Highlights: Insights Synthesis - Insights Gained Through Evidence-Based Design

"...aim to normalize the concept of self-care in SRH [sexual and reproductive health], tapping the potential of women's power with each other to bring about change to the status quo of SRH care."

Much of the previous research on self-injection (SI) of depot medroxyprogesterone acetate (DMPA-SC) contraception focuses on how best to integrate SI into health services, as well the feasibility and safety of the product. To address a perceived gap in evidence on women's experiences, desires, preferences, and needs related to SI, Delivering Innovation in Self-Care (DISC) undertook research to understand the decision-making process of individual women. This resource provides an overview of key findings from the DISC project's work to understand the self-inject landscape in Nigeria and Uganda; adopts a user-journey approach to distill factors influencing women's movement from awareness of SI to intent, use, continuation, and advocacy; and focuses on women's experiences and needs, as well as those of the public and private sector actors on whom they rely.

DISC, a five-year project funded by the Children's Investment Fund Foundation, undertook quantitative, qualitative, and design-based research with a user-centred approach. With a focus on early adopters of SI, DISC aims to gain insight into the perspectives of women in consumer segments likely to adopt SI in the future - namely: urban young women ages 18-24, urban young mothers ("mums") ages 18-24, and urban adult mums ages 25-34. Insight-gathering methods included consumer research interviews and in-depth discussion with 72 consumers and potential consumers of SI in Uganda and Nigeria; creative agency consumer-led insights; consumer insights from design workshops held in both Uganda and Nigeria; interviews with public and private sector providers; provider insights (from design workshops and preliminary trainings); and male influencer insights.

The consumer-focused findings shed light on women's conceptualisations of power, their perceptions of the pros and cons of SI, and the important roles of influencers (e.g., male partners, other women "like me", and parents) vis-à-vis social norms and associated stigma. On the provider side, findings illuminate perspectives of public and private sector service providers who act as both facilitators and potential barriers to the use of SI, depending on levels of training as well as motivation and incentive structures.

DISC analysed SI user perspectives at five different stages:

1. Awareness: the point at which the potential user becomes aware of SI and wishes to learn more through credible, trustworthy channels of information. Sample finding: There needs to be a focus on clear and informative messaging via multiple channels to enable women's autonomous decision-making as to whether and how best to move forward with SI. Both digital and in-person pathways hold promise for increased accessibility and relevance of SR) services and products.
2. Decision and intent: the point at which the potential user has received enough information and support to confidently decide on whether or not to use SI. Sample finding: Healthcare workers (HCWs) influence women's decisions in relation to contraception; biases and misunderstandings on the part of either providers or clients can preclude women from making fully informed decisions about contraception and SI.
3. Training and initiation: the point at which the user is provided with training and supplies and carries out an initial SI or uses DMPA-SC with the support of a partner. Sample finding: Women who enjoy greater freedoms - particularly mums - express interest in forms of group-based learning about SI. Some urban youth desired this learning to be online and fully anonymous, with any personal interaction left up to the user.
4. Continuation: the point at which the user has everything she needs to self-inject at home, including knowledge, skills and confidence, supplies, reminders, and access to ongoing support through trusted and accessible channels. Sample finding: Lack of supportive key influencers, stigma, supply chain issues, and dislike of side effects can result in discontinuation. Users value support to continue use, and many women continue to require full confidentiality (visible, auditory, or otherwise).
5. Advocacy: the point at which the user's experience has been so positive, in terms of both the product and the health system's support, that she becomes an "advocate" for SI - either among other women, and/or by calling for health system strengthening and policy change. Sample finding: Women's existing voice and agency to demand accountability from health system actors to support SRH self-care cannot be assumed. Women client advocates can play a role in improving quality of care through their demands and actions.

Intersecting each stage are seven themes that influence client and provider behaviours:

• Power: While women believe in their own decision-making power over their lives and SRH, their partners and community may not. At the decision and initiation stages, many women (primarily mothers) may wish to include their male partners in decision-making to use SI. Some, however, require outside resources and support to help them use their power to clandestinely access needed information, training, and commodities.
• Trust and credibility: Apart from HCWs, women most want to learn about sensitive SRH information from other credible women - those they deem to be "like me". Digital health and outreach interventions can be used to ensure that accurate information about SI and other self-care innovations reach women through the channels and profiles women deem reliable.
• Relevance: Particularly in the case of (often young, unmarried) women who have never been pregnant, or women who have infrequent sex, contraceptives are not perceived as valuable. To support young women to reach the first stage (awareness), messages should connect contraception and SI to their aspirations for their lives. Showing how specific contraceptive methods are tools that may help them achieve their life goals is important to incorporate into SI programmes aiming to reach all women.
• Convenience: The ways women defined "convenience" varied considerably, in large part based on the importance they placed on discretion. For some, then, "convenience" was any approach that might ensure total anonymity in their SRH care seeking behaviours, even if they had to travel to facilities far from home. SI-focused programmes should aim to safely deliver on the promise of convenience for all profiles of women: those who enjoy the support of family and community, as well as those who do not and thus value confidentiality most of all.
• Collectivism: Despite women's continuing desire for anonymity in their SRH decision-making, many DISC respondents feel a calling to support other women in finding ways to gain more control over their SRH. DISC findings suggest that programmes must offer multiple channels for women to collectivise by reaching out to others (e.g., via anonymous chat or WhatsApp forums) to offer information and support in ways that conceal identifying information about themselves.
• Voice and agency: Marketing campaign efforts are thus most likely to succeed at the awareness and decision stages by directly addressing women's agency. However, due to stigmatisation and a desire for privacy, self-care movement-building efforts thus may require concerted efforts to build spaces and forums in which women feel safe to advocate for self-care in the public sphere.
• Safety: Covert users face perceived and actual physical and social risks should their use become known. Self-care programmes like DISC can ensure their work is consumer-centred and responsive by designing interventions to protect women's confidentiality as they seek information and obtain and store self-care commodities.

These findings demonstrate key factors informing women's decision-making related to the user journey from women's awareness through to use, continuation, and advocacy for self-inject. The report highlights design and implementation opportunities, as well as potential areas for pause and/or further investigation, insights that the DISC project hopes will prove useful to the global community working toward advancement of self-inject as a cornerstone of SRH care.

Editor's note: A comprehensive, long-form version of the Insight Synthesis Report is available upon request Please email disc.info@psi.org