by Pierre Moon, PSI
For millennia, people have taken measures to care for themselves—prevent disease, promote health and cope with illness and disability—without a healthcare provider. While self-care is an old concept, new approaches have expanded the reach of self-care to health areas ranging from mental health to treatments for chronic diseases. However, it is in the sphere of sexual and reproductive health and rights (SRHR) where stigma abounds and privacy is so critical, that self-care can be especially transformative.
The forces driving self-care are shaped by challenges, but also opportunities.
Just last year, there were 135 million people in need of humanitarian assistance who had little or no access to the healthcare they needed. And in 2035, there will be an estimated shortage of 12.9 million healthcare workers. Meanwhile, low- and middle-income countries are home to 87 percent of the world’s youth. These young people are an opportunity for the world; the challenge is that they urgently need affordable, accessible, quality healthcare, but they live in contexts where their SRHR needs are often a low priority for the formal health system.
The World Health Organization (WHO) has recently announced “triple billion” targets: ensuring one billion more people benefit from universal health coverage (UHC); one billion more people are better protected from health emergencies; and one billion more people enjoy better health and well-being.
The need for self-care is not only borne from these global health challenges and ambitious goals; there are positive forces and opportunities that are shaping the evolution of self-care.
The 2018 “Lancet Global Health Commission on High Quality Health Services in the SDG Era” highlighted among its recommendations that services must be provided in a respectful people-centered manner: “To greatly improve healthcare, people-centered and patient-driven approaches that shift the power from the healthcare system and providers to the patients are needed.” Put simply, as a critical frontier in people-centred care, self-care is vital to the future of quality healthcare.
Meanwhile, as digital technologies evolve to inform growing numbers of consumers about healthcare, and as incomes rise in many low- and middle-income countries, so greater numbers of people demand better healthcare. Health consumers are increasingly aware of their rights and asking to receive quality, affordable healthcare.
As consumer expectations have evolved over the past decade, they have influenced the rapid development of four dimensions of healthcare that have brought self-care to the forefront. Examples of these four dimensions are highlighted below.
Drugs – Emergency Contraceptive Pill
Emergency contraceptive pills (ECPs) are not new, but important new variations of this drug and new insights into how women use ECPs bring new understandings of how it can be safely used.
Many pregnancies are mistimed or unplanned, even in settings where highly effective contraception is available, putting women and girls at risk. ECPs are the only contraceptive method that can prevent a pregnancy after intercourse. Despite its unique role, ECPs too often remain underutilized, stigmatized and, in many places, inaccessible.
Women choose ECPs, or “on demand” contraception as their primary contraceptive method for a variety of reasons—from having sporadic intercourse to the desire not to use a daily method with hormones. WHO’s criteria specifies that the method can be used in any circumstance. Many studies have shown that some women prefer to use ECPs multiple times within a cycle, preferring this option over other methods.
In African markets and in the US, the most commonly and cheaply available ECP product is made of 1.5 milligrams (mg) of the hormone levonorgestrel, which protects sperm from fertilizing an egg for 24 hours after intercourse. After 24 hours, its efficiency decreases—a critical factor given that sperm can potentially fertilize an egg up to five days after intercourse.
However, the newest generation of ECPs contains 30 milligrams of the selective progesterone receptor modulator ulipristal acetate (UPA), which remains effective for five days after intercourse. Despite its role as a more effective ECP product, the UPA ECP regimen remains unaffordable for the majority of low-income users, as the product is still on patent and sold at a prohibitively high price.
Diagnostics– Human Papilloma Virus (HPV) DNA Self-Sampling
Each year, 500,000 women are diagnosed with cervical cancer; more than half of these cases are fatal. Ninety percent now occur in low resource contexts, where cervical cancer is a much greater burden because most cases are detected at a very late stage, when treatment is no longer possible. Screening programs that detect treatable, precancerous cervical lesions are often inaccessible due to cost, equipment and provider shortages and lack of knowledge about these services.
Several strains of HPV are known to cause cervical cancer. Over the past decade, the evidence has expanded dramatically for use of HPV molecular testing. One of the widely recognized benefits of HPV testing is that it can be performed using self-collected vaginal swabs. The primary benefit of this approach is that the majority of women screened do not have to undergo a pelvic examination as part of the initial screening process. HPV self-sampling offers flexibility for how and where women collect their samples, offering new avenues for expansion of cervical screening coverage. Acceptability of HPV self-sampling among women is high, coupled with the potential to facilitate greater levels of screening, treatment and health impact in all settings.
Despite HPV self-sampling advantages, one size does not fit all. Not all women are comfortable with a self-sampling approach. Common concerns include physical discomfort or worry that they will not perform the sampling correctly. Others prefer a clinic setting because they can receive immediate treatment there, if required. PSI is piloting multiple service delivery models to identify the most efficient and impactful ways to offer HPV testing and self-sampling to provide women with a range of options that suit their specific needs, preferences and circumstances.
Devices – Subcutaneous DMPA (DMPA-SC)
The FP2020 goal is that 120 million more women and adolescent girls will use contraception by 2020. DMPA-SC, also known by its brand name Sayana® Press, is an injectable contraceptive that can dramatically expand access and choice for women. DMPA-SC has been available for over two decades; it is the challenges and opportunities of the goals set in the past decade that have led to renewed interest in the scale up of this device.
As opposed to the more complex intramuscular (IM) injection, such as Depo-Provera-IM, DMPA-SC requires a simpler injection just beneath skin. It is uniquely suited for self-injection or delivery by community-based distribution agents, pharmacists or drug shop workers.
Evidence indicates that DMPA-SC can reach new users of contraception, including young women and adolescent girls, and has the potential to promote continued contraceptive use. Launched in 2017, the DMPA-SC Access Collaborative, led by PATH and John Snow, Inc. in partnership with a broad group of stakeholders, is a three-year initiative working in up to 12 countries to increase use of DMPA-SC. There are already millions of girls and women using DMPA-SC and 25 countries have approved DMPA-SC for self-injection.
New technology in telemedicine, mobile phones, wearables and tablets are creating opportunities for consumers to take a more active role in their health and well-being. This is particularly true when it comes to sexual and reproductive health.
Digital health, the convergence of information and communication technologies for health information and services, is enabling the optimization and personalization of health information and resources. Sometimes digital health tools are the intervention, as with fertility monitoring apps. Alternatively, digital health tools can sometimes support an intervention, such as tablets and apps that convey information via videos.
This year—2019—marks a significant milestone for WHO with the anticipated release of normative guidelines addressing both digital health and self-care. Examining the evidence base for digital health, and providing recommendations for future research and practice, the guidelines highlight ways digital health can support self-care and increase self-efficacy and self-confidence in healthcare. And yet these guidelines provide a timely reminder that digital health interventions are not enough on their own, but rather should add value to the health system and to the individuals using these technologies.
Learn more about self-care at “Transforming Health Care through Self Care: Agency and Power in Sexual and Reproductive Health” a Women Deliver side event, on Wednesday, June 5 from 6:30-8:00 a.m. in VCC West, Room 211.
To find out about the growing evidence for self-care, join PATH’s Martha Brady and PSI Malawi’s Chiwawa Nkhoma at the “Self-Care: The Next Frontier in Women’s Health” concurrent session on Wednesday, June 5 at 3:00pm in VCC West, Room 217-219.
This article appears in PSI’s Impact magazine, released in tandem with Women Deliver 2019, as part of an ongoing conversation about putting #PowerInHerHands.
Banner Image: © PASMO/Victor Grigas