By Michael Titus, Social and Behavioral Change Communication Coordinator, SFH-Nigeria; Dr. Oluwaseun Adeleke, Senior Learning Advisor, SFH-Nigeria; Dr. Anthony Nwala, Project Lead, SFH-Nigeria; Mopelola Raji, Deputy Team Lead, SFH-Nigeria; Fidelis Edet, Business Research and Data Analyst, SFH-Nigeria
Injectable contraceptive methods are highly popular in Nigeria. In fact, they represent the most popular category of modern methods used by married couples and 88% of married women are aware of them (NDHS, 2018). Despite being a highly effective and convenient option to help women avoid frequent trips to the clinic, awareness and use of self-injection (SI) are eclipsed by provider-administered injectables. Women can learn to self-inject and take home extra units, which only need to be used once every three months for as long as she wishes to avoid pregnancy. The unique advantages of SI have yet to be realized at scale given that clients are still heavily dependent on providers to administer.
Like other forms of self-care, the Ministry of Health and local governments enthusiastically support SI, given that its increased use can potentially improve the efficiency of an overstretched healthcare system by reducing provider workloads. The Delivering Innovation in Self Care (DISC) project supports women to take greater control over their own sexual and reproductive health needs by scaling up access to contraceptive self-care methods such as self-injectable DMPA-SC. Leveraging the expertise of Population Services International (PSI) and Society for Family Health (SFH) in innovative demand-creation methods, DISC is increasing SI uptake using one of our most impactful approaches, in-person interpersonal communication (IPC).The health-seeking behavior of women of reproductive age tends to be heavily influenced by their partners, friends, family, and peers in the community. However, these key ‘influencers’ can stand in the way of family planning (FP) uptake when they lack accurate information, or spread myths and misconceptions about less familiar methods like DMPA-SC.
DISC and our partners — including Marie Stopes International of Nigeria, the Resilient & Accelerated Scale-up of DMPA-SC/Self-injection in Nigeria project implemented by the Association for Reproductive and Family Health, and national and local governments — are harnessing IPC to reverse the trend of FP misinformation in Nigerian communities. Our IPC interventions, conducted by volunteer community mobilizers, have already succeeded in increasing self-injection awareness and sensitization, providing linkages to SI services, and creating demand.
How does this work? By using an adaptive implementation approach, we’ve refined our IPC strategy:
- Prior to any engagement, we map health facilities providing FP services and the communities within their catchment areas, as well as identify influencers and gatekeepers — including community, religious, political, and trade group leaders. We target these leaders with key health messages and attain their buy-in, which can ‘make or break’ our ability to work in their community. Given that community leaders are typically male, their enthusiastic support of women’s contraception can encourage otherwise hesitant men in the community to support their partners’ FP decisions. This can be a game-changer to women’s uptake and continuation of modern methods like self-inject.
- To make mobilization more convenient for participants and maximize our reach, DISC meets women ‘where they are’ by organizing community outreach ‘events’ at bustling locations where women frequently gather or work – such as health centers on clinic days, markets, village squares, and religious centers. Community mobilizers go door-to-door and engage women individually to increase participation. Mobilizers often find groups of women in business areas that cater more to women and engage them there. Men are engaged when they proactively reach out with questions about FP.
- At each event, participants receive a group health education session from a trained provider. These sessions are specifically designed to counter misinformation and educate partners, friends, neighbors, relatives, and other community members about FP. Topics include birth spacing, an overview of different available FP methods, including self-injection, with live Q&A built into the agenda. Following the group session, clients have the option to receive one-on-one FP counselling. Women who opt for DMPA-SC can receive information about self-injection from a health provider. In parallel, DISC trains providers on empathy-based approaches to overcoming common barriers to self-injection such as fear and lack of confidence.
- In-person community mobilization is only one of our many demand creation channels — we are also active on radio, TV, interactive voice response (IVR), and online platforms. During these events, community mobilizers promote DISC’s online presence and invite people to engage with our IVR, digital companion (chat bot), Facebook page, and DiscoverYourPower These platforms are useful for asking questions and learning more about self-injection, including nearby providers who offer SI services.
The three DISC pilot states — Niger, Lagos, and Oyo — now have the highest number of women who self-inject DMPA-SC in Nigeria (per National DHIS and Access Collaborative data) and demand is increasing daily. DISC program data from January-December 2022 show that approximately 79% of women of reproductive age who opted for DMPA-SC adopted self-injection. The one-on-one discussions and group health education with referrals to the health facility are particularly impactful, contributing to 60% of the SI visits recorded.
We also observed increased levels of male involvement in the context of our community outreach activities, which we’ve attributed to DISC’s engagement of men as change agents. Increasingly, we’ve seen male partners show interest in actively supporting their wives and women in the community to seek family planning and self-injection contraceptive services.
Given DISC’s continual emphasis on adaptive implementation, we routinely gather data and insights to understand what’s working and what isn’t. Through in-depth interviews with community mobilizers, we’ve learned that social behavior change can sometimes feel like an uphill battle and mobilizers’ success often hinges upon their patience, tolerance, and readiness to respond to a variety of questions. As one mobilizer put it, “the job is not an easy one as there are people who slam the door on our faces and others drive us away. There were times I was talking to a willing person when suddenly a third party showed up and disparaged all I have said”. Mobilizers recognize the importance of their work. They strive to reduce unnecessary suffering and ensure that girls don’t have to drop out of school because of an unplanned pregnancy.
At present, DISC is expanding into 12 additional states in Nigeria, where the IPC model will be replicated and integrated into existing government-led demand-generation strategies. Integration of self-injection into government programming is a high priority for the Ministry of Health and there is full alignment with DISC’s objectives. Governments are enthusiastic about scaling up self-care as a means of reducing the overburdening of the healthcare system, and they’re keen to see SI well represented in the method mix. By continuing to scale up and adapt our proven IPC model, we aspire to make self-injection the first injectable that people think of to fulfill their contraceptive needs.