Health care provider and client experiences of counselling on depot medroxyprogesterone acetate subcutaneous (DMPA-SC) for self-injection in Malawi

Since the introduction of depot medroxyprogesterone acetate (DMPA-SC) in 2018, Malawi has achieved national coverage of trained providers in the public sector and steady increases in uptake of DMPA-SC. However, the rate of clients opting to self-inject DMPA-SC has remained lower than early acceptability studies suggested. Providers play an instrumental role in building client confidence to self-inject through counselling. This cross-sectional qualitative study explored the perspectives of providers and injectable clients on the integration of self-injection into contraceptive counselling, to identify best practices and gaps. The study was conducted at public sector sites in three districts (Nkhotakota, Mzimba South, Zomba) in Malawi. In-depth interviews were conducted with provider-administered injectable clients, self-injecting clients, and DMPA-SC trained providers. All providers interviewed reported successfully integrating self-injection into their approach. During health education sessions, providers tended to focus mainly on benefits of self-injection to spark interest in the method, and then follow that up with more in-depth information in individual counselling. Due to time pressures, a minority of providers reported replacing individual counselling with small-group counselling and limited their use of peer testimonials, visualizations, and demonstrations. Most providers skipped client practice on inanimate objects, feeling this was either not necessary or not appropriate given stock or resource constraints. Current self-injecting clients showed the best recall for self-injection steps and tended to report having received comprehensive, supportive counselling including aspects such as peer testimonials, visualizations, and demonstrations to build confidence. Injectable clients who had declined self-injection tended to demonstrate less detailed recall of key self-injection messages and report receiving incomplete information, and lack of peer testimonials, visualization, or demonstrations. Comprehensive counselling and training from supportive providers, including best practices identified in this study, are vital to improving client confidence to self-inject. Providers should be supported to overcome time- and resource-pressures to invest in these best practices.