Acceptability and effectiveness of empathy-based provider training and community-level awareness activities on self-injectable contraceptive use in Niger, Lagos, and Oyo States, Nigeria: A mixed methods program evaluation

Abstract

Background: Interventions aimed to increase healthcare provider empathy and capacity to deliver person-centered care have been shown to improve healthcare seeking and outcomes. In the context of self-injectable contraceptive service delivery, empathetic counseling and hands-on coaching are promising approaches for addressing “fear of the needle” among clients interested in using subcutaneous depot medroxyprogesterone (DMPA-SC). In Nigeria, the Delivering Innovation for Self-Care (DISC) project developed and evaluated an empathy-based in-service training and supportive supervision intervention for public sector family planning providers, which was implemented in conjunction with community-based sensitization. Methods: The DISC intervention was evaluated using a quasi-experimental mixed methods design. Effectiveness of the intervention on DMPA-SC service delivery, including DMPA-SC self-injection (SI) and provider administration (PA), was assessed using a single-group interrupted time series design that leveraged phased implementation in 36 study facilities. Service delivery data were extracted from the Nigerian Health Information System for the pre-intervention period and using program monitoring tools for the intervention and post-intervention maintenance period. Outcomes were modeled using linear generalized estimating equations. In-depth interviews were conducted with trained providers. Results: Mean DMPA-SC service provision increased by 28 (95% confidence interval [CI] 18.0-38.3) visits on average per facility in the first month of implementation, relative to a pre-intervention data strengthening phase. The intervention was associated with an increase in mean facility-level DMPA-SC SI service delivery of 25.6 visits (95% CI 15.3-35.4). The intervention was associated with overall increases in FP service delivery. Trained providers reported substantial increases in client demand for DMPA-SC SI, coupled by increased provider feelings of confidence and capacity to counsel and train clients to self-inject. While providers indicated that stockouts of intramuscular DMPA (DMPA-IM) resulted in shifts towards DMPA-SC, we did not observe group-level decreases in DMPA-IM or long-acting reversible contraception provision. Increases in DMPA-SC service provision were sustained in the post-intervention maintenance period. Discussion: Our findings demonstrate the effectiveness and acceptability of project implementing combined supply-and demand-side interventions aimed at expanding awareness and access to self-injectable contraception in Nigeria. In this context, family planning providers highly valued in-service training and ongoing support that built capacity for empathetic client engagement.