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.

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 contraception, empathetic counseling and coaching may be promising approaches for addressing "fear of the needle" among clients interested in using subcutaneous depot medroxyprogesterone (DMPA-SC). In Nigeria, the Delivering Innovation in Self-Care (DISC) project developed and evaluated an empathy-based in-service training and supportive supervision intervention for public sector family (FP) planning providers implemented in conjunction with community-based mobilization.

Methods: The DISC intervention was evaluated using a quasi-experimental mixed methods design. Effectiveness of the intervention on DMPA-SC service delivery, including self-injection (SI) and provider administration, was assessed using a single-group interrupted time series design that leveraged phased implementation in 36 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-training maintenance period. Outcomes were modeled using linear generalized estimating equations. In-depth interviews were conducted with trained providers to assess acceptability and perceived changes in SI attitudes and behaviors.

Results: Mean DMPA-SC service provision increased by 28.1 visits on average per facility in the first month of implementation, relative to a pre-intervention data strengthening phase (95% confidence interval [CI] 18.0-38.3). The intervention was associated with an increase in mean facility-level SI service delivery of 25.9 visits (95% CI 16.3-35.4). The intervention was associated with overall increases in FP service delivery. Increases in DMPA-SC service provision were sustained in the post-training maintenance period. In qualitative interviews, trained providers reported increased client demand for SI, coupled with increased provider confidence 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 decreases in DMPA-IM or long-acting reversible contraception provision in the quantitative data.

Discussion: Our findings demonstrate the effectiveness and acceptability of a program combining supply- and demand-side interventions aimed at expanding awareness and access to self-injectable contraception in Nigeria. In this context, providers highly valued in-service training and ongoing support that built capacity for empathetic client engagement.