abortion care: data from women in Rajasthan, India . Health Care Women Int. 2011;32(1):72–95. Puri MC, et al . 2018. Providers’ perspectives on denial of abortion care in Nepal: a cross sectional study . Reprod Health Matters. 2018;15(170):1. Samari G, et al . 2018. Pharmacy provision of medication abortion in Nepal: pharmacy owner and worker perspectives . Int Perspect Sex Reprod Health. 2018;44(3):81. WHO, Clinical practice handbook for safe abortion 2014, World Health Organisation. National Academies of Sciences, E., and Medicine. 2018. The Safety and Quality of Abortion Care in the United States . 2018, United States. Washington: The National Academies Press. Ankita Shukla, Lucia Vazquez-Quesada et al . 2022. Quality of care in abortion in the era of technological and medical advances and self-care . Reproductive Health (2022) 19:191. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3660786","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":252892159,"identity":"c4c48e38-97af-42df-8aaa-08debe414db6","order_by":0,"name":"Wilson 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clients\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-3660786/v1/f2fb84ba2b60c84b556bc673.png"},{"id":47228773,"identity":"ee5e8410-4e41-4cdb-815c-5f022c51b1f4","added_by":"auto","created_at":"2023-11-28 19:50:35","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":38580,"visible":true,"origin":"","legend":"\u003cp\u003eTrend in number of MA clients served through pharmacy outlets (April-Dec 2022)\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-3660786/v1/2885211c33d89a01fc85d203.png"},{"id":47228775,"identity":"907f4aa9-92a7-4c83-a811-a2693682bd26","added_by":"auto","created_at":"2023-11-28 19:50:35","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":29593,"visible":true,"origin":"","legend":"\u003cp\u003eAdvice and services provided by CHVs to post-MA clients at follow-up\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-3660786/v1/3cb30d1560d5fe3e9f5cb87f.png"},{"id":47228155,"identity":"234b28e7-019b-458b-a35e-b3ac43db2f99","added_by":"auto","created_at":"2023-11-28 19:42:35","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":16370,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of community dialogue forums organized by CHVs to discuss SRHR\u003c/p\u003e","description":"","filename":"12.png","url":"https://assets-eu.researchsquare.com/files/rs-3660786/v1/e362ae585d96b81476bc61d1.png"},{"id":47229981,"identity":"20624f6f-4a18-4c47-bec0-961620ce70bb","added_by":"auto","created_at":"2023-11-28 20:06:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1951536,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3660786/v1/2d812228-530b-4e27-b9b6-855701888569.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAssessing Feasibility and Acceptability of Increasing Access to Sexual and Reproductive Health and Rights through Pharmacies: Lessons from Pilot Study in Kenya\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003ch2\u003eBackground\u003c/h2\u003e\n\u003cp\u003eUnsafe abortion is a major public health problem globally. According to the World Health Organization, 73.3 million induced abortions occurred worldwide each year between 2015 and 2019 (WHO, 2020). The 2020 WHO report indicates that 3 out of 10 (29%) pregnancies, and 6 out of 10 (61%) unintended pregnancies, ended in an induced abortion. Among these, 1 out of 3 were carried out in the least safe or dangerous conditions, and 3 out of 4 abortions that occurred in Africa and Latin America were unsafe. The risk of dying from an unsafe abortion was highest in Africa, and each year 4.7% - 13.2% of maternal deaths can be attributed to unsafe abortion.\u003c/p\u003e\n\u003cp\u003eRecent evidence from work conducted by Guttmacher Institute shows that sub-Saharan Africa (SSA) has the highest unintended pregnancy rate and the highest estimated proportion of unsafe abortions in the world. It is estimated that unsafe abortion is responsible for approximately 7% of maternal mortality in the region. As of 2019, SSA had the highest annual case-fatality rate of any world region, at roughly 185 deaths per 100,000 abortions. These deaths are preventable and point to an urgent need for comprehensive and quality post-abortion care to prevent more women from dying from severe consequences of unsafe abortion (Bankole A \u003cem\u003eet al\u003c/em\u003e, 2020).\u003c/p\u003e\n\u003cp\u003eIn Kenya, 35% of maternal deaths are attributable to unsafe abortion (Center for Reproductive Rights, 2010; MOH Kenya, 2003). Over 2,600 women die annually in Kenya from complications of unsafe abortion and over a third of the women admitted with abortion complications were in the second trimester of pregnancy when risks of severe complications and mortality are substantially higher (Center for Reproductive Rights, 2010). In a 2002 study conducted at Provincial General Hospital in Kakamega, abortion was found to be the most common acute gynecological ailment with its complications accounting for the longest hospital stay (Wamwana, E.B. \u003cem\u003eet al\u003c/em\u003e, 2006). Yet, one-half of unmarried women and more than 4 in 10 of married women in Kenya who are pregnant report their current pregnancies as mistimed or unintended (APHRC, 2019; APHRC, 2013). Unintended pregnancy is a major contributor to girls leaving school, with an estimated 13,000 girls dropping out of school every year in Kenya (Undie, C. \u003cem\u003eet al\u003c/em\u003e, 2015). In Homa Bay County of Kenya, 70% of adolescent girls aged 13-19 years are out of school due to unintended pregnancy (Undie, C. \u003cem\u003eet al\u003c/em\u003e, 2015). These girls have limited access to sexual and reproductive health information and services and face stigma at health facilities.\u003c/p\u003e\n\u003cp\u003eThe World Health Organization (WHO) recommends the use of medical abortion (Mifepristone and Misoprostol) as a safe and effective method of stopping unwanted pregnancies (Bankole A \u003cem\u003eet al\u003c/em\u003e, 2020). The two drugs are registered in Kenya for various indications including treatment of incomplete abortion and miscarriage, treatment and prevention of post-partum haemorrhage (PPH), treatment of missed abortion in first trimester, treatment of intrauterine foetal death and cervical ripening. However, a large proportion of women and girls are not aware of medical abortion (MA) products and where to access these services. Similarly, the extent of provision and uptake of MA drugs in private pharmacies in Kenya is not well known. A study conducted among private pharmacies in three major urban centers in Kenya found that 32% of the pharmacies stocked MA drugs while mystery clients who were sent to the pharmacies as part of the study to assess the quality of care provided were offered the drugs in 54% of the encounters at the outlets (Liambila W \u003cem\u003eet al.\u003c/em\u003e, 2015; Reiss K \u003cem\u003eet al\u003c/em\u003e., 2016).\u003c/p\u003e\n\u003ch2\u003eResearch problem\u003c/h2\u003e\n\u003cp\u003eBased on the foregoing background, the following problems were identified, namely, high rate of unintended pregnancy among women and girls; high rate of unsafe abortion among women and girls; limited access to sexual and reproductive health information, products and services; and high prevalence of stigma associated with pregnancy termination. The study sought to address these problems by equipping pharmacy staff and CHVs with appropriate knowledge and counseling skills.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eResearch goal and objectives\u003c/h2\u003e\n\u003cp\u003eThe overall \u003cstrong\u003egoal\u003c/strong\u003e of the project was to reduce unsafe abortion among women and girls in Kenya by increasing access to medical abortion information, products and services. The \u003cstrong\u003eobjectives\u003c/strong\u003e of the study were to i) Assess the feasibility of increasing access to medical abortion information and products by women and girls through pharmacy-based provision; ii) Test the feasibility of using community health volunteers and local peer networks to increase demand for and referral to medical abortion information, products and services and ii) Assess the acceptability of pharmacy-based and community-based approaches in increasing uptake and utilization of medical abortion products by women and girls with unintended pregnancy in the context of choice.\u003c/p\u003e\n\u003ch2\u003eConceptual framework\u003c/h2\u003e\n\u003cp\u003eThe study team developed a conceptual framework to guide the implementation of the study and assist in clarifying the relationship between the problem, intervention strategies or inputs and expected outcomes (Figure 1).\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eProject design\u003c/h2\u003e\n\u003cp\u003eIn 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\u0026rsquo; (YPP) networks. The study was conducted over a period of 23 months (from February 2021 \u0026nbsp; December 2022).\u003c/p\u003e\n\u003ch2\u003eStudy site and population\u003c/h2\u003e\n\u003cp\u003eThe 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.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData collection, analysis and management procedures\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe 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\u003csup\u003e\u0026reg;\u003c/sup\u003e 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.\u003c/p\u003e\n\u003ch2\u003eEthical considerations\u003c/h2\u003e\n\u003cp\u003eEthical approval for the \u003cem\u003eTembe Mkononi\u003c/em\u003e project was obtained from AMREF Ethics and Scientific Review Committee vide letter Ref: ESRC/P995/2021 dated 18\u003csup\u003eth\u003c/sup\u003e 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 con\u0026shy;senting, data collectors emphasized to participants that the study was voluntary, the reason they were participating \u0026nbsp;and risks and benefits of participating.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIntervention activities\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIntervention 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ei. National and county level consultations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsultative and project inception meetings were held in March-April 2021 with Kisumu Medical and Educational Trust (KMET) who were the project\u0026rsquo;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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eii. Training of pharmacy staff, CHVs and YPPs:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipating 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, \u0026nbsp;referral and linkage of clients to pharmacy outlets, post MA follow-up, documentation and values clarification and attitude transformation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eiii. Deployment of online pharmacy platform:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 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\u0026rsquo;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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eiv. Strengthening of referral activities:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e\n\u003cp\u003ev. 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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003evi. 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.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003ch3\u003eBackground characteristics of study respondents\u003c/h3\u003e\n\u003cp\u003eStudy respondents comprised of 4 female and 6 male pharmacy staff as well as 17 female and 3 male CHVs. The mean age of participating pharmacy staff was 31 years with an average of 6 years\u0026rsquo; experience in the pharmacy field, while the mean age of CHVs was 40 years and almost all of them had worked as CHVs for 10 years. In terms of level of schooling, all the 10 pharmacy staff had attained college/university level education, while 3 out of the 20 CHVs had primary school level education, 9 had secondary school education, while 8 had attended college.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eNumber of MA clients served by participating pharmacy outlets\u003c/h2\u003e \u003cp\u003eWe obtained MA products sales data from each of the participating pharmacy outlets on monthly basis from April to December 2022. A total of 527 medical abortion clients were served at the participating pharmacy outlets, increasing from 15 clients in April 2022 to 112 in December 2022 (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Out of the 527 clients, the largest proportion (248 clients or 47%) was of women aged 20\u0026ndash;24 while girls aged 15\u0026ndash;19 years were fewer (134 clients accounting for 25%) of the total.\u003c/p\u003e\u003cp\u003eThere was variation in the workload between pharmacy outlets (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e), with pharmacies A, F and I having higher workload at 94 clients, 82 clients and 86 clients respectively, while pharmacies D, E and H had the least workload at 12 clients, 9 clients and 13 clients respectively.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSources of information on MA for clients\u003c/h3\u003e\n\u003cp\u003eClients who sought services from pharmacy outlets were asked to state the source of their information on SRHR services including MA. Analysis of the data revealed that a large proportion of clients who received MA services (308 clients) got information about accessing the products at pharmacy outlets from community outreach meetings, while 194 clients had been referred to the pharmacy outlets by CHVs (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Majority of clients seeking MA services were in the 20\u0026ndash;24 years age group.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eScreening of clients seeking MA services\u003c/h2\u003e \u003cp\u003ePharmacy staff were asked to state the type of screening they conducted on clients in order to determine their eligibility for obtaining MA services from the pharmacy outlets. All the 10 pharmacy staff reported that they asked clients about gestation period and reasons for wanting to terminate pregnancy before providing MA services, while 9 out of 10 pharmacy staff asked about the client\u0026rsquo;s age and requested clients to conduct a rapid pregnancy test before providing any further services (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA comparison of baseline and endline results showed that certain screening procedures either reduced or increased at the endline. For instance, asking clients whether they had referral forms, their medical history or whether they had prescription from medical practitioners reduced at the endline. On the other hand, certain screening questions including knowing the client\u0026rsquo;s age and asking for reasons for wanting to terminate the pregnancy increased at the endline. There were no major differences in the results of the other screening questions between baseline and endline.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eCounseling and information provision to MA clients\u003c/h2\u003e \u003cp\u003ePharmacy staff were asked to state the type of SRHR information and advice they provided to clients who came to them seeking pregnancy termination. At endline, all the 10 pharmacy staff reported advising clients on the side effects of MA drugs as well as on post-abortion family planning (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). The number of pharmacy staff who informed clients on how to confirm whether the MA process was successful increased from 4 at baseline to 9 at endline. Similarly, the number of pharmacy staff who mentioned to clients about complications that may arise from MA use increased from 7 at baseline to 9 at endline. The number of pharmacy staff who counseled clients on other available options for pregnancy termination, risk of failure of MA, and when and how to use MA drugs appears to have reduced at endline.\u003c/p\u003e \u003cp\u003eCommunity health volunteers were asked to state the nature of counseling, advice and information they provided to clients who sought pregnancy termination services. Marked improvements occurred regarding the number of CHVs who informed clients on how to confirm that the MA process was successful from 2 at baseline to 7 at endline. The number of CHVs who informed clients on when and where to seek help increased from 9 at baseline to 16 at endline, and those who informed clients on the side effects of MA drugs increased from 7 at baseline to 10 at endline (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIt should be noted that key tasks for CHVs involved creating awareness on availability of MA services and referring potential clients to pharmacy outlets. CHVs also worked in partnership with pharmacy staff to follow up post-MA clients to ensure that the MA process was successful.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOverall trend in client utilization of SRHR services at pharmacy outlets\u003c/h2\u003e \u003cp\u003eData from the online pharmacy platform showed a steady increase in the number of clients who obtained SRHR information, services and products from 14 clients in April to 112 clients in December 2022 (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e10\u003c/span\u003e). The decline in number of clients served between August and September 2022 could be attributed to the general elections held in Kenya during that period.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProvision of post-MA family planning methods to clients\u003c/h3\u003e\n\u003cp\u003eMonthly sales data from the online pharmacy platform showed that pharmacy staff were able to provide a variety of short-term contraceptive methods. For instance, the 3-months injectable contraceptive (DMPA) was the most commonly dispensed method (205 clients), followed by oral contraceptive pills (121 clients), while the emergency pill (5 clients) was the least FP method obtained (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-MA FP sales to clients by age category April-Dec 2022\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContraceptive Method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;19 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u0026ndash;24 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGrand Total\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3 Month Injectable\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCondoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmergency contraception\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImplant\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMethod desired but no method received\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo method desired\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOral Contraceptives\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReferred for contraception (PAFP)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGrand Total\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e133\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e246\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e144\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e523\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up referral for post-MA clients\u003c/h2\u003e \u003cp\u003eBoth pharmacy staff and CHVs were trained on the importance of conducting follow-up to post-MA clients. At endline, all the 10-pharmacy staff reported that they offered counseling and verbal reassurance to post-MA clients, provided pain medication, and referred the clients to CHVs for home support. Majority of CHVs also indicated that pharmacy staff referred women and girls who had undergone pregnancy termination to them for follow-up. All the 20 CHVs at endline indicated that they provided counseling and verbal reassurance to clients who came back or called in for post-abortion follow-up compared to 9 at baseline (Fig.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e11\u003c/span\u003e). There was also an increase in number of CHVs who referred post-abortion clients back to pharmacy outlets for further review from 3 at baseline to 6 at endline. Similarly, 17 CHVs advised post-abortion clients on available FP options at endline up from none at baseline.\u003c/p\u003e\u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCommunity level demand creation activities\u003c/h2\u003e \u003cp\u003e According to the Government of Kenya Community Health Strategy, community dialogue days provide a useful platform and forum for CHVs and community health committees to interact with members of the public to discuss priority public health issues affecting them. CHVs were asked whether they had conducted community dialogue forums in the past 6 months prior to the baseline and endline surveys at which SRHR issues were discussed. The number of CHVs who organized community forums to discuss SRHR issues including MA increased from 18 at baseline to 20 at endline. The number of CHVs who conducted 7\u0026ndash;9 meetings in the 6 months period preceding the baseline and endline surveys increased from 2 CHVs at baseline to 4 CHVs at endline, while the number of CHVs who had organized 10 meetings and above increased from 1 CHV at baseline to 5 CHVs at endline (Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe rest of the CHVs indicated having organized between 1 and 6 community dialogue forums in the 6 months preceding the baseline and endline surveys.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePharmacy staff and CHV satisfaction with provision of SRHR services\u003c/h3\u003e\n\u003cp\u003eIn order to assess the acceptability of providing SRHR services and products through pharmacy outlets, both pharmacy staff and CHVs were asked a number of questions. Pharmacy staff were asked whether they were satisfied with their role in providing counseling, information and services to MA clients including utilization of the online platform. All the 10 pharmacy staff indicated satisfaction with provision of MA products and services to clients. Key reasons for satisfaction mentioned by pharmacy staff were: privacy and confidentiality of service provision; accurate MA sales data capture and verification through online platform; and fast retrieval of records and tracing of clients.\u003c/p\u003e \u003cp\u003eSimilarly, CHVs were asked how satisfied they were with referring SRHR clients to pharmacy outlets for services. Eighteen out of 20 CHVs at baseline and all the 20 CHVs at endline indicated that they were satisfied with how they referred and linked clients to pharmacy outlets for MA services and products. Reasons provided by CHVs in support of their satisfaction with referral of clients to pharmacy outlets included positive feedback from clients as well as the pharmacy outlets on their performance, pharmacy outlets offering privacy and confidentiality to clients, friendly pharmacy staff and cooperative service providers, and proximity of pharmacy outlets to clients hence facilitating effective referrals.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDissemination of preliminary findings\u003c/h2\u003e \u003cp\u003eA forum for disseminating preliminary findings from the project was undertaken in December 2022 and attended by key national and county level stakeholders. Priority themes in the dissemination forum were: Strategies for scaling up utilization of pharmacy outlets in the provision of SRHR services, particularly medical abortion, to women and girls; Opportunities for institutionalizing provision of SRHR services including MA within Homa Bay County reproductive health agenda, work plans and budgets; and Role of Ministry of Health and Kenya Pharmaceutical Association in capacity building for pharmacy staff, CHVs and YPPs to strengthen provision of MA services, MA task-sharing and commodity security, and routine data collection and utilization.\u003c/p\u003e \u003cp\u003eStakeholders acknowledged the potential role played by pharmacy outlets in reaching more girls and women who require SRHR services. They explained that at present CHVs do refer clients to pharmacy outlets for counseling services and to obtain MA products. Once a client has been attended to, she is referred back to the CHV for follow up at the community level. To facilitate effective follow up, pharmacy staff agreed amongst themselves to be providing their telephone contacts and those of the CHVs to the clients. Participants at the dissemination meeting said that this referral model is easily scalable because it links the pharmacy outlets with the CHVs and clients.\u003c/p\u003e \u003cp\u003eAt the meeting, Kenya Pharmaceutical Association (KPA) indicated that with collaboration from other partners including Pharmacy and Poisons Board and Ministry of Health, it is able to advocate for scale up and utilization of pharmacy outlets as service points for MA services.\u003c/p\u003e \u003cp\u003eMajority of stakeholders noted that through the project, pharmacies are now able to counsel, advice clients, dispense MA drugs and contraceptives and conduct telephone-based follow-ups. Given that in the past, the primary role of pharmacies was to dispense drugs, the additional activities benefit clients by bringing SRHR services closer to them, making them available and within reach. From the findings, stakeholders indicated that utilizing pharmacy outlets is a sustainable avenue for girls and women to access and utilize SRHR services including MA.\u003c/p\u003e \u003cp\u003eStakeholders also pointed out the importance of linking data from pharmacy outlets to the national District Health Information System (DHIS). They expressed the need to advocate for linking of data from private sector health providers such as pharmacy outlets and health centres to the Ministry\u0026rsquo;s health management information system.\u003c/p\u003e \u003cp\u003eLastly, stakeholders recommended that findings and lessons from the project be integrated into the Homa Bay County work plans and budget. They pointed out that this would ensure sustainability of the interventions and the model.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eNumber of MA clients served\u003c/h2\u003e \u003cp\u003eAccording to the project\u0026rsquo;s proof of concept, it was expected that 300 girls aged 15\u0026ndash;19 years and 900 women aged 20\u0026ndash;49 years would be reached during the project period. The set targets were exceeded whereby 1,025 girls aged 15\u0026ndash;19 years and 1,389 women aged 20\u0026ndash;49 years were reached. In addition, CHVs also reached 526 men through community sensitization. At the end of the project period, a total of 527 MA clients were served at the participating pharmacy outlets, increasing from 15 clients in April 2022 to 112 in December 2022.\u003c/p\u003e \u003cp\u003eThe large number of women and girls who received MA information and services could be attributed to increased awareness created by CHVs through community outreach forums. Previous studies have provided evidence that community health cadres are effective in making safe abortion information and services accessible to women to facilitate decision-making in the context of choice (Gupta P, et al, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Rishita N, 2018; Olaniran A, et al, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The increased utilization of pharmacy outlets could also be attributed to the confidence the target population had in getting services from community pharmacy outlets, which offer privacy and confidential care. Similar studies have observed that the choice of service delivery points by clients seeking abortion services depends on waiting time, distance to access points, need for privacy and control (Newton D, et al, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Ho P., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Aiken A., et al, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Kanstrup C., et al, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). These studies argue that providing choices to consumers is an integral part of service delivery. In addition, the studies point out that health systems which do not provide options limit individuals\u0026rsquo; likelihood of opting for a safe method that meets their needs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCounseling and information provision by pharmacy staff\u003c/h2\u003e \u003cp\u003eThe project\u0026rsquo;s training activities for pharmacy staff aimed to build their capacity to deliver accurate information on medical abortion to prospective clients, conduct screening and counseling, dispense correct dosage of MA medication, and provide quality post-MA services. As shown in the results section of this paper, all the participating pharmacy staff were able to provide information and counsel clients on all critical aspects of MA services, thereby enabling clients to make informed decisions.\u003c/p\u003e \u003cp\u003eThese results demonstrate that pharmacy staff are strategically placed to increase access to and utilization of MA services even in contexts where provision of abortion and contraceptive services to adolescents is stigmatized. Previous studies have shown that pharmacy staff are often the first-line healthcare providers hence they have the responsibility of delivering accurate information and increasing access to interventions for unintended pregnancy. Training of pharmacy staff enables them to successfully provide information, conduct counseling and deliver healthcare related to stigmatized conditions including STIs, HIV \u0026amp; AIDS and pregnancy termination (Sneeringer R.K, et al, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Further, studies have shown that pharmacy outlets are often the most available healthcare outlets in communities, with short waiting time and less costly services. Their success has been due to their ability to facilitate rapid access to medications, supplies, medical information, and advice while maintaining client confidentiality (Lara D, et al, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Billings D.L., et al, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLinkage with wider health system\u003c/h2\u003e \u003cp\u003eThroughout the various project phases, it was evident that involvement of the county government and the leadership of the county and sub-county health management teams was critical to proper functioning of the health system including the provision of SRHR services. The issue of embracing a health system approach was also discussed during the dissemination meeting held in December 2022. Both the public and private sector representatives at the dissemination meeting acknowledged that through the project, pharmacy staff are now able to counsel, advise clients, dispense MA drugs and contraceptive methods, and conduct follow-up of clients after service provision. Participants also advocated for the linking of service data collected at pharmacy outlets to the national District Health Information System (DHIS 2) to be utilized for policy and programming on medical abortion. Participants pointed out the need to involve private sector providers, including pharmacy staff in update trainings on SRHR service provision organized by the public sector. They pointed out that the private sector is often left out during refresher trainings. They argued that task-shifting allows clinical staff to focus on clinical procedures whilst leaving pharmacy staff to focus on provision of MA services so long as it is undertaken within the recommended gestation period.\u003c/p\u003e \u003cp\u003eSimilar studies have emphasized the need for refresher trainings for all service cadres, both in public and private sectors, in order to guarantee the quality of services provision (Elul B., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Other studies have also emphasized the need for service providers to be competent in pregnancy determination, pre and post abortion counseling, gestation assessment, knowledge on need for referral and procedures involved, dispensing MA pills, patient monitoring, and follow-up assessment and care (Puri M.C. \u003cem\u003eet al\u003c/em\u003e, 2018; Samari G. et al, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; WHO, 2014; National Academy of Sciences, 2018). The involvement of pharmacy staff in the provision of MA services was viewed as strengthening the task-shifting approach. The approach allows medical staff with clinical skills such as doctors, nurses and clinical officers to focus on provision of surgical methods such as manual vacuum aspiration and dilation and curettage (D\u0026amp;C).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eImplication of study findings on maternal morbidity and mortality\u003c/h2\u003e \u003cp\u003eMorbidity and mortality related to unsafe abortion are major public health problems not only in Kenya but globally. Reducing maternal morbidity and mortality is a priority for low-and-middle-income countries. According to the World Health Organization, countries wanting to reduce maternal mortality but reluctant to address abortion, need to resolve their internal incoherence (Shukla, et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Furthermore, the rollout of universal health coverage (UHC) provides the opportunity to integrate abortion services more meaningfully with relevant reproductive health programs given that unsafe abortion is one of the leading causes of preventable maternal mortality in Kenya.\u003c/p\u003e \u003cp\u003eFindings from this project showed that it is feasible and acceptable to utilize pharmacy outlets to increase access to MA services by women and girls. Pharmacy outlets were found to be closest to women and girls in the communities where they reside and are the preferred first points of contact for MA and post-abortion contraceptive services. Further, it emerged from the findings that pharmacy outlets have MA drugs and contraceptives in stock all the time, a finding that guarantees uninterrupted availability of services. Therefore, attempts to reduce morbidity and mortality related to unsafe abortion have to consider involving the pharmacy outlets given the potential they have as the preferred first point of contact for MA and post-abortion services. Overall, the findings demonstrate that providing MA information and services to women and girls at pharmacy outlets is a promising strategy for increasing access. It is anticipated that improving access to MA would reduce unsafe abortions and ultimately maternal morbidity and mortality associated with such abortions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eThe main limitation of this study was the short time frame within which the project team was expected to implement activities. Initial requirements including obtaining ethical approval, contracting obligations with implementing partners and the COVID-19 situation prevailing at the time contributed to delays in the commencement of project activities. Another limitation is that the baseline survey was conducted a few months after commencement of project interventions including training of pharmacy staff and CHVs. The project team delayed collection of baseline data in order to give room for setting up of a functional online pharmacy platform, which was one of the main project interventions. This could explain the marginal differences between baseline and endline findings since the study participants had already been exposed to some aspects of the project interventions by the time of conducting the baseline survey, and also the interval between baseline and endline data collection was short.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOne, findings from the study showed that it is feasible and acceptable to increase access to SRHR information and services, including MA, through pharmacy provision and community health volunteers. Two, the steady increase in the number of clients who sought MA services during the project period could be attributed to increased awareness on availability of MA services by clients, as well as increased knowledge, skills and confidence of the pharmacy staff after undergoing training. Three, the support provided by the County Government of Homa Bay contributed to creating demand for SRHR services among the target population including MA information and products.\u003c/p\u003e "},{"header":"Recommendations","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003cp\u003eOne, there is need to scale up the provision of MA information, products and services through pharmacy outlets given its potential to reach the target population, and to deliver services in a private and confidential manner. Two, the Pharmacy and Poisons Board, Pharmaceutical Association of Kenya, the Division of Reproductive and Maternal Health (Ministry of Health), and County Governments should prioritize training of pharmacy staff in SRHR information, products and services through on-the-job training or continuous medical education. For sustainability purposes, such training could be undertaken as part of continuous professional development (CPD). Three, findings and lessons learned from the study point to the need for incorporating capacity building of health providers particularly pharmacy staff and CHVs as well as commodity security for SRHR into county annual work plans and budgets to ensure sustained service provision.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCHA Community Health Assistant\u003c/p\u003e \u003cp\u003eCHMT County Health Management Team\u003c/p\u003e \u003cp\u003eCHV Community Health Volunteer\u003c/p\u003e \u003cp\u003eDHS Demographic and Health Survey\u003c/p\u003e \u003cp\u003eEML National Emergency Medicines List\u003c/p\u003e \u003cp\u003eFGDs Focus Group Discussions\u003c/p\u003e \u003cp\u003eFP Family Planning\u003c/p\u003e \u003cp\u003eGBV Gender-Based Violence\u003c/p\u003e \u003cp\u003eIDIs In-Depth Interviews\u003c/p\u003e \u003cp\u003eIRB Institutional Review Board\u003c/p\u003e \u003cp\u003eKDHS Kenya Demographic and Health Survey\u003c/p\u003e \u003cp\u003eKMET Kisumu Medical and Educational Trust\u003c/p\u003e \u003cp\u003ePPB Pharmacy and Poisons Board\u003c/p\u003e \u003cp\u003eMA Medical Abortion\u003c/p\u003e \u003cp\u003eMOH Ministry of Health\u003c/p\u003e \u003cp\u003ePI Principal Investigator\u003c/p\u003e \u003cp\u003ePC-Kenya Population Council Kenya\u003c/p\u003e \u003cp\u003eRA Research Assistant\u003c/p\u003e \u003cp\u003eRCC Referral Care Centre\u003c/p\u003e \u003cp\u003eSCHMT Sub-County Health Management Team\u003c/p\u003e \u003cp\u003eSRHR Sexual and Reproductive Health and Rights\u003c/p\u003e \u003cp\u003eWHO World Health Organisation\u003c/p\u003e \u003cp\u003eYPP Youth Peer Provider\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the \u003cem\u003eTembe Mkononi\u003c/em\u003e project was obtained from AMREF Ethics and Scientific Review Committee vide letter Ref: ESRC/P995/2021 dated 18\u003csup\u003eth\u003c/sup\u003e June 2021. A research license for the project was obtained in December 2021 from the National Commission for Science, Technology and Innovation (NACOSTI) under license number NACOSTI/P/22/15033. Written consent was sought and obtained from all the participating pharmacy staff and CHVs prior to conducting interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors hereby give consent for the publication of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during this study are in the possession of the authors and are available for sharing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study was provided by Grand Challenges Canada under the OPTions Initiative Grant Number R-POC-OPT-2104-38141.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWL conceptualized the overall study; FO wrote the study design and methodology; MO, CN and BD interpreted data for accuracy; \u0026nbsp;SR and ZW reviewed the article for intellectual content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to appreciate the roles played by a team of research assistants, pharmacy staff, community health volunteers and youth peer providers who participated in the study. We acknowledge with thanks the contribution of Stephen Kizito of Population Council\u0026rsquo;s Data Management Unit in data analysis. We would also like to single out two KMET Staff, namely Griffin Odindo and Maureen Mobasi for having played important roles in project implementation and in coordinating data collection activities during baseline and endline phases of the project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuggested citation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWilson Liambila, Francis Onyango, Saumya RamaRao, Monica Oguttu, Carol Nyandat, Benedict Denga and Zeka Wekesa (2023): \u003cem\u003eAssessing Feasibility and Acceptability of Increasing Access to Sexual and Reproductive Health and Rights through Pharmacies: Lessons from Pilot Study in Kenya.\u003c/em\u003e Population Council Kenya; Nairobi.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization (WHO) Factsheet. 2020. \u003cem\u003ePreventing unsafe abortion\u003c/em\u003e. Geneva https://www.who.int/news-room/fact-sheets/detail/preventing-unsafe-abortion \u003c/li\u003e\n\u003cli\u003eBankole A \u003cem\u003eet al\u003c/em\u003e., \u003cem\u003eFrom Unsafe to Safe Abortion in Sub-Saharan Africa: Slow but Steady Progress\u003c/em\u003e, New York: Guttmacher Institute, 2020, https://www.guttmacher.org/report/from-unsafe-to-safe-abortion-in-sub-Saharan-Africa\u003c/li\u003e\n\u003cli\u003eCenter for Reproductive Rights. 2010. \u003cem\u003eThe impact of Kenya\u0026rsquo;s Restrictive Abortion Law\u003c/em\u003e.New York: Center for Reproductive Rights. Accessed at: [email protected].\u003c/li\u003e\n\u003cli\u003eMinistry of Health [Kenya]. 2003. \u003cem\u003eKenya National Post Abortion Care Curriculum: Trainer\u0026rsquo;s Manual\u003c/em\u003e. Nairobi: Ministry of Health.\u003c/li\u003e\n\u003cli\u003eWamwana, E.B., P.M. Ndavi, P.B. Gichangi, J.G. Karanja, E.G. Muia, and G.W. Jaldesa. 2006. \u0026ldquo;Socio-demographic characteristics of patients admitted with gynaecological emergency conditions at the provincial general hospital, Kakamega, Kenya.\u0026rdquo; \u003cem\u003eEast African Medical Journal\u003c/em\u003e 83(12):659-665.\u003c/li\u003e\n\u003cli\u003eAfrican Population and Health Research Center (APHRC), Ministry of Health [Kenya], Ipas, and Guttmacher Institute. 2013. \u003cem\u003eIncidence and Complications of Unsafe Abortion in Kenya: Key Findings of a National Study\u003c/em\u003e. Nairobi: APHRC, Ministry of Health [Kenya], Ipas, and Guttmacher Institute.\u003c/li\u003e\n\u003cli\u003eAfrican Population and Health Research Center (APHRC). 2019. \u003cem\u003eUnderstanding Contraceptive Uptake after Medical Abortion among Women and Adolescent Girls in Kenya: Formative Research Report\u003c/em\u003e. Nairobi: APHRC.\u003c/li\u003e\n\u003cli\u003eUndie, C, Birungi, H, Odwe, G. and Obare, F. 2015. \u003cem\u003eExpanding Access to Secondary School Education for Teenage Mothers in Kenya: A Baseline Study Report\u003c/em\u003e. STEP UP Technical Report. Nairobi.\u003c/li\u003e\n\u003cli\u003eLiambila, Wilson, Francis Obare, Edward Ikiugu, Vitalis Akora, Jesee Njunguru, Michael Njuma, Kate Reiss, and Harriet Birungi. 2015. \u003cem\u003eAvailability, use and quality of care for medical abortion services in private facilities in Kenya\u003c/em\u003e. Nairobi: Population Council and Marie Stopes International.\u003c/li\u003e\n\u003cli\u003eReiss, Kate, Katharine Footman, Vitalis Akora, Wilson Liambila, and Thoai D. Ngo. 2016. \u003cem\u003ePharmacy workers\u0026rsquo; knowledge and provision of medication for termination of pregnancy in Kenya.\u003c/em\u003e\u003cem\u003eJournal of Family Planning and Reproductive Health Care\u003c/em\u003e 42:2018-212.\u003c/li\u003e\n\u003cli\u003eGupta, P., Iyengar, S.D., Ganatra, B. \u003cem\u003eet al.\u003c/em\u003e\u003cem\u003eCan community health workers play a greater role in increasing access to medical abortion services\u003c/em\u003e? A qualitative study. BMC Women\u0026apos;s Health \u003cstrong\u003e17\u003c/strong\u003e, 37 (2017). https://doi.org/10.1186/s12905-017-0391-1 \u003c/li\u003e\n\u003cli\u003eNandagiri, Rishita (2018) \u003cem\u003e\u0026ldquo;They know everything\u0026rdquo;: the role of Community Health Workers in Abortion Access.\u003c/em\u003e In: Abortion and reproductive justice: the unfinished revolution III, 2018-07-08 - 2018-07-12, Rhodes University in Grahamstown (Makanda), South Africa. http://eprints.lse.ac.uk/id/eprint/89378\u003c/li\u003e\n\u003cli\u003eOlaniran A, Madaj B, Bar-Zev S\u003cem\u003e, et al.\u003c/em\u003e 2019.\u003cem\u003e The roles of community health workers who provide maternal and newborn health services: case studies from Africa and Asia\u003c/em\u003e. BMJ Global Health 2019;\u003cstrong\u003e4:\u003c/strong\u003ee001388. \u003c/li\u003e\n\u003cli\u003eNewton D, \u003cem\u003eet al\u003c/em\u003e. 2016. \u003cem\u003eHow do women seeking abortion choose between surgical and medical abortion? Perspectives from abortion service providers\u003c/em\u003e. Aust N Z J Obstet Gynaecol. 2016;56(5):523\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eHo P. \u003cem\u003eWomen\u0026rsquo;s perceptions on medical abortion.\u003c/em\u003e Contraception. 2006;74(1):11\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eAiken A, \u003cem\u003eet al\u003c/em\u003e. 2018. \u003cem\u003eBarriers to accessing abortion services and perspectives on using mifepristone and misoprostol at home in Great Britain\u003c/em\u003e. Contraception. 2018;97(2):177\u0026ndash;83.\u003c/li\u003e\n\u003cli\u003eKanstrup C, Makela M, Hauskov GA. 2018. \u003cem\u003eWomen\u0026rsquo;s reasons for choosing abortion method: a systematic literature review\u003c/em\u003e. Scand J Public Health. 2018;46(8):835\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eSneeringer, R. K., Billings, D. L., Ganatra, B., \u0026amp; Baird, T. L. (2012). \u003cem\u003eRoles of pharmacists in expanding access to safe and effective medical abortion in developing countries: a review of the literature\u003c/em\u003e. Journal of public health policy, 33(2), 218\u0026ndash;229. https://doi.org/10.1057/jphp.2012.11 \u003c/li\u003e\n\u003cli\u003eLara, D., Garc\u0026iacute;a, S. G., Wilson, K. S., \u0026amp; Paz, F. (2011). \u003cem\u003eHow often and under which circumstances do Mexican pharmacy vendors recommend misoprostol to induce an abortion?\u003c/em\u003e International perspectives on sexual and reproductive health, 37(2), 75\u0026ndash;83. https://doi.org/10.1363/3707511\u003c/li\u003e\n\u003cli\u003eBillings, D. L., Walker, D., Mainero del Paso, G., Clark, K. A., \u0026amp; Dayananda, I. (2009). \u003cem\u003ePharmacy worker practices related to use of misoprostol for abortion in one Mexican state\u003c/em\u003e. Contraception, 79(6), 445\u0026ndash;451. https://doi.org/10.1016/j.contraception.2008.12.011 \u003c/li\u003e\n\u003cli\u003eElul B. 2011. \u003cem\u003eAssessments of the importance of provider characteristics for abortion care: data from women in Rajasthan, India\u003c/em\u003e. Health Care Women Int. 2011;32(1):72\u0026ndash;95.\u003c/li\u003e\n\u003cli\u003ePuri MC, \u003cem\u003eet al\u003c/em\u003e. 2018. \u003cem\u003eProviders\u0026rsquo; perspectives on denial of abortion care in Nepal: a cross sectional study\u003c/em\u003e. Reprod Health Matters. 2018;15(170):1.\u003c/li\u003e\n\u003cli\u003eSamari G, \u003cem\u003eet al\u003c/em\u003e. 2018. \u003cem\u003ePharmacy provision of medication abortion in Nepal: pharmacy owner and worker perspectives\u003c/em\u003e. Int Perspect Sex Reprod Health. 2018;44(3):81.\u003c/li\u003e\n\u003cli\u003eWHO, \u003cem\u003eClinical practice handbook for safe abortion \u003c/em\u003e2014, World Health Organisation.\u003c/li\u003e\n\u003cli\u003eNational Academies of Sciences, E., and Medicine. 2018. \u003cem\u003eThe Safety and Quality of Abortion Care in the United States\u003c/em\u003e. 2018, United States. Washington: The National Academies Press.\u003c/li\u003e\n\u003cli\u003eAnkita Shukla, Lucia Vazquez-Quesada \u003cem\u003eet al\u003c/em\u003e. 2022. \u003cem\u003eQuality of care in abortion in the era of technological and medical advances and self-care\u003c/em\u003e. Reproductive Health (2022) 19:191.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"87f62a22-079e-4d91-b2ab-9c499228fae5","identifier":"10.13039/501100004828","name":"Grand Challenges Canada","awardNumber":"Grant Number R-POC-OPT-2104-38141","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Population Council Kenya","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sexual and reproductive health and rights, medical abortion, pharmacy, community health volunteer, Homa Bay County","lastPublishedDoi":"10.21203/rs.3.rs-3660786/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3660786/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBoth unintended pregnancy and unsafe abortion are major public health problems in Kenya. The World Health Organization recommends the use of medical abortion to stop unwanted pregnancies. However, the extent of provision and uptake of medical abortion through private pharmacies in Kenya is not well known. This study assessed the feasibility and acceptability of utilizing pharmacy outlets and community health volunteers to increase women\u0026rsquo;s and girls\u0026rsquo; access to information, medical abortion and other sexual and reproductive health services and rights.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study utilized a single arm (intervention only) pre-test and post-test design that involved implementing a set of interventions and comparing the baseline and endline indicators. The study, referred to as \u003cem\u003eTembe Mkononi\u003c/em\u003e project, was conducted from 1st February 2021 to 31st December 2022, in Homa Bay County. Data collection involved baseline and endline interviews with 10 pharmacy staff (drawn from 9 pharmacy outlets) and 20 community health volunteers while program data was extracted from pharmacy sales records.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 527 clients obtained medical abortion drugs from the 9 participating pharmacy outlets between April and December 2022. There was a steady increase in the number of clients served from 15 clients in April 2022 to 112 clients in December 2022. Out of the 527 clients, 523 of them obtained family planning methods. All the pharmacy staff and community health volunteers expressed satisfaction and positive attitude towards the services provided to clients.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eResults of the study show that the provision of medical abortion and other sexual and reproductive health services such as contraceptives to women and girls through private pharmacy outlets was feasible and acceptable. Building the capacity of community health volunteers to create awareness, strengthen referral and follow-up activities increased demand and uptake of sexual and reproductive health services including medical abortion over the project period. Overall, the interventions implemented in a rural county in Western Kenya have potential in addressing the problem of unsafe abortion which is one of the leading causes of maternal morbidity and mortality in Kenya and other developing countries.\u003c/p\u003e","manuscriptTitle":"Assessing Feasibility and Acceptability of Increasing Access to Sexual and Reproductive Health and Rights through Pharmacies: Lessons from Pilot Study in Kenya","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-28 19:42:30","doi":"10.21203/rs.3.rs-3660786/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"31c1e5df-f4aa-4739-8d6c-3a9779b5917c","owner":[],"postedDate":"November 28th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":26708082,"name":"Sexual \u0026 Reproductive Medicine"}],"tags":[],"updatedAt":"2023-12-10T12:44:19+00:00","versionOfRecord":[],"versionCreatedAt":"2023-11-28 19:42:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3660786","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3660786","identity":"rs-3660786","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}