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Learning from the experts: first-hand perspectives on self-care in Uganda

November 1, 2019 by Jennifer Drake

A woman in Uganda learns how to self-administer injectable contraception with support from a community health worker. Photo: PATH/Will Boase.

A woman in Uganda learns how to self-administer injectable contraception with support from a community health worker. Photo: PATH/Will Boase.

Women in Uganda trying contraceptive self-injection for the first time share invaluable perspectives on practicing self-care for sexual and reproductive health.

At PATH, we have a decades-long history of expanding options for self-care in sexual and reproductive health. We owe that history, in no small part, to the expertise and first-hand experiences of women practicing self-care.

Women’s first-hand experiences have guided the development of women-controlled products like the Caya® diaphragm and Woman’s Condom. They’ve informed pioneering research and practice on contraceptive self-injection and self-sampling for cervical cancer screening. Their experiences have also helped to set the agenda on the role of self-care in health systems, and to develop WHO’s new self-care guidance.

In Uganda, PATH recently interviewed women about their preferences for learning to self-inject contraception. We took the opportunity to ask women if they had experience with other forms of self-care, and what self-care means to them. Here’s what we learned.

“After I had reinjected, I went about my work. Not like walking from the facility—you get the injection and then walk a long distance. It is difficult, the journey to walk every three months.”
— Contraceptive self-injection client in Uganda

Women are already engaging in a wide range of self-care practices.

When asked about self-care practices, many women said they already had experience with sanitation and hygiene, nutrition and immunization for their children, and HIV self-testing and managing antiretroviral medications for themselves or someone in their lives. This experience lays a strong foundation for the self-care innovation of contraceptive self-injection. PATH and partners have been working for more than five years to expand access to contraceptive self-injection for women in the countries where we work, including Uganda.

We have engaged with clients throughout that process, soliciting their input on the design of Uganda’s self-injection program through human-centered design activities, gathering perspectives through mixed-methods research, and sharing program findings through community meetings in each program district. Our engagement has yielded rich insights on self-injection that are being directly integrated in the formulation of Uganda’s national guidelines. Women’s perspectives on self-care also inform PATH’s global advocacy on the topic.

Women appreciate the convenience of self-care practices like contraceptive self-injection.

Among the women we interviewed, convenience was the number one reason cited for learning to self-inject contraception. As one young woman in Uganda told us, “After I had reinjected, I went about my work. Not like walking from the facility—you get the injection and then walk a long distance. It is difficult, the journey to walk every three months.”

An issue directly related to convenience is the number of units women receive to take home after they first successfully self-inject contraception. Initially, the Uganda Ministry of Health preferred to give women up to two units to take home, because they were concerned that women would give away or not use units. In reality, during follow-up interviews, most clients reported they had injected all of their units—meaning very few were wasted. We also learned that most clients would prefer to take three units home with them instead. When combined with their first self-injection with the health worker, this amount gives them a full year of contraceptive protection.

There is still a role for the health system in self-care.

Self-care does not mean letting the health system off the hook—WHO’s new self-care guidelines take both a “people-centered” and “health systems” approach. The guidelines also emphasize equity in self-care—ensuring all people, including the most vulnerable, have access to support from health workers, high-quality informational materials, and reliable access to supplies in both public and private sector outlets. One married woman in her twenties told us: “Before I inject myself, I bring my calendar and job aid so if I am [starting] to forget a step, I just check on the sheet and it guides me.” Another woman in her thirties highlighted the importance of community health workers: “Whether you went to school or not you can still do all those things… Be close to your Village Health Team worker and listen to what she is training you with.”

Every woman’s self-care journey is different.

Some women will adopt self-care innovations right away. As one Ugandan woman in her twenties described it, “I was able to inject myself… one gets confident after being trained on how to self-inject. I have the love for it.”

Others need more time to consider, to make the decision, and to learn. Another young woman described her journey: “I learned about it and was afraid at first, contemplating if I will be able to do it. I told myself in case I get another training I will be able to do it. After another trip to another safe space [site for adolescent health services], I gained that. When I returned to the center to be trained again, I had courage and with practice…my courage was built the more.” This diversity is at the heart of self-care, a core component of people-centered primary health care.

A woman in Uganda holds subcutaneous DMPA (DMPA-SC, brand name Sayana® Press) for self-injection of contraception. PATH/Will Boase

A woman in Uganda holds subcutaneous DMPA (DMPA-SC, brand name Sayana® Press) for self-injection of contraception. Photo: PATH/Will Boase

What’s next for contraceptive self-injection in Uganda?

PATH is working with the Uganda Ministry of Health and other partners to ensure that these critical perspectives drive the design and rollout of the country’s new self-injection program. For example, we are emphasizing access to self-injection informational materials as a priority, and sharing experiences with other countries who are developing their own programs. We are using the data on preferences and behavior to inform discussions with policymakers and program managers in Uganda and elsewhere. As a result, we are already seeing perspectives change on key issues, like increasing the number of units women are given to take home. We have developed a self-injection program design guide that highlights the importance of offering contraceptive self-injection in the context of informed choice—recognizing some women will want to self-inject as soon as they hear about the practice, while others will prefer to use other contraceptive options.

Keeping people at the center of our work—and providing more product options that meet their needs—will ensure that the global self-care movement delivers on its promise of a healthier, more equitable world.