SELF CARE INTERVENTIONS FOR SEXUAL AND REPRODUCTIVE

Self care interventions to advance health and BMJ: first published as 10.1136/bmj.l688 on 1 April 2019. Downloaded from wellbeing: a conceptual framework to inform normative guidance Manjulaa Narasimhan and colleagues argue that there is a pressing need for a clearer conceptualisation of self care to support

elf care existed well before formal promote health, prevent disease, maintain another focused on how self care relates health systems and is an impor- health, and cope with illness and disability to the : people centred and tant contributor to health out- with or without the support of a health-care system centred. comes. For many people, self care provider.”5 6 While this is a broad definition The capacity and ability of an individual within well established cultural that includes many activities, it is impor- to make informed health decisions and Sand social norms may be the only health- tant for health policy to recognise the make use of available health resources is an care they access. Where healthcare systems importance of self care, especially where it important component of effective prevention do exist, self care remains a crucial compo- intersects with health systems and health and management of a health condition. nent for maintaining health. For example, professionals (fig 1). The recent global con- The ability to access and use societal and brushing teeth is a daily self care practice ference on primary , which cele- familial resources contributes to personal in which individuals are in control of their brated the 40th anniversary of the Alma Ata agency and autonomy and determines dental health, but it can link to healthcare declaration, again underlined the impor- health outcomes. Seen thus, self care is should check-ups or advanced interven- tance of empowering and supporting peo- about caring and the relational context, tions be needed. Moreover, interventions ple in acquiring the knowledge, skills, and finding ways to enable good self care and that were previously available only through resources needed to maintain their health avoid social and cultural iatrogenesis of facility based healthcare providers are now or the health of those for whom they care.7 self medicalisation.8 From this perspective, http://www.bmj.com/ being accessed in the self care environ- A growing globalised market of drugs, the capacity to meet physical, physiological, ment. Pregnancy tests, for instance, have diagnostics, and devices, coupled with psychological, and self fulfilment needs is transitioned to self care. rapid advances in digital technologies, important.9 Self care interventions in the health sector is making new configurations of self care Given the potential to enhance health have increased since the primary healthcare possible. Many of these interventions will and wellbeing, self care is an important movement began,1 fuelled by an increased be regulated, but many more will not. Given component of people centred care.6 A people focus on empowering women,2 improving the increasing number of new interventions, centred framing emphasises psychological, the intrinsic capacity of older people,3 and the importance of linkage to care, and the empowerment, and self fulfilment needs,10 on 23 September 2021 by guest. Protected copyright. the role of self care in the management of supportive part the health system can placing less emphasis on technical activities chronic diseases, including .4 play, there is a pressing need for a clearer and instead looking at self care in terms of The World Health Organization’s working conceptualisation of self care to support capacities, building on a person’s “health definition of self care includes “the ability health policy. assets,” both as a condition for and a of individuals, families and communities to product of the practice of self care.11 System and people centred framing of self care A complementary perspective on self Self care ranges from a set of activities to care is a “system centred” framing, which KEY MESSAGES a set of capacities. It is possible to think focuses on activities that can add value in • Self care interventions increase about self care from two complementary dealing with specific diseases or health choice, accessibility, and affordability, perspectives, one focused on improving issues that healthcare managers and as well as opportunities for individuals the capacity of individuals to self care and policy makers consider important. The to make informed decisions regarding their health and healthcare Health systems Everyday life • Self care interventions may also exac- erbate inequalities and therefore need Self management, to be monitored and, where appropri- self medication, self treatment, self examination, self injection, ate, linked with health systems self administration, self use • Self care can be thought of using two Self care complementary frames: people cen- Self testing, Self awareness, tred and system centred. self sampling, self screening, self help, self education, Normative guidance will be essential self diagnosis, self collection, self regulation, self efficacy, • self monitoring self determination to redraw the boundaries of a stronger healthcare system that includes self care Fig 1 | Self care in the context of interventions linked to health systems the bmj | BMJ 2019;365:l688 | doi: 10.1136/bmj.l688 1 SELF CARE INTERVENTIONS FOR SEXUAL AND REPRODUCTIVE HEALTH

dominant paradigm from this perspective framework to support WHO normative and information, appropriately tailored to

is summarised by a Kaiser Permanente guidance (fig 3). The aim of the framework different needs. BMJ: first published as 10.1136/bmj.l688 on 1 April 2019. Downloaded from pyramid12 that features self care as distinct is to support healthcare policy makers and Individuals can be in control of some self from, but complementary to, professional implementers who are thinking through the care interventions, such as using condoms; healthcare (fig 2).12 From this perspective, complexity of promoting high quality self while others, such as a positive HIV self test, the effect of self care on health outcomes care for individuals. The framework aims to will require confirmation within a healthcare and its division from professional care are ensure that all individuals are considered, setting; and others still, such as self sampling key considerations. Promoting task shifting including those who may not be aware of of HPV, will require the health setting to do or sharing between professionals and the their and those who may fall the test. This dynamic interaction between general public or optimising the linkage to through the cracks of the existing healthcare individuals and the health system can also professional care are priorities to harness system. change over time in line with the needs and self care to enhance specific health system Naturally, given the importance of a choices of individuals. The health system outcomes.13 14 In this framing, the focus is on people centred approach, self carers and supporting people for self management of managing and mitigating health concerns or care givers are at the centre of the framework health conditions remains an integral part risk factors. that is focused on health and wellbeing. The of self care. key principles for promoting self resilience, Accountability for health outcomes is Conceptual framework for self care autonomy, and agency in any health policy reflected at multiple levels in the conceptual Individuals choose a self care health inter- guidance for self care are recognising framework, and accountability of the health vention for many positive reasons, includ- human rights, sex equality, and other ethical sector remains a key factor in the equitable ing convenience, cost, empowerment, and considerations. Two further key principles support to quality self care interventions. a better fit with values or lifestyle. A proved include taking a holistic approach to health Meaningful community engagement where efficacy and endorsement by the health sys- and recognising that needs change across a self care is championed and advocated by tem may be another reason to choose self person’s life course. patient groups is also an essential factor in care interventions. The conceptual framework recognises the success of linkage to care. Given that an ideal, well functioning health that in addition to the traditional self system is seldom a reality, particularly in care practices that societies have passed Self care for sexual and reproductive health resource constrained settings, individuals on through generations, people are and rights may also opt for self care interventions accessing new information, products, and While self care is important in all aspects to avoid the health system owing to poor interventions through stores, , of health, it is particularly important and quality services or because information, and the internet. Digital health and mobile challenging to manage for populations http://www.bmj.com/ interventions, or products are inappropriate, technologies are increasing rapidly, not only negatively affected by sex, political, cul- unaffordable, or inaccessible. Stigma as places of access but in many other aspects tural, and power dynamics. This is true from healthcare providers or from within of self care.16 for sexual reproductive health and rights, families and communities may be another The next layer of the framework where many people are not able to have reason people turn to self care. Self care recognises that a supportive and safe autonomy over their body or to make deci- interventions fulfil a particularly important enabling environment for the introduction sions around sexuality and reproduction.

role in these situations, as the alternative of self care interventions is essential and Safe linkage between self care and quality on 23 September 2021 by guest. Protected copyright. might be no access at all to health promoting that self care interventions should be healthcare for vulnerable individuals is crit- interventions.15 implemented in the context of a supportive ically important to avoid harm. When self Challenges exist in mitigating the inherent legal and policy environment. This means care is not a positive choice but born out of risks in promoting self care, particularly in access to the following: justice; a strong, fear or because there is no alternative, it can terms of ensuring safety and protecting accountable, people centred healthcare increase vulnerabilities. people against unnecessary expenditure and system; integrated and accessible services In a number of areas in sexual and harmful interventions. Just as high quality of good quality; protection from violence, reproductive health and rights, effective healthcare is important, high quality self coercion, and discrimination; social self care with safe links to healthcare has care is too. We have developed a conceptual inclusion and acceptance; and knowledge the potential to substantially improve health. These include self care interventions for fertility regulation (for example, 17 18 Complex cases High proportion of pregnancy tests and contraception ); with comorbidities professional care sexual (for example, Professional care seeking advice and information through digital health for sexually transmitted Higher risk cases Equally shared care infections,19 virility enhancement,20 and Self care alleviation of menopause symptoms21); disease prevention and control activities (for example, use of HIV pre-exposure 70-80% of people High prophylaxis22); and treatment (for example, with long term proportion of 23 conditions shared care self management of abortion and self administered HIV antiretroviral drugs in community based treatment clubs24). Alongside these interventions, supportive approaches ensure equity and quality of Fig 2 | Health systems perspective on the relation between self and professional care

2 doi: 10.1136/bmj.l688 | BMJ 2019;365:ll688 | the bmj SELF CARE INTERVENTIONS FOR SEXUAL AND REPRODUCTIVE HEALTH BMJ: first published as 10.1136/bmj.l688 on 1 April 2019. Downloaded from Accountability

Enabling Private sector environment Health sector Commodity accountability Trained health accountability security workforce Places of access Psychosocial Home Regulated, Care givers support quality products and Key interventions principles Supportive laws and Holistic Human policies Self care rights Traditional Pharmacies and for health and sociocultural wellbeing Individual Health practices Donor ‚nancing accountability accountability Access to Life Gender justice course equality Health services Ethics Economic Education Community empowerment (eg, housing, food security,

Digital http://www.bmj.com/ ability to pay technologies for healthcare) Information and platforms

Protection from Social violence, coercion, Government accountability and discrimination accountability on 23 September 2021 by guest. Protected copyright.

Fig 3 | Framework for self care interventions

self care—for example, in providing care systems to positively engage with self care multiple sectors to consider the quality to dependents, including differently abled, could make a substantial contribution. of evidence on health outcomes of self newborn, or young children; seeking WHO has begun developing consolidated care interventions, a balance of benefits medical assistance, including going to a people centred, evidence based normative and harms, the acceptability of self care health centre, counselling, and treatment; guidance around self care to support these interventions to health workers and the or for confirmatory testing (such as for a aims. This guideline will aim to advance populations that they serve, resources that positive HPV test result).25 universal health coverage without exposing enable self care, feasibility of making better individuals, families, and communities to links between self care and professional Reimagining healthcare delivery financial hardship; reduce health inequities care, financial costs to vulnerable WHO’s current strategic priorities are by tackling human rights, gender, ethical, populations, and equity. The guidance focused on the “triple billion” goals, which legal, social, economic, and environmen- will acknowledge that self care activities are for one billion more people to benefit tal determinants of health; and increase are undertaken by lay people on their own from universal health coverage, one billion access to quality health information, inter- behalf, either alone or in collaboration with more people to be better protected from ventions, products, and care in areas where professionals,26 and that a solid evidence health emergencies, and one billion more the burden of disease and the scope for base, still largely to be constructed, requires people to enjoy better health and wellbeing. improved wellbeing is the greatest. further research. Achieving these goals will not be straight- The development of this guidance entails Reimagining, reinvesting, and forward, but reorienting formal health broad, consultative processes across recommitting to healthcare that recognises the bmj | BMJ 2019;365:l688 | doi: 10.1136/bmj.l688 3 SELF CARE INTERVENTIONS FOR SEXUAL AND REPRODUCTIVE HEALTH

the strengths of individuals, their families, external peer review, editing, and publication of these 12 Health Services Management Centre. Improving care articles. Open access fees are funded by HRP. for people with long-term conditions: A review of UK communities, and social networks as active BMJ: first published as 10.1136/bmj.l688 on 1 April 2019. Downloaded from 1 and international frameworks. NHS, 2006. agents in their health and not merely passive Manjulaa Narasimhan, scientist 2 13 Logie C, Khoshnood K, Okumo M, et al. Self recipients of health services can contribute Pascale Allotey, director care interventions could advance sexual and 3 to improving the health and wellbeing of Anita Hardon, scientific lead reproductive health in humanitarian settings. 1 BMJ 2018;365:l1083. doi:10.1136/bmj.l1083 even the most vulnerable populations. World Health Organization, including Special Programme for Human Reproduction, Geneva, 14 World Health Organization. Guidelines on HIV Although risk and benefit calculations may Switzerland self-testing and partner notification: supplement vary across settings and population groups, 2 to consolidated guidelines on HIV testing services. UN University International Institute for , World Health Organization, 2016. with appropriate guidance and an enabling Kuala Lumpur, Malaysia 15 World Health Organization. Ethical, legal, human 3 environment, self care interventions offer Amsterdam Institute for Advanced Studies, rights and social accountability of self-initiated an exciting way forward to reach a range of Amsterdam, Netherlands interventions. Brocher Meeting report. WHO, 2018. improved health outcomes.27 Correspondence to: M Narasimhan 16 World Health Organization. WHO guidelines for [email protected] digital health interventions. WHO, 2016. This is particularly relevant for sexual 17 Robinson JH. Bringing the pregnancy test home reproductive health and rights, where self from the . Soc Stud Sci 2016;46:649-74. care could improve awareness and decision doi:10.1177/0306312716664599 18 Hardon A. Women’s views and experiences of making around sexuality and reproduction. hormonal contraceptives: what we know and what Providing individuals with the capacity to This is an Open Access article distributed under we need to find out. beyond accept users’ perspect access resources for effective, evidence the terms of the Creative Commons Attribution IGO contracept. Reprod Health Matters 1997;:68-77. based self care is a public good. It is an License (https://creativecommons.org/licenses/ doi:10.1016/S0968-8080(97)90087-2 by-nc/3.0/igo/), which permits use, distribution, 19 Gkatzidou V, Hone K, Sutcliffe L, et al. User interface undervalued part of attempts to provide and reproduction for non-commercial purposes in design for mobile-based sexual health interventions people with universal access to healthcare any medium, provided the original work is properly for young people: design recommendations they need and responds to the autonomy cited. from a qualitative study on an online Chlamydia clinical care pathway. BMC Med Inform Decis and self reliance people value in their life. 1 Declaration of Alma Ata. 1978. https://www.who.int/ Making 2015;15:72. doi:10.1186/s12911-015- Developing normative guidance for policy publications/almaata_declaration_en.pdf 0197-8 makers, donors, and researchers will be 2 Murray M, Brady M, Drake J. Women’s self-care: 20 Both R. A matter of sexual confidence: young men’s non-prescription use of Viagra in Addis Ababa, essential to redraw the boundaries of a products and practices. Outlook on Reproductive Health 2017 Nov. https://path.azureedge.net/media/ Ethiopia. Cult Health Sex 2016;18:495-508. doi:10. stronger healthcare system that includes documents/RH_Outlook_Nov_2017.pdf 1080/13691058.2015.1101489 self care. 3 Steverink N, Lindenberg S, Slaets JPJ. How to 21 Thompson JJ, Ritenbaugh C, Nichter M. Why women choose compounded bioidentical hormone therapy: We thank Susan Norris, Christopher Pell, and Wim Van understand and improve older people’s self-

lessons from a qualitative study of menopausal http://www.bmj.com/ Lerberghe for their critical feedback. The Children’s management of wellbeing. Eur J Ageing 2005;2:235- decision-making. BMC Womens Health 2017;17:97. Investment Fund Foundation and the UNDP-UNFPA- 44. doi:10.1007/s10433-005-0012-y doi:10.1186/s12905-017-0449-0 UNICEF-WHO-World Bank Special Programme of 4 Lucock M, Gillard S, Adams K, Simons L, White 22 Calabrese SK, Magnus M, Mayer KH, et al. Putting Research, Development and Research Training in R, Edwards C. Self-care in mental health PrEP into practice: lessons learned from early- Human Reproduction provided financial support. The services: a narrative review. Health Soc Care adopting US providers’ firsthand experiences contents are the responsibility of the authors and do Community 2011;19:602-16. doi:10.1111/j.1365- providing HIV pre-exposure prophylaxis and not necessarily reflect the views of the World Health 2524.2011.01014.x associated care. PLoS One 2016;11:e0157324. Organization. 5 Hatch S, Kickbusch I, eds. WHO self help and health in Europe. New approaches in health care. WHO doi:10.1371/journal.pone.0157324 Contributors and sources:MN is leading the WHO Regional Office for Europe, 1983. 23 Webster N. Unsafe abortion: regulation of the social on 23 September 2021 by guest. Protected copyright. normative guideline development at WHO on self care 6 World Health Organization. Self care for health: body even beyond time and space. Cult Health interventions for sexual and reproductive health and a handbook for workers and Sex 2013;15:358-71. doi:10.1080/13691058.201 rights (SRHR) . PA co-chaired the meeting on ethical, volunteers. WHO Regional Office for South-East Asia, 2.758313 legal, human rights, and social accountability of self 2013. http://apps.searo.who.int/PDS_DOCS/B5084. 24 Venables E, Edwards JK, Baert S, Etienne W, care for SRHR. AH co-chaired some of the scoping pdf Khabala K, Bygrave H. “They just come, pick and meetings, including the WHO expert meeting on self 7 World Health Organization. Astana declaration on go.” the acceptability of integrated medication care interventions (15-16 March, 2018, Geneva, primary health care. 2018. https://www.who.int/ adherence clubs for HIV and non communicable Switzerland), where some of the concepts in this docs/default-source/primary-health/declaration/ disease (NCD) patients in Kibera, Kenya. PLoS article were developed. AH also co-chaired the gcphc-declaration.pdf One 2016;11:e0164634. doi:10.1371/journal. guideline development group (GDG) meeting (14-16 8 Dowrick C, Frances A. Medicalising unhappiness: pone.0164634 January, 2019, Montreux, Switzerland). Both PA and new classification of depression risks more patients 25 Allen-Leigh B, Uribe-Zúñiga P, León-Maldonado L, AH are members of the guideline development group. being put on drug treatment from which they will not et al. Barriers to HPV self-sampling and cytology MN wrote the first draft of the document, and all benefit. BMJ 2013;347:f7140. doi:10.1136/bmj. among low-income indigenous women in rural areas authors contributed extensively to its development f7140 of a middle-income setting: a qualitative study. BMC and finalisation. 9 Godfrey CM, Harrison MB, Lysaght R, Lamb Cancer 2017;17:734. doi:10.1186/s12885-017- M, Graham ID, Oakley P. Care of self —care by 3723-5 Competing interests: We have read and understood other—care of other: the meaning of self-care from 26 World Health Organization. Health education in self- BMJ policy on declaration of interests and have no research, practice, policy and industry perspectives. care: possibilities and limitations. 1984. http://www. relevant interests to declare. Int J Evidence-Based Healthcare 2011;9:3-24. who.int/iris/handle/10665/70092 doi:10.1111/j.1744-1609.2010.00196.x 27 Narasimhan M, Kapila M. Implications of self- Provenance and peer review: Commissioned; 10 World Health Organization. Package of essential care for health service provision. Bull World externally peer reviewed. noncommunicable (PEN) disease interventions for Health Organ 2019;97:76-76A. doi:10.2471/ This article is part of a series proposed UNDP/UNFPA/ primary health care in low-resource settings. World BLT.18.228890 Unicef/WHO/World Bank Special Programme for Health Organization, 2010. Human Reproduction (HRP) and commissioned by 11 Brady M. Women’s self-care: a new take on an old Cite this as: BMJ 2018;365:l688 The BMJ. The BMJ retained full editorial control over practice. PATH, 2018. http://dx.doi.org/10.1136/bmj.l668

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