We all want the power to invest in our wellbeing, to be able to take care of our emotional, physical and mental health. But without reliable information and appropriate tools, reasonable options and adequate support, it’s not always possible.
Self-care is changing the face of healthcare. It focuses on equipping and entrusting people to take a central role in their own health. For women, this can involve an important shift to being able to make decisions about their own care, when they may not have had this autonomy before.
Doctors Without Borders/Médecins Sans Frontières (MSF) has seen in our programmes how self-care can improve healthcare access and quality.
How can self-care can empower women and girls in crisis-affected communities achieve to enjoy healthier lives, just like women anywhere else in the world?
What is self-care?
The World Health Organization (WHO) defines self-care as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health-care provider.”
As a medical-humanitarian organisation, MSF is adopting self-care within a patient-centred approach, supporting people with the knowledge and skills to undertake self-care safely but retain access to formal health services when they need or wish.
Self-care includes:
- self-management of medication, treatment, examination, injection and administration;
- self-testing, ranging from sampling and screening to diagnosis, collection and monitoring; and
- self-awareness, spanning self-help, self-education, self-regulation, self-efficacy and self-determination.
Self-care is not about people having to do all their own healthcare without support; it is about entrusting people to manage parts of their own healthcare if they choose to do so.
Simplified tests and treatments, point-of-care devices and mobile technology have all made self-care more possible in recent years – with great potential benefit for women and girls.
Why is self-care important for women?
Globally, many women still do not have access to essential healthcare, and struggle with managing sexual and reproductive health issues that may be stigmatised.
Close to one in four women of reproductive age still has no access to modern contraception, to help her plan or limit her pregnancies. Just over half the people aged over 15 living with HIV around the world are women. Unsafe abortion remains a major cause of death in pregnant women globally who are unable to access a safe alternative.
The many social, economic, logistical and other barriers to accessing healthcare can be compounded by violence and discrimination. The situation is also aggravated in acute humanitarian crises. Now, COVID-19 has amplified the health service discrepancies in these settings, worsening sexual and reproductive health outcomes. And while lockdowns have been instigated to keep us safe, they have also increased the danger for some women at home.
In such circumstances, the obstacles can be so great that women will neither come nor ask for care, even if they need it.
Self-care is an opportunity to address this, as recognised by the WHO with its first ever self-care intervention guidelines in 2019, developed specifically for sexual and reproductive health.
DRC: Bringing family planning closer to home
In many parts of the Democratic Republic of Congo (DRC), recurrent conflict and displacement of people can make it difficult for women to regularly access health centres.
As a result, many girls and women miss out on consistent access to contraception that would allow them to space out their births and avoid unwanted pregnancies.
Since 2019, Doctors Without Borders/Médecins Sans Frontières (MSF) has been offering women a long-acting contraceptive called Sayana Press in four projects in the DRC. This injectable contraceptive lasts three months and is highly effective (99 per cent) against pregnancy when used correctly.
Women can receive their first injection in a health centre, where a healthcare provider or community health worker teaches them how to do the next injection themselves and provides up to four doses to take home – enough to last for one year.
This self-care approach means that women can manage their own contraceptive needs without having to regularly visit the health centre, or take daily pills.
MSF nurse in Drodro, Naomi Kugonza, says Sayana Press can be lifesaving because it means that women are less likely to have unsafe abortions.
“We also use it to reduce the rates of maternal mortality caused by unwanted pregnancies and clandestine abortions caused by sexual violence or pregnancies too close together,” Naomi says.
Unsafe abortion is one of the top five causes of maternal mortality globally.
“This is a woman-centred method; they can self-inject the medication and do the follow-up alone,” she adds.
The drug can also be stored at room temperature and is easy to transport, which is helpful in this area where women and girls are often forced on the move.
The Sayana Press is similar in formulation to the injectable contraceptive Depo-Provera but contains a lower dose and is administered just under the skin using a single-use syringe with a short needle.
MSF is currently offering the contraceptive in Mambasa, Nizi, Drodro and Angumu in DRC.
How does self-care improve healthcare, and health?
Self-care can expand access to healthcare in remote locations, unstable contexts or areas with poor health infrastructure. It can extend healthcare outside the hospital or the clinic, beyond the doctor or the nurse. It can be a pragmatic response where healthcare resources are stretched, but also enable links to care where they didn’t exist before.
Self-care interventions can deliver evidence-based and low-risk healthcare options directly and discreetly in the community or people’s individual homes—like self-injectable contraception. Offering more convenience or more confidentiality, self-care approaches can enable early diagnosis and more timely medical care—like HIV self-testing.
Through focusing on a woman’s individual needs, they can also improve the quality of care that she receives: care that is appropriate, respectful and built on trust.
For some women, self-care may be the only safe alternative, without which they may be forced to seek unsafe services or give up hope of care altogether. In the case of self-managed medication abortion to prevent an unsafe abortion, self-care can be lifesaving.
How can women be empowered through self-care?
Self-care empowers women because it gives them access to information and services that allow them to decide on what works best for them. Women gain choices, and autonomy.
Self-care also allows women to help and take care of others in their community, by sharing reliable information peer-to-peer, delivering care as community health workers, and engaging with people within the same lived experience and health needs.
How is MSF supporting self-care?
We’re currently building capacity for self-care as part of a patient-centred approach to healthcare. As the evidence base grows, we’re continuing to trial different interventions, to understand what works, for whom. We know that often it is communities that can lead the way, and no model is one-size-fits-all.
Whatever the self-care option, we will always ensure that women have access to a trained health worker when they want or need one, and can be referred to the next treatment step without delay.
This is extremely important, as self-care should not substitute for formal healthcare. It needs to be part of the continuum of care, from the formal health system through to community-based models of care. It needs to add value, not stand in as second-best for people otherwise excluded from care.
Where is MSF integrating self-care into our projects?
HIV IN ESWATINI
In Shiselweni district in Eswatini, we’ve been offering oral HIV self-testing in our HIV and TB prevention and treatment programme since May 2017. Eswatini has the highest prevalence of HIV in the world. Nationwide investment in comprehensive services has reduced transmission, but there is still considerable stigma attached to HIV, often associated with social inequality.
Knowledge is power, and for women, knowing their HIV status means they can take control of their own health. Many women in our programme have taken up the oral self-test; with a wait time of just 20 minutes for the results, they can test reliably once a month in the comfort of their home. They’re also motivated to go further: if they are at particularly high risk, to take up pre-exposure prophylaxis (PrEP); or encourage others to test, or take medication.
And if they face the challenge of a positive test result, our counsellors can support them, in person or via our hotline, to self-manage and continue their lives on antiretroviral treatment.
MENTAL HEALTH IN PALESTINE
In Nablus, Palestine, our specialised mental health project for people with moderate to severe mental illness and victims of violence treats children to adults, among them victims of domestic violence. Last year, as COVID-19 lockdowns restricted movement in communities around the world, women in Nablus were suddenly trapped at home, with no escape. The only way we could reach them and continue our support was to pivot to tele-counselling – something new for our therapists and patients alike.
Evidence soon emerged worldwide that intimate partner violence was increasing in the pandemic. The situation in Nablus was no different and, concerningly, the abuse increased in severity as well, putting women’s safety at greater risk. But as a testament to the women’s resilience, they adapted and innovated.
They worked with their therapists to develop safety plans; they established self-care regimes to help reduce their anxiety when things were calm; they chose code words to warn that their partner could overhear the counselling call. In fact, fewer women dropped out of counselling than was the norm before.
Once lockdowns eased, although numbers were restricted, it was important to be able to see the highest priority patients face-to-face again. But COVID-19 has shown that tele-counselling can be feasible and effective, and can be offered in addition to face-to-face therapy as another pathway to care.
CERVICAL CANCER IN ZIMBABWE
In Gutu district in Zimbabwe last year, our cervical cancer prevention and early treatment programme with the Zimbabwean Ministry of Health and Child Care was the springboard for a trial comparing women self-swabbing for human papillomavirus infection versus being swabbed by a nurse. Without better access to cervical cancer prevention, women in high prevalence countries like Zimbabwe continue to face a premature death.
The screening method known as Visual Inspection with Acetic Acid, the mainstay of our programme and others like it, needs human resources, training and equipment that can limit its roll-out. What if the simpler high vaginal swab to collect an HPV DNA sample could be effectively conducted not only by nurses, but the women themselves? It could significantly expand access to diagnosis for women unable to access healthcare workers or clinics.
The trial found nurses and lay patients equally effective in collecting a sample. Most women found the self-collection procedure comfortable; and almost all would recommend self-collection for HPV testing to a friend. We look forward to delving more into the preferences of women and nurses in participating in this care.
WORLDWIDE – SAFE ABORTION CARE
In sexual and reproductive health, safe abortion is the most restricted of all care. But thanks to medication abortion and its regimen of pills taken over 24 hours, termination of pregnancy has not only been simplified, it can be available in the privacy of a woman or girl’s own home.
In our experience, self-managed abortion can be managed in several ways. In MSF’s remote support service, women can come to the health facility for an assessment and to receive the drugs and instructions for use; be remotely counselled and emotionally supported through the abortion until the process is complete; and only need to visit the facility again if they have a (rare) complication or any concern. They will also receive family planning advice, and the contraceptive of their choice. Or they can be assessed and supported remotely, receiving the medication separately.
Depending on the context, this is a game-changer for unmarried women, victims of rape, displaced women, and any other woman who has an unwanted pregnancy and wishes to manage it privately. Women tell us this, and tell each other. The next step is to continue to adapt the service and make it more accessible, through toll-free hotlines and home delivery of the medication and instructions, for example.
Integrating self-care
There is great potential to expand quality, patient-centred care for women and girls through self-care approaches, especially in contexts where MSF works: places affected by an acute crisis, or hard to reach. Self-care should always be linked to more formal care, but it can play a particularly useful role where there is little health infrastructure or few health workers, or marginalised people needing care outside of a formal system.
From our experience in such settings, working with health authorities, local organisations and grassroots communities, we believe much can be achieved to build the capacity to integrate self-care, and allow women and girls to contribute to their own health and wellbeing.
