From the outset, the World Health Organization’s (WHO) consolidated guidance on self-care acknowledges “[t]he principle of autonomy, expressed through free, full and informed decision-making” as particularly relevant in the context of self-care for sexual and reproductive health (SRH). In a similar vein, the theme of agency—as well as power and voice—emerged strongly in Delivering Innovation in Self-Care’s (DISC) insight research with women as a key factor in their contraceptive use experiences. Yet, how we define and measure concepts like autonomy, agency, or empowerment is hard to pin down. Specific to empowerment, Demographic and Health Surveys (DHS) and the United Nations rely on composites, made up of assessments of economic autonomy, attitudes towards domestic and gender-based violence, and an individual’s role in household decision-making, amongst others. There’s no one universally accepted way to measure this construct. And that’s appropriate. Experiences of power are highly subjective, varying from person to person and across contexts.
So, what does empowerment mean in the context of self-care? And how should we measure and understand it?
One common survey question used in some of the existing and validated reproductive empowerment metrics asks women to identify who is responsible for making decisions about contraception. There is an implied logic, in how responses are scored, that a woman whose independent decision-making power is upheld by others in her life is a woman with optimal empowerment. Whereas those with less power make decisions with others, and women with the least power have decisions made for them by others. But what if a woman can act on her own agency to self-inject even when she lacks support from others? Is she experiencing power or empowerment then? If yes, is that sufficiently transformative? There are legitimate arguments to be made on both sides of this. And while we’re at it, if a woman wants shared decision-making with her partner and she can achieve that, is that not power? There’s lots to unpack here…
In the context of self-care, understanding how power operates and how women experience their power is important—and somewhat new territory from an evidence standpoint. Thankfully, we do have some guardrails to help us navigate this new road. There has been an immense amount of research on how to measure empowerment in differing contexts and domains. This research has shown us that participatory approaches to measuring empowerment are important.
DISC strives to heed this good advice, and not select our empowerment metrics ‘off the shelf’ without first understanding what power looks like to the women we aim to serve. So, in June 2021, we launched a series of participatory workshops in the two countries where DISC is implementing. The workshops’ participatory methods have created space for Nigerian and Ugandan women in DISC’s key segments—urban youth, urban young mothers, and urban adult moms to explore their own understandings and experiences of ‘power’ and ‘empowerment’ in their lives. This encompasses SRH, contraceptive use, self-care, and beyond. Our goal is to see power as these women see it, so that we can select the most relevant validated metrics to measure empowerment in the context of our self-care focus and meaningfully interpret our findings.
Getting this right matters for more reasons than just DISC’s own concern with ensuring we have useful program data. In truth, it matters for our sector. And it matters for women. Going back to the WHO’s guidance, there is a clear responsibility we take to heart: “Where self-care is not a positive choice but is prompted by fear or lack of alternatives, it can increase vulnerabilities.”
If we recognize that technological innovations in self-care have great potential to change the face of SRH, then as an evidence community we have an even greater need to proceed responsibly. In the context of DISC, we can’t know whether the change self-inject brings will be for better or for worse, unless we take care to generate the evidence that will help us see (and understand) the full picture of women’s experiences.
The participatory process we’ve undertaken to select and interpret empowerment metrics is our first step towards this broader goal. For the steps on this path to follow, we’re looking forward to continuing to learn with our incredible community of self-care technical peers about the promises (and perils) of self-care interventions.