Improving Contraception Outreach through Human-Centered Design: A Pilot Study of the Ndingathe ("I Can") Intervention...

In Malawi, community health workers known as Health Surveillance Assistants (HSAs) can facilitate access to contraception through rural outreach. Self-injectable contraception also shows promise to facilitate contraceptive access, as women can store doses and re-inject on their own. We previously developed the Ndingathe ("I Can") intervention via human-centered design to strengthen contraception outreach by addressing HSAs' workflow challenges and enhancing self-injection (SI) counseling and support for interested clients. We piloted Ndingathe in two rural districts from June to December 2023.

To assess the feasibility, acceptability, and potential effectiveness of Ndingathe, we conducted: pre- and post-surveys with 60 HSAs; 450 surveys with clients at HSAs' community outreach clinics; interviews with 40 clients, 20 HSAs, four health system stakeholders, and 20 experienced SI users who supported clients; and 20 observations of outreach clinics. We analyzed quantitative data using descriptive and inferential statistics. We conducted a thematic analysis of qualitative data.

Intervention components aimed at improving HSAs' workflow, including bicycles, lunch allowances, and workflow planning templates, were well-received by HSAs and health system stakeholders, and appeared to improve outreach clinic frequency and duration: the percentage of HSAs reporting conducting at least one outreach clinic per week rose from 65% to 95% after the pilot and observations suggested outreach clinic hours extended into the afternoon, instead of ending before lunch, which clients appreciated. HSAs' average scores on the Role Conflict and Ambiguity in Complex Organizations and Role Overload Scales decreased after six months (2.9 to 2.3, p < 0.0001 and 3.7 to 3.0, p < 0.001, respectively). Both HSAs and clients positively received Ndingathe's SI mnemonic, designed to aid memory of SI steps, and support from experienced SI users during counseling. Clients' median self-reported fear of needles decreased from 3 (of 4) to 1 after interacting with an experienced user (p < 0.001). Clients felt reassurance when experienced SI users visited their homes for follow-up visits, conducted without HSAs, to offer support for SI. Challenges during the pilot included delays in lunch allowance disbursement, which impacted HSAs' morale and ability to expand outreach clinic hours.

The Ndingathe intervention was feasible and acceptable from the viewpoint of multiple stakeholders in rural Malawi. Pilot findings suggest the intervention has the potential to improve contraception accessibility and reduce fear of self-injectable contraception.