Overcoming Client Fear to Self-Inject: Consumer Insights Light a Path toward DMPA-SC Scale-Up

Self-care presents an opportunity to strengthen overstretched health systems by offering delivery efficiencies while placing people at the center of its design. Countries around the world are recognizing this potential, many of whom are adopting and adapting the World Health Organization’s Consolidated Guideline on Self Care Interventions for Health, which provides clear recommended self-care approaches worthy of integration in national/subnational health systems. This shift to integrate self-care more formally within health systems requires a new set of behaviors. Not just for the consumer (or ‘self-carer’) but for the entire health ecosystem around them, including, perhaps most importantly, the healthcare provider. But critical questions remain: 

• What might behavior change for an ecosystem of healthcare actors look like in practice? 
• What is the role of the healthcare provider in self-care? 
• How might consumer insights light a path toward defining those behavior change efforts? 

The Population Services International-led Delivering Innovation in Self-Care (DISC) program—being implemented in Nigeria and Uganda—aims to answer these questions as they relate to self-injectable contraception, DMPA-SC. And, in doing so, demonstrate that self-care offers health systems a new and critical partner: consumers themselves.  

In 2020-2021, DISC conducted extensive programmatic research, including interviews with ‘early adopters’ of DMPA-SC, prospective users, and the public and private sector providers on whom women rely (distilled in this Insight Synthesis Report). In collaboration with the PATH-led Access Collaborative initiative and the Ministries of Health in Nigeria and Uganda, we honed in on the insight that fear of the needle and/or pain was a major barrier at the decision stage to self-inject. Yet, most providers aren’t trained to address this fear. This presented a behavior change opportunity worth testing: what if providers were equipped to directly address client fear to self-inject? Would more women voluntarily choose to self-inject? 

In response, DISC launched the ‘Moment of Truth’ Innovation in 20 public and private outlets–designated as “Innovation Sites,” –throughout Nigeria and Uganda to test this question and to incubate and test new training approaches. Our work in the innovation sites is focused on optimizing the training curriculum for self-inject providers by improving providers’ confidence in counseling women to take up self-injectable contraceptives and helping them to address client fears related to taking up self-inject. Innovation Sites were launched in September 2021 and qualitative and quantitative data were captured over a six-week period. The emerging results are promising. While qualitative findings need to be explored to fully understand the drivers of performance, voluntary uptake conversion rates dramatically increased following exposure to the ‘Moment of Truth’ Innovation approach. In fact, Innovation Sites in both countries quickly outperformed global benchmarks for self-injection conversion rates in both public and private sectors (see figure).  

DISC is currently in the process of analyzing the results to optimize provider training and associated activities. We’re also working with partners to identify pathways to scale up in Nigeria and Uganda—either through other partners or by incorporating the training into national curricula.  

This small-scale innovation illustrates the potential for consumer insights to better inform behavior change of a health ecosystem and, in doing so, support the evolution of health systems to be more responsive and resilient. 

During its ongoing update of the National Family Planning Curriculum, the Uganda Ministry of Health is incorporating a module on addressing client fear. In Nigeria, the Ministry of Health is excited about this approach and sees it as something that may inform policy change. If the results are as promising as they appear to be during our initial stages of analysis, this relatively simple adjustment to provider curriculum could help encourage providers to offer self-injection. It could also increase the potential for women to experience her own power and agency over her sexual and reproductive health care needs, a unique advantage of this self-care method. Equally important, this small-scale innovation illustrates the potential for consumer insights to better inform behavior change of a health ecosystem and, in doing so, support the evolution of health systems to be more responsive and resilient, with consumers at their core.