A longitudinal study examining how self-injection social norms are associated with contraceptive self-injectable interest and use in rural Uganda

Abstract

Background: There is mounting evidence that social norms affect attitudes, decision-making, and behaviors related to contraceptive use. Integral to the self-care movement for women to have more control over their reproductive health, subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is a contraceptive that can be safely administered by women themselves after training. DMPA-SC was introduced in Uganda in 2017 and is slowly gaining traction, especially among women who value a convenient and private method. However, only a small percentage of DMPA-SC users choose to self-inject, perhaps missing women who could benefit from its convenience and privacy. To date, no studies have tested if and how social norms are associated with interest and use of DMPA-SC self-injection.

Methods: We analyzed two waves of data from rural Uganda collected as part of the Innovations for Choice and Autonomy (ICAN) cohort study (n = 2,170 women of reproductive age who were not using self-injectable contraception at baseline). First, we used exploratory factor analysis to create a self-injection social norms scale. Next, we used unadjusted logistic regression models to examine the association between self-injection social norms scale scores at baseline and the two outcomes (interest in self-injection at baseline and self-injection use at six-month follow-up). Finally, we used multivariable logistic regression to examine the same associations controlling for confounding by sociodemographic characteristics.

Results: Factor analysis showed a four item, one factor solution for the Self-injection Social Norms Scale (alpha = .78). After adjusting for confounding variables, Self-injection Social Norms Scale scores were associated with an increased odds of being interested in self-injecting at baseline (AOR: 1.92, CI: 1.66- 2.22) and increased odds of self-injecting at follow up (AOR: 1.55, CI: 1.19- 2.00).

Discussion: The Self-injection Social Norms Scale is a new 4-item measure that can be used by researchers and program implementors. Our finding that social norms related to self-injection are associated with women's interest in, and subsequent use of, self-injectable contraception suggest that promoting supportive social norms around self-injection shows potential as one strategy to enhance programmatic work aimed at bolstering women's ability to choose this method if it aligns with their preferences.

Keywords: Contraceptive agency; Evaluation; Intervention; Longitudinal; Qualitative; Uganda.