BY HASIYA AHMADU, RESEARCH OFFICER (SFH-NIGERIA); STEPHEN ALEGE, HEAD OF SBC (PSI-UGANDA); CLAIRE COLE, EVIDENCE AND LEARNING LEAD, DISC; ROBIN SWEARINGEN, PROGRAM MANAGER, DISC
Much of the past research on self-injection of the contraceptive DMPA-SC focuses on how best to integrate self-injection into health services—as well the feasibility and safety of the product. While these are certainly important considerations, limited attention has been paid to women’s contraceptive experiences, desires, preferences, and needs. What does it mean to put more power in her hands through a self-care innovation like self-injection? How does she envision acting on that power? How does she feel once she does, and what kind of support does she want to help her initiate and continue use?
To fill these knowledge gaps, in the last year the DISC project has conducted extensive programmatic research[1], including interviews with ‘early adopters’ of the product, prospective users, and the public and private sector providers on whom women rely. The consumer-powered insights gathered directly from young women, young mothers, and adult mothers in Uganda and Nigeria provide rich insights that have informed DISC interventions, and formed the foundation of our innovation and learning agenda.
DISC’s learnings shed light on the pathway toward self-injection as a cornerstone of women’s sexual and reproductive healthcare (SRH) journey, making it an accessible and attractive option for women.
DISC’s recently released Insight Synthesis Report distills these findings and examines self-injection from a “user journey” perspective that breaks down the multitude of considerations facing consumers and providers across five stages.
Intersecting each stage are seven discrete themes that influence client and provider behaviors: 1) Power, 2) Trust and Credibility, 3) Relevance, 4) Convenience, 5) Collectivism, 6) Voice and Agency, and 7) Safety. Read on to learn more about what DISC discovered!
POWER
As previously discussed in a post by DISC Uganda Project Lead, Alexandrina Nakanwagi, women’s contraceptive decisions tend to go hand-in-hand with their perception of their power, expressed in four domains: power within, power to, power with, and power over.[2] Importantly, though nearly all women across DISC evidence streams demonstrated a clear identification with their own power, many did not feel they could trust others in their lives to uphold it. While women believe in their own decision-making power over their lives and SRH, their partners and community may not. At the DECISION and INITIATION stages of the self-inject use journey, many women—primarily mothers—may wish to include their male partners in decision-making to use self-inject. Some, however, require outside resources and support to help them use their power to clandestinely access needed information, training, and commodities.
TRUST AND CREDIBILITY
While healthcare workers remain women’s most trustworthy source of information in both Uganda and Nigeria, DISC findings show there is also a compelling opportunity to foster women’s accurate knowledge and positive attitudes about strategic insights through informal channels. Apart from health workers, women most want to learn about sensitive SRH information from other credible women—women they deem to be “like me.” At the AWARENESS and DECIDE stages, women have varying ways of discerning just who is credible—in southern Nigeria, many women find high-profile social media figures to be “like me,” whereas DISC respondents in northern Nigeria expressed distrust of social media icons, and instead trust local women in their community. Digital health and outreach interventions can put these learnings to use by ensuring that accurate information about self-injection and other self-care innovations reach women through the channels and profiles women deem reliable.
PERCEIVED RELEVANCE OF SELF-INJECTION AND CONTRACEPTION OVERALL
Young women may not automatically consider contraception to be relevant to them, in part because many do not self-identify with their sexual activity status. Particularly in the case of (often young, unmarried) women who have never been pregnant, or women who have infrequent sex, contraceptives are not perceived as valuable. Thus, just as most contraceptive programs require targeted effort to reach and resonate with youth, so too does outreach on self-injection. To support young women to reach the first stage of their use journey—AWARENESS—messages must connect contraception and self-injection to what they do identify with and place value on. Namely: their aspirations for their lives. Showing how specific contraceptive methods are tools that may help them achieve their life goals is a key finding important to self inject programs aiming to reach all women.
CONVENIENCE
Across DISC respondent groups, women responded positively to convenience as a central value proposition of self-injection. However, the ways that women defined ‘convenience’ varied considerably, in large part based on the importance women placed on discretion. While some women discussed the ‘convenience’ offered by self-injection in terms of reduced cost due to less frequent transit to the health care facility, or the ability to keep up to nine months of coverage at home at a time, this was not the sole definition. Rather, many women discussed ‘convenience’ as the confidentiality afforded by long journeys to seek SRH care, going out of their way to reach facilities far from home. For them, ‘convenience’ was any approach that might ensure total anonymity in their SRH care seeking behaviors. Self-inject focused programs like DISC may be well-served, then, to ensure that outreach and supply approaches are able to safely deliver on the promise of convenience for all profiles of women: those who enjoy the support of family and community, as well as those who do not and thus value confidentiality most of all.
COLLECTIVISM
Despite women’s continuing desire for anonymity in their SRH decision-making, many women can and do feel a calling to support other women—particularly those they perceive as less fortunate than themselves—in finding ways to gain more control over their SRH. DISC respondents voiced a willingness to be a bridge for others in need of information and services. This desire may prove particularly meaningful for self-care initiatives like DISC, as we aim to normalize the concept of self-care in SRH, tapping the potential of women’s power with each other to bring about change to the status quo of SRH care. As we do this though, DISC findings suggest that programs must offer multiple channels for women to collectivize—defaulting to forums that can allow for degrees of anonymity, so that even as women may reach out to others to offer information and support, they can do so in ways that conceal identifying information about themselves. Some examples of this may include anonymous chat or WhatsApp forums.
VOICE AND AGENCY
Women’s sense of identity is strongly linked to their perception of self-efficacy to achieve their goals and influence others. Marketing campaign efforts are thus most likely to succeed at the AWARENESS and DECISION stages by directly addressing women’s agency, i.e., their power within and power to. However, due to stigmatization and a desire for privacy, many women are not inclined to extend their voice and agency to engage in formal publicly-facing ADVOCACY to demand health system actors’ accountability to uphold and support women’s self-care as a part of their SRH health care journey. Self-care movement-building efforts thus may require targeted investments, and adequate time and financial resourcing, to build spaces and forums in which women feel safe to advocate for self-care in the public sphere.
PHYSICAL SAFETY AND SOCIAL RISK
Global enthusiasm for self-injection and its potential to support women’s power over their SRH care is well founded. However, DISC findings echo global partners’ recent calls to approach this enthusiasm responsibly. Amidst women’s enthusiasm for the convenience offered by self-injection, DISC findings also demonstrate some women’s ongoing concerns about using and storing DMPA-SC units, particularly in environments where women’s immediate family or social circles are not supportive of their contraceptive use. Covert users face perceived and actual physical and social risks should their use become known. Self-care programs like DISC can ensure our work remains consumer-centered and responsive by designing interventions to protect women’s confidentiality as they seek information, and obtain and store self-care commodities. Furthermore, by setting evidence agendas focused on understanding women’s full user experiences—including and beyond what it takes to support initial use—we can gain further insight into what is needed to help women take more control over their SRH and their lives.
There is no ‘silver bullet’ for catalyzing the market for self-care (including contraceptives). DISC findings demonstrate that SRH interventions must seek to understand and respect the diversity of consumers’ needs, wants and life experiences, avoiding a one-size-fits all approach. DISC’s insights have proven foundational for design and initial implementation of a cutting-edge suite of client-centered demand generation and discrete supply-side innovations. It is our hope that they will also prove useful to our global partners.
[1] With thanks to Sue Newport Consulting, Maternal & Infant Health Consulting, and Busara
[2] For more information, see: www.justassociates.org/en/power
