This episode will dig deeper into one of the themes that came up throughout the season and is also relevant to menstrual health: self-care.
www.knowledgesuccess.org/inside-the-fp-story
From Knowledge SUCCESS and FHI 360, this is Season 6 of Inside the FP Story—a podcast developed with the family planning workforce, for the family planning workforce.
Each season, we hear directly from implementers and decision makers from around the world on issues that matter to our programs and services. Through these honest conversations, we learn how we can improve our family planning programs as we work together to build a better future for all.
I am Sarah Harlan, Partnerships Team Lead with the Knowledge SUCCESS project. I am pleased to introduce our narrator, Charlene Mangweni-Furusa.
Narrator Welcome to Season 6 of Inside the FP Story. This season, we are moving beyond a narrow definition of “family planning” to explore the larger context of sexual and reproductive health (SRH). Being able to understand the holistic framework and the range of concerns that affect FP clients—including but not limited to contraception—can help ensure access to higher quality services for all who need them. Last episode, we provided a look at contraceptive-induced menstrual changes. This episode will dig deeper into one of the themes that came up throughout the season and is also relevant to menstrual health: self-care.
Narrator What do you think of when you hear the term “self-care”? [Pause] Exercising? Taking quiet time for yourself? What about using a condom? Using an at-home pregnancy or HIV test? Tracking your menstrual cycle? Texting a question about sexually transmitted infections to a chatbot? These last four examples are considered SRH self-care, which has been around for a long time, but in recent years it has gained traction and momentum. In 2019, the World Health Organization released its first guidance on self-care, and defined the term as, “the ability for individuals, families and communities to promote, maintain health, prevent disease and cope with illness with or without the support of a healthcare provider.”
SRH self-care includes accessing or receiving information from the internet, community- or facility-based healthcare providers, which increases people’s knowledge about their own health and where they can access services. Many SRH commodities can be safely and effectively self-administered without a healthcare provider or physical exam such as condoms, HIV self-tests, pregnancy tests, fertility-awareness-based methods, and emergency or oral contraceptive pills. Clients can initiate and continue using these methods with or without the support of a healthcare provider. Other methods such as self-administered contraceptive injections require a healthcare provider to train clients and provide units of the injectable which clients can take home and use themselves. Multi-month distribution of contraceptive pills or antiretroviral HIV medication by providers or a decentralized system such as community sites or depots are also forms of SRH self-care.
Narrator Self-care can improve the experience of clients who want more autonomy, privacy, and convenience in managing their sexual and reproductive health. It can save clients time and money visiting healthcare providers and also increase continuation rates. For example, a randomized controlled trial in Malawi, led by FHI 360 in collaboration with the Malawi Ministry of Health, found that compared to women who received contraceptive injections from a provider, women who self-injected were significantly more likely to continue using the method. Clients who use self-care methods should have access to follow-up care and should not be discouraged from seeking services from a facility or community-based provider if they prefer those options.
Increasing the use of self-care can also reduce the burden on the health system by lowering the number and frequency of clients visiting facilities or community-based health workers. However, despite many benefits of self-care, it is not a replacement for high-quality, well-functioning health systems.
Narrator The Self-Care Trailblazer Group (SCTG) is a global coalition that aims to advance evidence-based SRH self-care policies and programs. They recently launched the first ever State of Self-Care Report, which shares emerging evidence about SRH self-care, lessons learned, and recommendations. Let’s hear from our first guest, Aissatou Thioye, who works for FHI 360 on the Knowledge SUCCESS project and serves on the Self-Care Trailblazer Group steering committee on behalf of FHI 360. She is based in Senegal.
Aissatou Thioye Self-care gives individuals autonomy over their sexual and reproductive health. It is an opportunity to acquire and use the knowledge necessary for a better understanding of sexuality and reproductive health more generally. Self-care is the way to give people the choice to understand and make appropriate choices about reproductive health services without taboos…help people understand their own body is important because, for example, when they know their menstrual health or when they know what is the good moment to be pregnant, what is the need that their body have?
Narrator Now let’s hear from Amanda Joan Gillian Mary Banura, who was also in the first and second episodes of this season. She is the Founder and Executive Director of the Uganda Youth Alliance for Family Planning and Adolescent Health.
Amanda Banura So the role of self-care in SRH, it's an opportunity for increasing accessibility and increasing proper usage of commodities in SRH. Self-care speaks to many other things like mental health, you know, someone gets a relief of being able to have that commodity they really need to prevent many things: Unwanted pregnancy and still enjoying the privileges of life and still having sex[ual] pleasure. So the role of self-care in SRH speaks to accessibility, speaks to demand, speaks to increased commodity distribution.
Narrator We just heard about some of the benefits of self-care in terms of better understanding one’s body and health and increasing accessibility and use of SRH services and commodities.
Narrator One challenge our guests talked about was the term “self-care” and how people and healthcare providers feel about it. Here is Innocent Grant, who was in the first and second episodes of this season. He is the Program Director of the Young and Alive Initiative, a youth-led organization based in Tanzania.
Innocent Grant When you speak in an angle of self-love and taking care of your own body, when you [are] speaking that way, speaking about the issues of privacy and comfortability and being at your own place, and being happy about taking care of yourself, it works. I think the challenge is how do we frame our language into introducing self-care? I think we should always when engaging with the community or when engaging with actors possibly avoid like a lot of medical information. But it should frame it in a way of self, love and self-care and taking care of your own body.
I think that could bring some really good changes in the field of self care and innovation for instance the use of self injectables and even the digital interventions that we are now designing you know access to information.
Narrator Innocent discussed the importance of not over-medicalizing the concept of self-care, but rather emphasizing the importance of taking good care of one’s body and bodily autonomy and agency. At the same time, it is important to recognize the role that healthcare providers can play in self-care. Aissatou also shared how we do not want people or healthcare providers to think that self-care means that people don’t need providers:
Aissatou Thioye It is necessary for programs and for people who are promoting self-care to be sure at the beginning that people and also health workers have a good understanding of self-care to ensure that the relationship between communities and health workers remains strong and stays strong. So not that they don't need a health worker. It is an important confusion that we need to clarify when we are promoting self-care.
Narrator She went on to describe how community health workers may be especially well-placed to support people to use self-care methods:
Aissatou Thioye It is more easy for people to work with community based health workers, to access information related to their health, to access services related to health in general. I think that it is a good opportunity for us to promote at the community level because it is more easy for people to get information, to get training from their peers.
Narrator Similar to what these guests shared, the Research for Scalable Solutions—or R4S project—which is led by FHI 360, conducted a study to find out how women understood self-care in the context of family planning and to explore their behaviors and preferences. The study—which took place in Nepal, Niger, and Uganda—found that women may not necessarily understand the term “self-care” as it is defined by the WHO. When asked to elaborate, they said it's about taking care of yourself and family broadly, and when asked about it in the context of family planning, they said it’s about spacing pregnancies.
Earlier, Aissatou explained the important role community health workers can play in assisting people with self-care. The R4S study also found that women want and prefer some contact with the health system, whether facility or community-based, for reasons of quality and help in managing side effects from certain contraceptive methods. In fact, task shifting provision of family planning from facility-based providers to community health workers is part of self-care as it brings methods closer to the people who need them and allows them to engage in self-care practices including self-injection, menstrual health practices, fertility awareness knowledge and body literacy, among others, but still with the support of qualified health providers when desired.
Narrator Self-care may be particularly useful for certain groups or in certain settings. For example, as we’ve heard throughout this season, young people face many obstacles to accessing SRH information and care due to social norms, policies, and providers being unwilling to or thinking they should not provide services to adolescents. Young people may want to use contraception without the knowledge of their parents or partners. So, when privacy and confidentiality are concerns, certain methods that do not require regular interaction with healthcare providers and more discreet methods, such as self-injection, may be especially desirable for them. Using digital health options is another form of self-care that may be especially appealing to youth as it is private and often free. This can include online access to information, trackers, reminders, booking systems or virtual provision of care. Yet, we must also remember that as more and more online options become available there is a growing need for quality assurance and metrics to measure effectiveness in achieving positive SRH outcomes and contributing to the general well-being of users.
Aissatou Thioye Knowing what you need and where you can find what you need without being in contact with health providers or anyone else is important for youth specifically.
Narrator Additionally, people who may be at high risk for acquiring HIV—for example, sex workers or men who have sex with men—may fear facing stigma and discrimination at a health center, but could use community depots to access HIV tests that they can use privately. People living with HIV may also fear being seen at the health center getting a refill of their antiretroviral medication. Through the USAID- and PEPFAR-supported LINKAGES project, FHI 360 developed a client-led online booking system software called the Online Reservation and Case Reservation and Case Management App (ORA). ORA is a simple website that allows people to confidentially search for and book appointments, including for SRH, in their area. It is now used in 35 countries, mainly through a project called EpiC, and also some other HIV programs led by others, including Ministries of Health. In many countries, ORA is used to allow clients to book virtual consultations and home delivered services that are more convenient and can avoid some aspects of in-person stigma and discrimination.
These types of self-care programs are important for youth and people at risk of HIV because they serve an urgent need. But it is important to note that this should all be happening while at the same time working to improve health care systems and combat stigma.
Narrator Self-care holds unrealized potential in fragile settings, where an estimated 450 million people live. There is emerging action around this, for example, the Inter-Agency Working Group (IAWG) on Reproductive Health in Crises recently put out a call to action to advance SRH self-care in fragile and humanitarian settings. Here is Male Herbert, who was in Episode 3 in season 4. He shared how the South Sudan MOMENTUM program uses self-care approaches specifically for family planning continuity of care.
Male Herbert Self-care in South Sudan is a very promising approach to ensure continuity of [voluntary] family planning services during shocks and stresses. The examples of self-care include the lactational amenorrhea method where we encourage breastfeeding mothers to exclusively breastfeed their babies in their first six months in order to avoid the return of their fertility. We also have the fertility awareness methods where a woman seeks information about the periods when she is likely to get pregnant and the periods that are safe for her to have unprotected sexual intercourse. We have oral pills, condoms—both the male and female—and then most importantly, we are working on Sayana press self-injection, where women [learn how to administer the self injections from health provider, then] obtain injections, go back home and they're able to administer these injections for family planning by herself, without the supervision of health providers.
Narrator A note that the Lactational Amenorrhea Method requires three conditions, all three of which must be met. First, the mother’s monthly bleeding cannot have returned; second, the baby must be fully or nearly fully breastfed, and must feed often; and third, the baby must be less than six months old.
Making a wide-range of contraceptive options available—including those that can be self-managed—has been essential in the context of South Sudan as well as other fragile settings.
Self-care also holds promise to enable people to use SRH methods during emergencies or health system disruptions such as the COVID-19 pandemic. For example, the most recent edition of the Family Planning Global Handbook for Providers, the most widely used reference guide on the topic globally, added recommendations such as wider access to self-administered contraceptives and the use of digital technologies by providers based on the experience of the COVID-19 pandemic.
Narrator Self-care is sure to be an interesting field to follow as the world strives to make progress towards universal health care and equity as part of the sustainable development goals.
This brings us to the end of an exciting season on SRH. We have heard from guests from around the world about intersecting influential dynamics of SRH, such as social norms around sex and gender, menstrual health, youth, FP and HIV integration. We hope this has inspired you to continue to work on promoting holistic, comprehensive, inclusive, evidence-based SRH programs and policies wherever you work.
Season 6 of Inside the FP Story is produced by Knowledge SUCCESS and FHI 360. This episode was written by Catherine Packer and edited and mixed by Elizabeth Tully. It was supported by an additional team, including Sarah Harlan, Emily Hoppes, and Brittany Goetsch. Thanks also to Holly Burke, Trinity Zan, Barbara Sow, and Benjamin Eveslage for reviewing this episode.
Special thanks to our guests Aissatou Thioye, Amanda Joan Gillian Mary Banura, Innocent Grant, and Male Herbert.
To download episodes, please subscribe to Inside the FP Story on Apple Podcasts or Spotify; and visit knowledgesuccess.org for additional links and materials.
The opinions in this podcast do not necessarily reflect the views of USAID or the United States Government.
If you have any questions or suggestions for future episodes, feel free to reach out to us at info@knowledgesuccess.org.
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