Examining the relationship between reproductive empowerment and contraceptive self-injection: tackling the endogeneity problem

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It is also believed that those who are empowered are more likely to use self-care. Though critical for ensuring equity of these interventions, evidence for the relationship between empowerment and contraceptive self-care is scant. However, studying this relationship is challenging. In addition to the potential reversed causality between these two constructs, empowerment is determined by similar factors as the motivation for using self-care, contributing to an endogeneity problem. If not addressed, endogeneity can lead to incorrect causal assertions. Methods: Using data from a study of 400 women from six public health facilities in Addis Ababa, Ethiopia who opted to self-inject DMPA-SC, we assessed the directionality between the two constructs through two models: the first assessed the change in empowerment after participants’ first self-injection and the second assessedthe effect of empowerment on potential future use of self-injection. To address potential endogeneity, we identified instrumental variables of empowerment and then applied a two-stage regression approach to predict desire to continue self-injecting at follow-up with an instrument for empowerment, controlling for other variables. Results: Empowerment scores among the 343 women who were followed-up were high and did not significantly change from baseline to endline. Most women (78%) wanted to continue self-injecting. The following variables were associated with endline empowerment, but not with desire to continue and were therefore used as instruments: religion, employment status and postsecondary school attendance. The final model did not identify a significant relationship between desire to continue self-injecting and empowerment. The test of exogeneity was marginally significant (p=0.08). Conclusions: We did not find evidence of a significant relationship between reproductive empowerment and desire to continue self-injecting. Though there are limitations to this secondary data analysis, we recommend future research investigate this relationship using the methodology we demonstrate to address endogeneity inherent in answering this critical question about self-care interventions. Self-care empowerment DMPA-SC subcutaneous depot medroxyprogesterone acetate self-injection endogeneity instrumental variable model Figures Figure 1 Figure 2 Plain English Summary Self-care is when people who are not clinically trained give healthcare to themselves. An example of self-care is women injecting themselves with medicine to prevent pregnancy. Some people think that by doing self-care, people will feel in control of their health. Some think that those who already feel in control are more likely to use self-care. There is little information about how women’s feelings of control are related to their using self-care to prevent pregnancy. It is difficult to learn about this relationship because the ideas of control and use, and the ways we measure them, are related. These ideas are expressed by individuals instead of being characteristics that are fixed. This needs to be addressed in the way we look at the data. Otherwise, the information that we learn will not be correct. We used data from 400 women who decided to self-inject medicine to prevent pregnancy in Addis Ababa, Ethiopia, to learn how their feelings of control are related to their use of self-care. We looked at the data in two ways. We looked to see if women’s feelings of control increased after their first self-injection. We then looked to see if feelings of control increase women’s plans to self-inject in the future. Our approach accounts for the type of relationship we are dealing with. We did not see a major change in women’s feelings of control over time. We also did not find a clear relationship between feelings of control and plans to self-inject in the future. Background According to the World Health Organization (WHO), self-care interventions in family planning are a promising approach to improve reproductive health. Self-care is defined 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 worker.”(1) Self-care spans a range of practices including self-awareness, self-testing, and self-management. Family planning self-care interventions, such as self-administration of contraceptive injectables, have the potential to reduce contraceptive unmet need by increasing access and coverage; to improve health equity by reaching new users; to ensure continuity of pregnancy protection during humanitarian emergencies; and to reduce costs to the health system. The WHO endorsed contraceptive self-injection with a “strong recommendation” in the Consolidated Guidelines on Self-Care Interventions for Health .(2) Contraceptive self-injection is available through a formulation of depot medroxyprogesterone acetate (DMPA) delivered subcutaneously (DMPA-SC) in a prefilled, auto-disabled Uniject™ injection system, known by the brand name Sayana® Press (Pfizer, New York, NY, USA). This easy-to-use injectable method is suitable for administration by community health workers and by clients themselves.(3-9) After being trained, a self-injector may be dispensed additional doses to take away for future use. DMPA-SC self-injection is gaining considerable traction such that the product is now available in at least 30 FP2030 countries and is approved by regulatory agencies in nearly 60 countries worldwide.(10) Forty-three countries have introduced or are currently introducing self-injection, of which 16 countries are in the process of scaling up self-injection, all in sub-Saharan Africa.(11) Self-care interventions, particularly related to family planning, have often been described to have benefits beyond health care, with statements that they can be empowering to users.(12) The WHO describes empowerment as a core principle of self-care , however, empowerment is a broad concept. One dimension of this concept related to contraception is reproductive empowerment. The International Center for Research on Women and MEASURE Evaluation define reproductive empowerment as: “Both a transformative process and an outcome, whereby individuals expand their capacity to make informed decisions about their reproductive lives, amplify their ability to participate meaningfully in public and private discussions related to sexuality, reproductive health and fertility, and act on their preferences to achieve desired reproductive outcomes, free from violence, retribution or fear.”(13) While it is widely assumed that family planning self-care interventions are empowering to users, little evidence supports this claim.(14) The self-care guidelines highlight this gap, directing researchers to investigate the relationship between reproductive empowerment and self-care. Existence of this relationship remains a question and so too does its directionality. It is hypothesized that use of self-care will lead to higher levels of empowerment, however, it is also possible that those who are more empowered are more likely to adopt self-care strategies. The direction of the relationship is important to understand because equity is a key consideration for self-care, and it is critical that self-care is accessible to all who need or want these interventions, not only those who are empowered. In addition, unmeasured confounding can contribute to an endogeneity problem. This and the potential reversed causality between empowerment and use of self-care make this relationship challenging to study.(15) If not addressed, endogeneity can lead to incorrect assertions about causality. Recently, we conducted a systematic review examining the relationship between self-care and empowerment and we found substantial gaps in the evidence base.(12) Most of the studies in the review focused on condom use. The review identified positive relationships between condom use self-efficacy and use of/intention to use condoms. However, with few studies pertaining to other methods and their low-quality evidence, strong conclusions about other self-care contraceptive strategies could not be drawn. Further, only one of the 37 studies in the review explored DMPA-SC self-injection. The authors also noted that few studies meeting the eligibility criteria employed validated measures of reproductive empowerment. As such, there is a need for research to investigate the relationship between other contraceptive self-care methods and reproductive empowerment using rigorous methods. In a recent study assessing the pilot introduction of DMPA-SC self-injection in Addis Ababa, Ethiopia, we had the opportunity to include questions from a validated measure of reproductive empowerment. We present an analysis of these data that aims to explore the relationship between reproductive empowerment and the use and acceptability of DMPA-SC self-injection among new self-injectors. We use instrumental variable techniques to mitigate the problem of endogeneity.(15) Methods Setting The self-injection pilot study took place across six high-volume public health facilities in Addis Ababa, Ethiopia, that were selected by the Ministry of Health to pilot rollout of DMPA-SC self-injection. Recent data indicate that 48% of married women of reproductive age in Addis Ababa currently use a modern method of family planning (16). Of those using any contraceptive method, injectables are the most widely used, representing 34% of the method mix in the city (16). According to the 2016 Ethiopia Demographic and Health Survey, 32% of women in Addis Ababa had completed secondary education or higher and 88% were literate (17). Study design We used data from our recent study which aimed to generate information on the safety, acceptability, and feasibility of introduction and scale-up of DMPA-SC self-injection in select sub-cities in Addis Ababa, Ethiopia. This was achieved through a mixed-methods implementation research design, enrolling a prospective cohort of adult family planning users seeking injectable contraceptive services from public sector providers, who were followed-up over a three-month period. Data collection Four-hundred participants were recruited between August-December 2021. All family planning users at the pilot sites who were medically eligible and interested in DMPA-SC self-injection were invited by public health family planning providers to participate in the study, until the target sample size was reached. The target sample size of 400 was determined to be sufficient for assessing competency in DMPA-SC self-injection at three months, which was the primary outcome of the pilot study. Trained research assistants administered a tablet-based enrollment questionnaire to document participants’ sociodemographic characteristics and perceptions of self-injection prior to training. Providers then trained participants to self-administer DMPA-SC, who were invited to practice self-injection on a prosthetic, and then inject themselves. Providers assessed participants’ self-injection performance using a standardized observation form.(6, 9, 18-20) Those who demonstrated that they could competently self-inject were given one additional unit of DMPA-SC to take away with them to reinject three months later. These participants were eligible for follow-up. During the follow-up visit, the research assistants administered a tablet-based questionnaire to capture participants’ experience with self-injection training, 3-month self-injection, storage, disposal, and side effects, as well as their perceptions on acceptability of the method. Participants then demonstrated self-injection technique on a prosthetic while the research assistants assessed their performance using the standardized observation tool. Reproductive empowerment was measured during both the enrollment and follow-up surveys using the validated Reproductive Empowerment Scale.(21, 22) This scale was selected because it meets the three levels of agency outlined by the Reproductive Empowerment Framework.(23) Specifically, this study utilized the reproductive health decision-making sub-scale as this component is most closely linked to individual behavior that may be related to DMPA-SC self-injection. The sub-scale is comprised of four questions scored from 1-4 for a total maximum score of 16, with higher scores representing higher levels of reproductive empowerment. Two of the questions employ Likert scales (from strongly disagree to strongly agree) focusing on one’s ability to use contraception or refuse sex when one’s partner is in opposition. The other two questions ask about one’s current and preferred contraceptive decision-makers such that those responding with “my partner and myself jointly” receive the highest score, then those saying “myself”, then “my partner” and finally all other options.(24) The mean response score was imputed for participants with two or fewer missing responses. Participants with three or more missing responses needed for the subscale were excluded from analysis. Acceptability of DMPA-SC self-injection was assessed through the following questions (1) uptake of self-injection (measured through participation in the study), (2) re-injection at 3-months (dichotomous, measured at 3-month follow-up visit), and (3) desire to continue using DMPA-SC self-injection in the future (dichotomous, measured at 3-month follow-up visit). Related concepts of comfort and confidence with self-injection were also measured over time. Comfort with self-injection was measured using a 4-point Likert scale (very nervous, somewhat nervous, at ease, very at ease) and confidence was measured with a 3-point Likert scale (very confident, somewhat confident, not very confident). Participants were asked to consider their comfort with self-injection prior to self-injection training (measured during the enrollment survey prior to self-injection training), after training, and after reinjection approximately 3-months after training (both assessed in the follow-up survey). Confidence about self-injection was with respect to self-injection at enrollment, reinjection 3-months later, and regarding future self-injection, all of which were asked about during follow-up. Data analysis Descriptive analysis was performed to describe the characteristics of participants who completed a 3-month follow-up visit. We first assessed if there were changes in reproductive empowerment by performing a paired t-test to compare reproductive empowerment scores from enrollment to the 3-month follow-up visit. We performed this same paired t-test assessing changes in reproductive empowerment scores again among a restricted sample that only included participants who had already reinjected at the time of follow-up to explore if there was a difference for this subgroup. We then built a multivariable model to adjust for confounders and assess the factors related to the change in reproductive empowerment scores from baseline to endline. We used a data-driven approach to build the model, starting with separate regression analyses for each of the variables under consideration, with inclusion of baseline empowerment as the only confounding factor. Variables were considered for analysis based on theoretical plausibility that they may affect reproductive empowerment. Any variable with p<0.1 in this analysis was considered for inclusion in the final model. To avoid introducing endogeneity problems, variables measured at the time of follow-up were not eligible for inclusion in the model, with one exception. We considered self-injection competency at follow-up because this indicator was measured through independent observation of injection technique and may not be affected by the same factors as our measure of reproductive empowerment at follow-up. The model included the baseline reproductive empowerment score as a covariate to control for incoming levels of reproductive empowerment. We assessed the models using the variable inflation factor to identify multicollinearity problems, and AIC and R-squared, dropping additional variables based on this model assessment. We selected one measure of acceptability of DMPA-SC self-injection to assess the relationship with empowerment. For this analysis, we considered desire to continuing using DMPA-SC self-injection as our main outcome of interest as it more closely reflects future behavior intentions, and we hypothesized that higher empowerment would lead to better acceptability. The modeling approach described below could be done for other acceptability measures. To explore the relationship between empowerment and the desire to continue using DMPA-SC self-injection, we built an instrumental variable probit model. As described above, empowerment and measures of acceptability may be affected by similar unmeasured factors or have a reversed causality relationship. For example, is self-injecting empowering and/or are those with higher levels of empowerment more likely to continue self-injecting? This potential endogeneity could result in biased estimates unless an appropriate methodology is followed. To address the potential endogeneity, we identified instrumental variables of endline reproductive empowerment and then applied a two-stage regression approach to predict desire for continuation with an instrument for empowerment, controlling for other variables. For this exploratory analysis, we used a data-driven approach to identify suitable instrumental variables by first conducting a bivariate regression model for any variable that could potentially be related to desire to continue using self-injection, among those collected, and then selecting those with a p-value <0.1 for inclusion in the multivariable model. Variables were further selected based on measures of good fit including AIC and BIC. We compared multivariable models for our main outcome of desire to continue self-injecting and that of our potentially endogenous variable of endline reproductive empowerment. The model for endline reproductive empowerment was used rather than that of change in reproductive empowerment as we theorized that one’s level of reproductive empowerment at follow-up was more likely to be related to future use than the change in empowerment experienced over the last 3 months. However, the final models for both endline and change in reproductive empowerment resulted in the inclusion of the same factors (Supplemental material). Variables found to be associated with endline reproductive empowerment but not with desire to continue with DMPA-SC self-injection were selected as instruments. To help explain the model results, we also explored changes in comfort and confidence to self-inject over time (not in relation to reproductive empowerment). We compared individual change in response to the question regarding how comfortable participants felt with self-injecting over time, among those who re-injected at 3-months. We also compared individual change in response to the question regarding how confident participants felt about self-injection over time, among those who re-injected at 3-months. We calculated the proportion of participants who shifted responses between time points and tested whether significant shifts in response categories occurred between time points using the Stuart-Maxwell marginal homogeneity test for symmetry. A visual depiction of these shifts is illustrated through Sankey diagrams. All analyses were conducted using Stata version 16 and final tests of associations with p<0.05 were considered significant for two-sided comparisons.(25) Results Among the 343 participants surveyed at follow-up, over 40% had not completed primary school and 30% were 18-24 years old at enrollment (Table 1). Most identified as Orthodox Christian and 50% reported working for payment within the last year. A minority disclosed they were using family planning discretely and few had prior self-injection experience. At the three-month follow-up visit, most participants (78%) wanted to continue self-injecting DMPA-SC. Table 1. Descriptive characteristics of participants followed-up at 3 months (n=343) Participant characteristic No (%) Health facility Health facility 1 25 (7.3) Health facility 2 71 (20.7) Health facility 3 75 (21.9) Health facility 4 70 (20.4) Health facility 5 61 (17.8) Health facility 6 41 (12) Age , mean (sd) [range] 27.8 (5.3) [18-47] Educational level achieved No education 27 (7.9) Some Primary, but incomplete 116 (33.8) Completed Primary 39 (11.4) Some Secondary, but incomplete 50 (14.6) Completed Secondary 56 (16.3) Some Post-secondary, but incomplete 19 (5.5) Completed Post-secondary 36 (10.5) Attended postsecondary education No 288 (84) Yes 55 (16) Religion Orthodox Christian 238 (69.4) Protestant 47 (13.7) Catholic 3 (0.9) Muslim 55 (16) Employed in last year No 172 (50.2) Yes 171 (49.9) Covert user status Not a covert user 309 (90.1) Covert user 34 (9.9) Prior self-injection experience No 314 (91.6) Yes 24 (7) Don’t know 5 (1.5) Injected by follow-up No 104 (30.3) Yes 239 (69.7) Desire to continue method No 66 (19.2) Yes 267 (77.8) Don’t know 10 (2.9) Reproductive empowerment score at enrollment Mean (sd) [range] 12.32 (2) [3-16] Reproductive empowerment score at follow-up Mean (sd) [range] 12.28 (1.7) [3.3-16] Change in reproductive empowerment score Mean (sd) [range] -0.04 (2.2) [-7.7-11] Sd = standard deviation Reproductive empowerment and desire to continue using DMPA-SC self-injection Reproductive empowerment scores were high both at baseline and endline (about 12 out of 16 points on the sub-scale for both, Table 1). There was no statistically significant difference in reproductive empowerment scores from enrollment to follow-up (n=343; p=0.76). Among the restricted sample of those who reinjected by the 3-month follow-up visit (n=239), there was similarly no significant difference in reproductive empowerment scores over time (p=0.77). The final model of the change in reproductive empowerment (Table 2) included postsecondary education, employment, health facility, and religion, adjusting for baseline empowerment. Baseline reproductive empowerment scores were strongly independently associated with the change in reproductive empowerment in this model. For each 1-point increase in baseline reproductive empowerment, there was a 0.77-point decrease in the change in scores, such that participants with higher initial reproductive empowerment scores experienced less of a change in their score. Attendance of postsecondary education and working within the last year were significantly associated with increases in reproductive empowerment, after adjusting for other factors. Religion was significantly independently associated with the change in reproductive empowerment, whereby participants identifying as Protestant had a 0.65-point lower change in reproductive empowerment score than those identifying as Orthodox Christian. There were only three participants who identified as Catholic. Due to issues of small cell size and since we considered it inappropriate to combine these participants into another category of religion, they (<1% of sample) were excluded from this analysis. Enrollment health facility was related to the change in reproductive empowerment however no one health facility was significantly different from the reference facility. The model explained 51% of the variability in the change in reproductive empowerment scores. Table 2. Factors associated with change in reproductive empowerment score (n=340) Characteristic Adjusted for baseline reproductive empowerment only Coefficient (95% CI) Final model Coefficient (95% CI) Postsecondary education 0.59 (0.12-1.05)* 0.53 (0.04-1.02)* Employed 0.38 (0.04-0.73)* 0.35 (0-0.69)* Health facility (ref=HF 1) ** ** Health facility 2 -0.14 (-0.87-0.59) -0.18 (-0.9-0.54) Health facility 3 0.72 (-0.01-1.44) 0.71 (0-1.43) Health facility 4 -0.13 (-0.86-0.6) -0.2 (-0.91-0.52) Health facility 5 -0.02 (-0.76-0.73) -0.35 (-1.11-0.4) Health facility 6 0.66 (-0.13-1.45) 0.62 (-0.16-1.4) Religion (ref = Orthodox Christian) * * Protestant -0.58 (-1.08--0.07)* -0.65 (-1.15--0.15)* Muslim -0.37 (-0.85-0.12) -0.46 (-0.95-0.03) Reproductive empowerment score at enrollment N/A -0.77 (-0.85--0.68)** Age -0.02 (-0.05-0.02) Covert user 0.16 (-0.42-0.74) * p<0.05, **p<0.01; N/A = not applicable; CI = confidence interval; ref = reference group. To develop the instrumental variable probit model for desire to continue using DMPA-SC self-injection, we first modeled endline reproductive empowerment and desire for continuation separately. We compared the variables included in each of the models of best fit. Variables significantly related to endline reproductive empowerment that were not significantly associated with desire to continue DMPA-SC were identified as instruments. These included religion, employment status and postsecondary school attendance. This is consistent with the results of the model for change in empowerment in Table 2. The final model did not identify a significant relationship between desire to continue using DMPA-SC self-injection and reproductive empowerment either at baseline or at follow-up using the instruments, after adjusting for other variables (Table 3). Desire to continue the method was significantly associated with participants’ health facility at enrollment and their experience of side effects, when accounting for other factors. Compared to participants who did not experience any side effects, those who did experience them and reported increasing levels of interference in their everyday life, were significantly less interested in continuing to use DMPA-SC self-injection in the future. The Wald test of exogeneity was not significant at the p<0.05 level, indicating there is insufficient information in the sample to conclude that there is a clear endogeneity problem, though it was marginally significant (p=0.086). Table 3. Factors associated with desire to continue using DMPA-SC self-injection (n=325) Characteristic Coefficient (95% CI) p-value Health facility Health facility 2 1.13 (0.36-1.91) 0.004 Health facility 3 0.64 (-0.27-1.54) 0.166 Health facility 4 0.38 (-0.28-1.04) 0.261 Health facility 5 1.47 (0.47-2.46) 0.004 Health facility 6 0.57 (-0.32-1.47) 0.211 Interference of side effects (ref: no side effects experienced) Not at all -0.31 (-0.8-0.17) 0.203 Very little -0.96 (-1.74--0.19) 0.014 Little -1.32 (-2.22--0.42) 0.004 Moderate -1.74 (-2.85--0.62) 0.002 Very much -2.83 (-4.23--1.43) 0 Competence at follow-up 0.29 (-0.3-0.87) 0.335 Reproductive empowerment score at baseline -0.1 (-0.23-0.04) 0.160 Reproductive empowerment at follow-up (instrumented) 0.32 (-0.05-0.69) 0.086 Instruments: religion, employment status, postsecondary education Wald test of exogeneity (corr = 0): chi2(1) = 2.97 Prob > chi2 = 0.0849 Comfort and confidence to self-inject over time About half of participants felt somewhat nervous about DMPA-SC self-injection at enrollment, prior to receiving self-injection training (174/343, 51%; Figure 1). There was no significant change in individual reporting of comfort level with self-injection from pre- to post-training (p=0.17). However, there was a significant shift in participants’ level of comfort reported at the 3-month follow-up as compared to their feelings immediately after training, among those who reinjected (n=239, p<0.001). Among the 133 participants who said they felt somewhat nervous immediately after training, only 29% still felt somewhat nervous after their 3-month reinjection while 71% said they then felt at ease or very at ease. Similarly, only 12% of the 82 participants who felt very nervous post-training continued to feel very nervous after reinjection, while 81% of those who said they were very at ease remained at ease. Those who did not reinject by the time of the follow-up visit were included in Figure 1 to illustrate the pathways of all 343 participants. However, the test for comparing the shifts between the two time points only considers the 239 who reinjected (70% of the 343 participants follow-up at 3-months). The majority of those who did not reinject had felt very or somewhat nervous about self-injection. It should be noted however that some participants who had not reinjected at the time of follow-up said they still planned to do so. At the time of follow-up, 71% of respondents (169/239) reported feeling at ease or very at ease with self-injection. To see the results of Figure 1 in table format see Additional File 1. Figure 1. Comfort with DMPA-SC self-injection across time points (n=343) *SI=self-injection The changes in confidence over time followed similar trends (Figure 2 and Additional File 1). All three questions about confidence were included in the follow-up survey but asked participants to reflect on different experiences – their confidence during their first injection, during their second injection at 3-months and about future self-injection. Most participants (59%) said they felt somewhat confident about injecting their first time at the health facility. There was a significant shift in participants’ reported confidence levels from this first injection to their second injection such that respondents indicated higher levels of confidence (p<0.001). For example, only 10% of those who initially said they felt not very confident continued to feel this way after reinjection, while the other 90% said they now felt somewhat or very confident. There continued to be a significant shift towards higher confidence levels from one’s reinjection to one’s perception about future injection (p<0.001). 93% of participants who felt very confident at reinjection also anticipated feeling very confident about future self-injection. Of those who said they were somewhat confident about their 3-month injection, 59% continued to feel this way while 38% felt very confident about future use. Overall, 61% of respondents said they were very confident about their ability to self-inject in the future. Figure 2. Confidence to self-inject DMPA-SC over time (n=237) Discussion As family planning self-care interventions such as contraceptive self-injection become increasingly available around the world, there is an urgent need to understand if these interventions are further widening access gaps between those who have greater versus fewer resources—including power to achieve their desired reproductive outcomes. It is also important to understand if these interventions can increase users’ reproductive empowerment which may offer benefits beyond pregnancy prevention. However, studying this important, but potentially reversed causal relationship is complicated by the potential for endogeneity requiring researchers to take additional steps during data analysis to avoid making incorrect causal statements. Using longitudinal data from a recent pilot study of DMPA-SC self-injection, we explored the relationship between reproductive empowerment and the desire to continue using DMPA-SC self-injection. These constructs are theoretically endogenous, and their relationship cannot be assessed through traditional association analyses. We used a two-stage regression approach to predict desire for continuation with an instrument for empowerment, controlling for other variables. We found that participants in this pilot study had high reproductive empowerment scores at both enrollment and the 3-month follow-up visit, and we observed nonsignificant differences in scores over time. The study population may have been highly empowered to begin with (at least according to the measure of empowerment we used) because they all agreed to join our study and try self-injection—a new method being offered in their communities. Since scores were high to begin with there was not much room in the scale for the scores to increase over a 3-month period and this “ceiling effect” likely prevented us from observing differences over time. At least in this highly empowered population, we did not find evidence of self-care use affecting empowerment. This analysis should be replicated with a population with lower initial empowerment. For example, future studies should examine this relationship for those that are eligible for but decide not to try self-injection. We explored models for change in empowerment from baseline as well as for endline empowerment to identify suitable instrumental variables. The variables found to be associated with endline reproductive empowerment but not with desire to continue with DMPA-SC self-injection were selected as instruments. These included religion, employment status and postsecondary school attendance, and are consistent with previous research that did not find women’s sociodemographic factors associated with the risk of discontinuation of DMPA-SC.(5) Our final model did not identify a significant relationship between reproductive empowerment, either at baseline or at follow-up using the instruments, and desire to continue using DMPA-SC self-injection. While advocates of self-care describe self-injection as empowering, our findings do not support this conclusion. At the same time, we only measured a change in reproductive empowerment over a short time frame (3-months, only one reinjection) but perhaps changes take longer to occur. This warrants further research with longer follow-up. Also, we specifically explored reproductive empowerment and measured it through a specific measure. There are several scales available that measure reproductive empowerment-related concepts which cover different domains.(23) If we had used another measure of reproductive empowerment, we might have found a different outcome. Also, as noted in the background section, empowerment is a broad concept with many related constructs. It is possible that self-injection, and perhaps self-care more broadly, are not related to reproductive empowerment but rather other types of empowerment. While the test of exogeneity did not meet our prespecified threshold for significance, it is marginally significant and the constructs theoretically endogenous and as such, we still recommend future research investigate this relationship using appropriate methodology beyond single equation models. In addition, measurement of latent constructs pose additional challenges. Other measures of acceptability of self-injection may be more clearly endogenous. In either case, previous research examining simple associations are methodologically flawed and researchers should always approach this question first with an analysis addressing endogeneity. After testing and confirming no endogeneity in a particular analysis, researchers could then modify their models. The factors that we found significantly associated with desire to continue self-injection—participants’ experience of side effects and the health facility where they were enrolled into the study—are consistent with previous studies.(26-28) Compared to participants who did not experience any side effects, those who did experience them and reported increasing levels of interference in their everyday life, were significantly less interested in continuing to use DMPA-SC self-injection in the future. The association with health facility may be related to differences in the (unmeasured) characteristics of participants attending the different health facilities or may be related to variations in provider counseling and training on DMPA-SC self-injection. This site-level effect warrants further investigation to ensure that counseling and training are high-quality and empathy-based across all health facilities. Like other studies, we found that comfort and confidence to self-inject increased over time.(7, 29) Interestingly, we found no change in comfort level from pre- to post-training, but we did see a significant increase in participants’ comfort after re-injection 3-months after training. It appears that users begin to feel more comfortable with this method after having injected themselves once on their own. This suggests that it is important for providers to focus on helping adopters through the first injection. We found that participants’ confidence significantly increased over time from the first injection to the 3-month re-injection, and towards future self-injections. Only 4% of participants who re-injected at 3-months were not very confident in their ability to self-inject in the future. These results indicate that there may be further gains in constructs related to empowerment over a longer period of time. Exploring measures of self-confidence and self-efficacy may be of interest in future research on this topic. Limitations As a secondary analysis, we were limited by the study design and data that were collected to answer the primary research question. The two main outcomes in this analysis are conceptually endogenous, as described in the introduction. Our analysis attempted to address the endogeneity concern, but it is affected by the data (measurement and design) as well as the potential for some misspecification (important confounders, appropriate instruments). Other study designs and inclusion of different subgroups could mitigate the endogeneity concerns by controlling for who chooses to participate in self-care, by design. On the other hand, our analysis is strengthened by the use of longitudinal data, which is rarely available. Further, our analysis uses robust methods to appropriately disentangle the endogeneity in our outcomes, offering more valid conclusions than naive regression analysis. Both better data and appropriate modelling addressing the endogeneity of these outcomes, are needed. Importantly, endogeneity should not be ignored. Another limitation of this study is that our measures of comfort with self-injection post-training and after re-injection 3-months later were measured at the same time, during the 3-month follow up visit. However, it is reassuring that despite the two measures being taken at the same time, the responses to these questions varied which is an indication that the participants were engaged during the survey and increases our confidence in the validity of their responses. Conclusion To our knowledge this the first analysis examining the relationship between reproductive empowerment and a contraceptive self-care intervention that used a modelling technique to better address the endogeneity problem that is rooted in the nature of these constructs. We also attempted to assess the directionality between the two constructs—a pressing question in the family planning self-care space. We did this through two models: the first assessed the change in empowerment after participants’ first self-injection and the second assessed the effect of empowerment on potential future use self-injection. Though the data we had available to us in this secondary data analysis had limitations, through this analysis we shine a light on the serious issue of endogeneity inherent in answering this question and offered a strategy for how to appropriately answer it in future studies. Abbreviations CI Confidence interval N/A Not applicable Sd Standard deviation SI Self-injection DMPA-SC Subcutaneous depot medroxyprogesterone acetate Ref Reference group WHO World Health Organization Declarations Ethics approval and consent to participate This study was approved by the Ethiopian Public Health Institute Institutional Review Board, FHI 360’s Protection of Human Subjects Committee and PSI’s Research Ethics Board. All participants provided written informed consent to participate. Consent for publication Not applicable Availability of data and materials The datasets generated and analyzed during the current study are not publicly available due to organizational policy but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research was funded by the Children’s Investment Fund Foundation. Authors' contributions KMA and HMB secured funding and HMB conceptualized the study. HMB, MML and MC designed the methodology. AA, TM and TT led data collection, MML, AA, TM and TT managed and coordinated the study and HMB and KMA provided supervision support. MML led analysis and visualization with support from MC. MML and HMB led manuscript development, with contributions from MC, and all authors reviewed and edited the manuscript. Acknowledgements The authors would like to acknowledge Dr. Meseret Zelalem, Professor Mirkuzi Wolde, and Dr. Zerihun Bogale of the Federal Ethiopian Ministry of Health, along with Abaynesh Ahmed of the Addis Ababa Health Bureau and Fikreselassie Getachew of the Ethiopia Public Health Institute for their support of this research and the Children’s Investment Fund Foundation for their financial support to conduct the pilot study. We thank Carter Crew for verifying the results and Donna McCarraher for her review of the paper. References World Health Organization. WHO guideline on self-care interventions for health and well-being, 2022 revision. WHO Consolidated Guideline on Self-Care Interventions for Health: Sexual and Reproductive Health and Rights. WHO Guidelines Approved by the Guidelines Review Committee. Geneva, Switzerland: World Health Organization; 2022. World Health Organization. WHO Consolidated Guideline on Self-Care Interventions for Health. WHO Consolidated Guideline on Self-Care Interventions for Health: Sexual and Reproductive Health and Rights. WHO Guidelines Approved by the Guidelines Review Committee. Geneva: World Health Organization© World Health Organization 2019.; 2019. Lerma K, Goldthwaite LM. Injectable contraception: emerging evidence on subcutaneous self-administration. Curr Opin Obstet Gynecol. 2019;31(6):464-70. Burke HM, Packer C, Buluzi M, Healy E, Ngwira B. Client and provider experiences with self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) in Malawi. Contraception. 2018;98(5):405-10. Burke HM, Chen M, Buluzi M, Fuchs R, Wevill S, Venkatasubramanian L, et al. Factors Affecting Continued Use of Subcutaneous Depot Medroxyprogesterone Acetate (DMPA-SC): A Secondary Analysis of a 1-Year Randomized Trial in Malawi. Global Health: Science and Practice. 2019;7(1):54. Burke HM, Mueller MP, Packer C, Perry B, Bufumbo L, Mbengue D, et al. Provider acceptability of Sayana® Press: results from community health workers and clinic-based providers in Uganda and Senegal. Contraception. 2014;89(5):368-73. Burke HM, Chen M, Buluzi M, Fuchs R, Wevill S, Venkatasubramanian L, et al. Women's satisfaction, use, storage and disposal of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) during a randomized trial. Contraception. 2018;98(5):418-22. Burke HM, Chen M, Packer C, Fuchs R, Ngwira B. Young Women's Experiences With Subcutaneous Depot Medroxyprogesterone Acetate: A Secondary Analysis of a One-Year Randomized Trial in Malawi. J Adolesc Health. 2020;67(5):700-7. Burke HM, Chen M, Buluzi M, Fuchs R, Wevill S, Venkatasubramanian L, et al. Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomised controlled trial. Lancet Glob Health. 2018;6(5):e568-e78. Brady M, Drake JK, Namagembe A, Cover J. Self-care provision of contraception: Evidence and insights from contraceptive injectable self-administration. Best Pract Res Clin Obstet Gynaecol. 2020;66:95-106. DMPA-SC Access Collaborative. Looking back, thinking forward, and scaling up: Insights from the DMPA-SC Access Collaborative DMPA-SC Resource Library2021 [updated April 2021. Available from: https://fpoptions.org/resource/webinar-ac-insights/. Burke HM, Ridgeway K, Murray K, Mickler A, Thomas R, Williams K. Reproductive empowerment and contraceptive self-care: a systematic review. Sex Reprod Health Matters. 2021;29(2):2090057. Edmeades J, Hinson L, Sebany M, Murithi L. A conceptual framework for reproductive empowerment: empowering individuals and couples to improve their health. Washington DC: International Center for Research on Women. 2018. Zohra S. Lassi, Komal Abdul Rahim, Alexandra Maria Stavropoulos, Lareesa Marie Ryan, Jyoti Tyagi, Bisi Adewale, et al. Use of contraceptives, empowerment and agency of adolescent girls and young women: a systematic review and meta-analysis. BMJ Sexual &amp; Reproductive Health. 2024:bmjsrh-2023-202151. Le Bourdonnec K, Samieri C, Tzourio C, Mura T, Mishra A, Trégouët D-A, et al. Addressing unmeasured confounders in cohort studies: Instrumental variable method for a time-fixed exposure on an outcome trajectory. Biometrical Journal. 2024;66(1):2200358. Ethiopian Public Health Institute, ICF. Ethiopia Mini Demographic and Health Survey 2019: Key Indicators. Rockville, Maryland, USA: EPHI and ICF; 2019. Central Statistical Agency, ICF. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville Maryland, USA: CSA and ICF; 2016. Burke HM, Mueller MP, Perry B, Packer C, Bufumbo L, Mbengue D, et al. Observational study of the acceptability of Sayana® Press among intramuscular DMPA users in Uganda and Senegal. Contraception. 2014;89(5):361-7. Cover J, Ba M, Lim J, Drake JK, Daff BM. Evaluating the feasibility and acceptability of self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA) in Senegal: a prospective cohort study. Contraception. 2017;96(3):203-10. Cover J, Namagembe A, Tumusiime J, Lim J, Drake JK, Mbonye AK. A prospective cohort study of the feasibility and acceptability of depot medroxyprogesterone acetate administered subcutaneously through self-injection. Contraception. 2017;95(3):306-11. Mandal M, Albert LM. Reproductive Empowerment Scale: Psychometric Validation in Nigeria. Chapel Hill, NC, USA: MEASURE Evaluation, University of North Carolina; 2020. Mandal MT-K, S.; Mejia, C. . Validating Measures of Reproductive Empowerment in Kenya. Chapel Hill, NC, USA: MEASURE Evaluation, University of North Carolina; 2020. Burke HM, Thomas R. Thematic Analysis and Mapping of Reproductive Empowerment Scales: A Tool for Family Planning Self-Care Programming and Research. Global Health: Science and Practice. 2022;10(3):e2100794. Reproductive Empowerment Scale: MEASURE Evaluation; 2020 [Available from: https://www.measureevaluation.org/resources/publications/tl-20-81/at_download/document. StataCorp. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC; 2019. MacLachlan E, Atuyambe LM, Millogo T, Guiella G, Yaro S, Kasasa S, et al. Continuation of subcutaneous or intramuscular injectable contraception when administered by facility-based and community health workers: findings from a prospective cohort study in Burkina Faso and Uganda. Contraception. 2018;98(5):423-9. Cover J, Namagembe A, Tumusiime J, Nsangi D, Lim J, Nakiganda-Busiku D. Continuation of injectable contraception when self-injected vs. administered by a facility-based health worker: a nonrandomized, prospective cohort study in Uganda. Contraception. 2018;98(5):383-8. Cover J, Ba M, Drake JK, MD ND. Continuation of self-injected versus provider-administered contraception in Senegal: a nonrandomized, prospective cohort study. Contraception. 2019;99(2):137-41. Kohn JE, Simons HR, Della Badia L, Draper E, Morfesis J, Talmont E, et al. Increased 1-year continuation of DMPA among women randomized to self-administration: results from a randomized controlled trial at Planned Parenthood. Contraception. 2018;97(3):198-204. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4360966","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":300042410,"identity":"d8a9d099-679e-4e6b-b03e-313ced94c4dc","order_by":0,"name":"Megan M 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1","display":"","copyAsset":false,"role":"figure","size":1147359,"visible":true,"origin":"","legend":"\u003cp\u003eComfort with DMPA-SC self-injection across time points (n=343)\u003c/p\u003e\n\u003cp\u003e*SI=self-injection\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4360966/v1/edcc4fa43a03eacb5d73d830.png"},{"id":56281143,"identity":"c725340d-20cd-4760-90a7-737cd5287e14","added_by":"auto","created_at":"2024-05-10 21:08:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":779864,"visible":true,"origin":"","legend":"\u003cp\u003eConfidence to self-inject DMPA-SC over time (n=237)\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4360966/v1/379738e6d503d88762e5b839.png"},{"id":57338117,"identity":"a43d5913-28b0-4fbf-baa1-173e9a60371d","added_by":"auto","created_at":"2024-05-29 09:54:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2399908,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4360966/v1/4c3bae5a-5340-4945-801b-e26d45910e32.pdf"},{"id":56281245,"identity":"9fc62a1e-5d2c-47ee-8d2e-c0f46aa2b8c5","added_by":"auto","created_at":"2024-05-10 21:10:15","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":24282,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4360966/v1/54b80294cd299baa3fa93cd0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Examining the relationship between reproductive empowerment and contraceptive self-injection: tackling the endogeneity problem","fulltext":[{"header":"Plain English Summary","content":"\u003cp\u003eSelf-care is when people who are not clinically trained give healthcare to themselves. An example of self-care is women injecting themselves with medicine to prevent pregnancy. Some people think that by doing self-care, people will feel in control of their health. Some think that those who already feel in control are more likely to use self-care. There is little information about how women\u0026rsquo;s feelings of control are related to their using self-care to prevent pregnancy. It is difficult to learn about this relationship because the ideas of control and use, and the ways we measure them, are related. These ideas are expressed by individuals instead of being characteristics that are fixed. This needs to be addressed in the way we look at the data. Otherwise, the information that we learn will not be correct.\u003c/p\u003e\n\u003cp\u003eWe used data from 400 women who decided to self-inject medicine to prevent pregnancy in Addis Ababa, Ethiopia, to learn how their feelings of control are related to their use of self-care. We looked at the data in two ways. We looked to see if women\u0026rsquo;s feelings of control increased after their first self-injection. We then looked to see if feelings of control increase women\u0026rsquo;s plans to self-inject in the future. Our approach accounts for the type of relationship we are dealing with. We did not see a major change in women\u0026rsquo;s feelings of control over time. We also did not find a clear relationship between feelings of control and plans to self-inject in the future.\u0026nbsp;\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eAccording to the World Health Organization (WHO), self-care interventions in family planning are a promising approach to improve reproductive health. Self-care is defined as \u0026ldquo;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 worker.\u0026rdquo;(1)\u0026nbsp;Self-care spans a range of practices including self-awareness, self-testing, and self-management. Family planning self-care interventions, such as self-administration of contraceptive injectables, have the potential to reduce contraceptive unmet need by increasing access and coverage; to improve health equity by reaching new users; to ensure continuity of pregnancy protection during humanitarian emergencies; and to reduce costs to the health system. The WHO endorsed contraceptive self-injection with a \u0026ldquo;strong recommendation\u0026rdquo; in the \u003cem\u003eConsolidated Guidelines on Self-Care Interventions for Health\u003c/em\u003e.(2)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eContraceptive self-injection is available through a formulation of depot medroxyprogesterone acetate (DMPA) delivered subcutaneously (DMPA-SC) in a prefilled, auto-disabled Uniject\u0026trade; injection system, known by the brand name Sayana\u0026reg; Press (Pfizer, New York, NY, USA). This easy-to-use injectable method is suitable for administration by community health workers and by clients themselves.(3-9)\u0026nbsp;After being trained, a self-injector may be dispensed additional doses to take away for future use. DMPA-SC self-injection is gaining considerable traction such that the product is now available in at least 30 FP2030 countries and is approved by regulatory agencies in nearly 60 countries worldwide.(10)\u0026nbsp;Forty-three countries have introduced or are currently introducing self-injection, of which 16 countries are in the process of scaling up self-injection, all in sub-Saharan Africa.(11)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSelf-care interventions, particularly related to family planning, have often been described to have benefits beyond health care, with statements that they can be empowering to users.(12)\u0026nbsp;The WHO describes empowerment as a core principle of self-care\u003cem\u003e,\u0026nbsp;\u003c/em\u003ehowever, empowerment is a broad concept. One dimension of this concept related to contraception is reproductive empowerment. The International Center for Research on Women and MEASURE Evaluation define reproductive empowerment as:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Both a transformative process and an outcome, whereby individuals expand their capacity to make informed decisions about their reproductive lives, amplify their ability to participate meaningfully in public and private discussions related to sexuality, reproductive health and fertility, and act on their preferences to achieve desired reproductive outcomes, free from violence, retribution or fear.\u0026rdquo;(13)\u003c/p\u003e\n\u003cp\u003eWhile it is widely assumed that family planning self-care interventions are empowering to users, little evidence supports this claim.(14)\u0026nbsp;The self-care guidelines highlight this gap, directing researchers to investigate the relationship between reproductive empowerment and self-care. Existence of this relationship remains a question and so too does its directionality. It is hypothesized that use of self-care will lead to higher levels of empowerment, however, it is also possible that those who are more empowered are more likely to adopt self-care strategies.\u0026nbsp;The direction of the relationship is important to understand because equity is a key consideration for self-care, and it is critical that self-care is accessible to all who need or want these interventions, not only those who are empowered. In addition, unmeasured confounding can contribute to an endogeneity problem. This and the potential reversed causality between empowerment and use of self-care make this relationship challenging to study.(15)\u0026nbsp;If not addressed, endogeneity can lead to incorrect assertions about causality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRecently, we conducted a systematic review examining the relationship between self-care and empowerment and we found substantial gaps in the evidence base.(12)\u0026nbsp;Most of the studies in the review focused on condom use. The review identified positive relationships between condom use self-efficacy and use of/intention to use condoms. However, with few studies pertaining to other methods and their low-quality evidence, strong conclusions about other self-care contraceptive strategies could not be drawn. Further, only one of the 37 studies in the review explored DMPA-SC self-injection. The authors also noted that few studies meeting the eligibility criteria employed validated measures of reproductive empowerment. As such, there is a need for research to investigate the relationship between other contraceptive self-care methods and reproductive empowerment using rigorous methods.\u003c/p\u003e\n\u003cp\u003eIn a recent study assessing the pilot introduction of DMPA-SC self-injection in Addis Ababa, Ethiopia, we had the opportunity to include questions from a validated measure of reproductive empowerment. We present an analysis of these data that aims to explore the relationship between reproductive empowerment and the use and acceptability of DMPA-SC self-injection among new self-injectors. We use instrumental variable techniques to mitigate the problem of endogeneity.(15)\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eSetting\u003c/h2\u003e\n\u003cp\u003eThe self-injection pilot study took place across six high-volume public health facilities in Addis Ababa, Ethiopia, that were selected by the Ministry of Health to pilot rollout of DMPA-SC self-injection.\u0026nbsp;Recent data indicate that 48% of married women of reproductive age in Addis Ababa currently use a modern method of family planning\u0026nbsp;(16). Of those using any contraceptive method, injectables are the most widely used, representing 34% of the method mix in the city\u0026nbsp;(16). According to the 2016 Ethiopia Demographic and Health Survey, 32% of women in Addis Ababa had completed secondary education or higher and 88% were literate\u0026nbsp;(17). \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eWe used data from our recent study which aimed to generate information on the safety, acceptability, and feasibility of introduction and scale-up of DMPA-SC self-injection in select sub-cities in Addis Ababa, Ethiopia. This was achieved through a mixed-methods implementation research design, enrolling a prospective cohort of adult family planning users seeking injectable contraceptive services from public sector providers, who were followed-up over a three-month period.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData collection\u003c/h2\u003e\n\u003cp\u003eFour-hundred participants were recruited between August-December 2021.\u0026nbsp;All family planning users at the pilot sites who were medically eligible and interested in DMPA-SC self-injection were invited by public health family planning providers to participate in the study, until the target sample size was reached. The target sample size of 400 was determined to be sufficient for assessing competency in DMPA-SC self-injection at three months, which was the primary outcome of the pilot study.\u0026nbsp;Trained research assistants administered a tablet-based enrollment questionnaire to document participants\u0026rsquo; sociodemographic characteristics and perceptions of self-injection prior to training.\u0026nbsp;Providers then trained participants to self-administer DMPA-SC, who\u0026nbsp;were invited to practice self-injection on a prosthetic, and then inject themselves. Providers assessed participants\u0026rsquo; self-injection performance using a\u0026nbsp;standardized observation form.(6, 9, 18-20)\u0026nbsp;Those who demonstrated that they could competently self-inject were given one additional unit of DMPA-SC to take away with them to reinject three months later. These participants were eligible for follow-up. During the follow-up visit, the research assistants administered a tablet-based questionnaire to capture participants\u0026rsquo; experience with self-injection training, 3-month self-injection, storage, disposal, and side effects, as well as their perceptions on acceptability of the method. Participants then demonstrated self-injection technique on a prosthetic while the research assistants assessed their performance using the standardized observation tool.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eReproductive empowerment was measured during both the enrollment and follow-up surveys using the validated Reproductive Empowerment Scale.(21, 22)\u0026nbsp;This scale was selected\u0026nbsp;because it meets the three levels of agency outlined by the Reproductive Empowerment Framework.(23)\u0026nbsp;Specifically, this study utilized the reproductive health decision-making sub-scale as this component is most closely linked to individual behavior that may be related to DMPA-SC self-injection. The sub-scale is comprised of four questions scored from 1-4 for a total maximum score of 16, with higher scores representing higher levels of reproductive empowerment. Two of the questions employ Likert scales (from strongly disagree to strongly agree) focusing on one\u0026rsquo;s ability to use contraception or refuse sex when one\u0026rsquo;s partner is in opposition. The other two questions ask about one\u0026rsquo;s current and preferred contraceptive decision-makers such that those responding with \u0026ldquo;my partner and myself jointly\u0026rdquo; receive the highest score, then those saying \u0026ldquo;myself\u0026rdquo;, then \u0026ldquo;my partner\u0026rdquo; and finally all other options.(24)\u0026nbsp;The mean response score was imputed for participants with two or fewer missing responses. Participants with three or more missing responses needed for the subscale were excluded from analysis.\u003c/p\u003e\n\u003cp\u003eAcceptability of DMPA-SC self-injection was assessed through the following questions (1) uptake of self-injection (measured through participation in the study), (2) re-injection at 3-months (dichotomous, measured at 3-month follow-up visit), and (3) desire to continue using DMPA-SC self-injection in the future (dichotomous, measured at 3-month follow-up visit). Related concepts of comfort and confidence with self-injection were also measured over time. Comfort with self-injection was measured using a 4-point Likert scale (very nervous, somewhat nervous, at ease, very at ease) and confidence was measured with a 3-point Likert scale (very confident, somewhat confident, not very confident). Participants were asked to consider their comfort with self-injection prior to self-injection training (measured during the enrollment survey prior to self-injection training), after training, and after reinjection approximately 3-months after training (both assessed in the follow-up survey). Confidence about self-injection was with respect to self-injection at enrollment, reinjection 3-months later, and regarding future self-injection, all of which were asked about during follow-up.\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eDescriptive analysis was performed to describe the characteristics of participants who completed a 3-month follow-up visit.\u0026nbsp;We first assessed if there were changes in reproductive empowerment by performing a paired t-test to compare reproductive empowerment scores from enrollment to the 3-month follow-up visit. We performed this same paired t-test assessing changes in reproductive empowerment scores again among a restricted sample that only included participants who had already reinjected at the time of follow-up to explore if there was a difference for this subgroup. We then built a multivariable model to adjust for confounders and assess the factors related to the change in reproductive empowerment scores from baseline to endline. We used a data-driven approach to build the model, starting with separate regression analyses for each of the variables under consideration, with inclusion of baseline empowerment as the only confounding factor. Variables were considered for analysis based on theoretical plausibility that they may affect reproductive empowerment. Any variable with p\u0026lt;0.1 in this analysis was considered for inclusion in the final model. To avoid introducing endogeneity problems, variables measured at the time of follow-up were not eligible for inclusion in the model, with one exception. We considered self-injection competency at follow-up because this indicator was measured through independent observation of injection technique and may not be affected by the same factors as our measure of reproductive empowerment at follow-up. The model included the baseline reproductive empowerment score as a covariate to control for incoming levels of reproductive empowerment. We assessed the models using\u0026nbsp;the variable inflation factor to identify multicollinearity problems, and AIC and R-squared, dropping additional variables based on this model assessment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe selected one measure of acceptability of DMPA-SC self-injection to assess the relationship with empowerment. For this analysis, we considered desire to continuing using DMPA-SC self-injection as our main outcome of interest as it more closely reflects future behavior intentions, and we hypothesized that higher empowerment would lead to better acceptability.\u0026nbsp;The modeling approach described below could be done for other acceptability measures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo explore the relationship between empowerment and the desire to continue using DMPA-SC self-injection, we built an instrumental variable probit model. As described above, empowerment and measures of acceptability may be affected by similar unmeasured factors or have a reversed causality relationship. For example, is self-injecting empowering and/or are those with higher levels of empowerment more likely to continue self-injecting? This potential endogeneity could result in biased estimates unless an appropriate methodology is followed. To address the potential endogeneity, we identified instrumental variables of endline reproductive empowerment and then applied a two-stage regression approach to predict desire for continuation with an instrument for empowerment, controlling for other variables. For this exploratory analysis, we used a data-driven approach to identify suitable instrumental variables by first conducting a bivariate regression model for any variable that could potentially be related to desire to continue using self-injection, among those collected, and then selecting those with a p-value \u0026lt;0.1 for inclusion in the multivariable model. Variables were further selected based on measures of good fit including AIC and BIC. We compared multivariable models for our main outcome of desire to continue self-injecting and that of our potentially endogenous variable of endline reproductive empowerment. The model for endline reproductive empowerment was used rather than that of change in reproductive empowerment as we theorized that one\u0026rsquo;s level of reproductive empowerment at follow-up was more likely to be related to future use than the change in empowerment experienced over the last 3 months. However, the final models for both endline and change in reproductive empowerment resulted in the inclusion of the same factors (Supplemental material). Variables found to be associated with endline reproductive empowerment but not with desire to continue with DMPA-SC self-injection were selected as instruments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo help explain the model results, we also explored changes in comfort and confidence to self-inject over time (not in relation to reproductive empowerment). We compared individual change in response to the question regarding how comfortable participants felt with self-injecting over time, among those who re-injected at 3-months. We also compared individual change in response to the question regarding how confident participants felt about self-injection over time, among those who re-injected at 3-months. We calculated the proportion of participants who shifted responses between time points and tested whether significant shifts in response categories occurred between time points using the Stuart-Maxwell marginal homogeneity test for symmetry. A visual depiction of these shifts is illustrated through Sankey diagrams. All analyses were conducted using Stata version 16 and final tests of associations with p\u0026lt;0.05 were considered significant for two-sided comparisons.(25)\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong the 343 participants surveyed at follow-up, over 40% had not completed primary school and 30% were 18-24 years old at enrollment (Table 1). Most identified as Orthodox Christian and 50% reported working for payment within the last year. A minority disclosed they were using family planning discretely and few had prior self-injection experience. At the three-month follow-up visit, most participants (78%) wanted to continue self-injecting DMPA-SC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Descriptive characteristics of participants followed-up at 3 months (n=343)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant characteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth facility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eHealth facility 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e25 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eHealth facility 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e71 (20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eHealth facility 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e75 (21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eHealth facility 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e70 (20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eHealth facility 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e61 (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eHealth facility 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e41 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e,\u003cem\u003e\u0026nbsp;mean (sd) [range]\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e27.8 (5.3) [18-47]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational level achieved\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eNo education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e27 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eSome Primary, but incomplete\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e116 (33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eCompleted Primary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e39 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eSome Secondary, but incomplete\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e50 (14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eCompleted Secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e56 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eSome Post-secondary, but incomplete\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e19 (5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eCompleted Post-secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e36 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttended postsecondary education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e288 (84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e55 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eOrthodox Christian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e238 (69.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eProtestant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e47 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e3 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e55 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployed in last year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e172 (50.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e171 (49.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCovert user status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eNot a covert user\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e309 (90.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eCovert user\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e34 (9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrior self-injection experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e314 (91.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e24 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e5 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInjected by follow-up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e104 (30.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e239 (69.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesire to continue method\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e66 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e267 (77.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e10 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReproductive empowerment score at enrollment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMean (sd) [range]\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e12.32 (2) [3-16]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReproductive empowerment score at follow-up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMean (sd) [range]\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e12.28 (1.7) [3.3-16]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange in reproductive empowerment score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"71.27882599580713%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMean (sd) [range]\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.72117400419287%\" valign=\"top\"\u003e\n \u003cp\u003e-0.04 (2.2) [-7.7-11]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSd = standard deviation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eReproductive empowerment and desire to continue using DMPA-SC self-injection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReproductive empowerment scores were high both at baseline and endline (about 12 out of 16 points on the sub-scale for both, Table 1). There was no statistically significant difference in reproductive empowerment scores from enrollment to follow-up (n=343; p=0.76). Among the restricted sample of those who reinjected by the 3-month follow-up visit (n=239), there was similarly no significant difference in reproductive empowerment scores over time (p=0.77).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe final model of the change in reproductive empowerment (Table 2) included postsecondary education, employment, health facility, and religion, adjusting for baseline empowerment. Baseline reproductive empowerment scores were strongly independently associated with the change in reproductive empowerment in this model. For each 1-point increase in baseline reproductive empowerment, there was a 0.77-point decrease in the change in scores, such that participants with higher initial reproductive empowerment scores experienced less of a change in their score.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAttendance of postsecondary education and working within the last year were significantly associated with increases in reproductive empowerment, after adjusting for other factors. Religion was significantly independently associated with the change in reproductive empowerment, whereby participants identifying as Protestant had a 0.65-point lower change in reproductive empowerment score than those identifying as Orthodox Christian. There were only three participants who identified as Catholic. Due to issues of small cell size and since we considered it inappropriate to combine these participants into another category of religion, they (\u0026lt;1% of sample) were excluded from this analysis. Enrollment health facility was related to the change in reproductive empowerment however no one health facility was significantly different from the reference facility. The model explained 51% of the variability in the change in reproductive empowerment scores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Factors associated with change in reproductive empowerment score (n=340)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted for baseline reproductive empowerment only\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCoefficient (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinal model\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCoefficient (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostsecondary education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.59 (0.12-1.05)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.53 (0.04-1.02)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.38 (0.04-0.73)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.35 (0-0.69)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth facility (ref=HF 1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealth facility 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.14 (-0.87-0.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.18 (-0.9-0.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealth facility 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.72 (-0.01-1.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.71 (0-1.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealth facility 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.13 (-0.86-0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.2 (-0.91-0.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealth facility 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.02 (-0.76-0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.35 (-1.11-0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealth facility 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.66 (-0.13-1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.62 (-0.16-1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(ref = Orthodox Christian)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003eProtestant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.58 (-1.08--0.07)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.65 (-1.15--0.15)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.37 (-0.85-0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.46 (-0.95-0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eReproductive empowerment score at enrollment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.77 (-0.85--0.68)**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.02 (-0.05-0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCovert user\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.16 (-0.42-0.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* p\u0026lt;0.05, **p\u0026lt;0.01; N/A = not applicable; CI = confidence interval; ref = reference group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo develop the instrumental variable probit model for desire to continue using DMPA-SC self-injection, we first modeled endline reproductive empowerment and desire for continuation separately. We compared the variables included in each of the models of best fit. Variables significantly related to endline reproductive empowerment that were not significantly associated with desire to continue DMPA-SC were identified as instruments. These included religion, employment status and postsecondary school attendance. This is consistent with the results of the model for change in empowerment in Table 2. The final model did not identify a significant relationship between desire to continue using DMPA-SC self-injection and reproductive empowerment either at baseline or at follow-up using the instruments, after adjusting for other variables (Table 3). Desire to continue the method was significantly associated with participants\u0026rsquo; health facility at enrollment and their experience of side effects, when accounting for other factors. Compared to participants who did not experience any side effects, those who did experience them and reported increasing levels of interference in their everyday life, were significantly less interested in continuing to use DMPA-SC self-injection in the future. The Wald test of exogeneity was not significant at the p\u0026lt;0.05 level, indicating there is insufficient information in the sample to conclude that there is a clear endogeneity problem, though it was marginally significant (p=0.086). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Factors associated with desire to continue using DMPA-SC self-injection (n=325)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"top\"\u003e\n \u003cp\u003eCoefficient (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth facility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealth facility 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.13 (0.36-1.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealth facility 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.64 (-0.27-1.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.166\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealth facility 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.38 (-0.28-1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.261\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealth facility 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.47 (0.47-2.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"bottom\"\u003e\n \u003cp\u003eHealth facility 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.57 (-0.32-1.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.211\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterference of side effects\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(ref: no side effects experienced)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"bottom\"\u003e\n \u003cp\u003eNot at all\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.31 (-0.8-0.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.203\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"bottom\"\u003e\n \u003cp\u003eVery little\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.96 (-1.74--0.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"bottom\"\u003e\n \u003cp\u003eLittle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e-1.32 (-2.22--0.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"bottom\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e-1.74 (-2.85--0.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"bottom\"\u003e\n \u003cp\u003eVery much\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e-2.83 (-4.23--1.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompetence at follow-up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.29 (-0.3-0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.335\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReproductive empowerment score at baseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e-0.1 (-0.23-0.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.160\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.637239165329056%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReproductive empowerment at follow-up\u003c/strong\u003e \u003cem\u003e(instrumented)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.077046548956663%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.32 (-0.05-0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eInstruments: religion, employment status, postsecondary education\u003c/p\u003e\n\u003cp\u003eWald test of exogeneity (corr = 0): chi2(1) = 2.97 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Prob \u0026gt; chi2 = 0.0849\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eComfort and confidence to self-inject over time\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbout half of participants felt somewhat nervous about DMPA-SC self-injection at enrollment, prior to receiving self-injection training (174/343, 51%; Figure 1). There was no significant change in individual reporting of comfort level with self-injection from pre- to post-training (p=0.17). However, there was a significant shift in participants\u0026rsquo; level of comfort reported at the 3-month follow-up as compared to their feelings immediately after training, among those who reinjected (n=239, p\u0026lt;0.001). Among the 133 participants who said they felt somewhat nervous immediately after training, only 29% still felt somewhat nervous after their 3-month reinjection while 71% said they then felt at ease or very at ease. Similarly, only 12% of the 82 participants who felt very nervous post-training continued to feel very nervous after reinjection, while 81% of those who said they were very at ease remained at ease. Those who did not reinject by the time of the follow-up visit were included in Figure 1 to illustrate the pathways of all 343 participants. However, the test for comparing the shifts between the two time points only considers the 239 who reinjected (70% of the 343 participants follow-up at 3-months). The majority of those who did not reinject had felt very or somewhat nervous about self-injection. It should be noted however that some participants who had not reinjected at the time of follow-up said they still planned to do so. At the time of follow-up, 71% of respondents (169/239) reported feeling at ease or very at ease with self-injection. To see the results of Figure 1 in table format see Additional File 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1.\u003c/strong\u003e Comfort with DMPA-SC self-injection across time points (n=343)\u003c/p\u003e\n\u003cp\u003e*SI=self-injection\u003c/p\u003e\n\u003cp\u003eThe changes in confidence over time followed similar trends (Figure 2 and Additional File 1). All three questions about confidence were included in the follow-up survey but asked participants to reflect on different experiences \u0026ndash; their confidence during their first injection, during their second injection at 3-months and about future self-injection. Most participants (59%) said they felt somewhat confident about injecting their first time at the health facility. There was a significant shift in participants\u0026rsquo; reported confidence levels from this first injection to their second injection such that respondents indicated higher levels of confidence (p\u0026lt;0.001). For example, only 10% of those who initially said they felt \u003cem\u003enot very confident\u003c/em\u003e continued to feel this way after reinjection, while the other 90% said they now felt somewhat or very confident. There continued to be a significant shift towards higher confidence levels from one\u0026rsquo;s reinjection to one\u0026rsquo;s perception about future injection (p\u0026lt;0.001). 93% of participants who felt very confident at reinjection also anticipated feeling very confident about future self-injection. Of those who said they were somewhat confident about their 3-month injection, 59% continued to feel this way while 38% felt very confident about future use. Overall, 61% of respondents said they were very confident about their ability to self-inject in the future. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2.\u003c/strong\u003e Confidence to self-inject DMPA-SC over time (n=237)\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs family planning self-care interventions such as contraceptive self-injection become increasingly available around the world, there is an urgent need to understand if these interventions are further widening access gaps between those who have greater versus fewer resources\u0026mdash;including power to achieve their desired reproductive outcomes. It is also important to understand if these interventions can increase users\u0026rsquo; reproductive empowerment which may offer benefits beyond pregnancy prevention. However, studying this important, but potentially reversed causal relationship is complicated by the potential for endogeneity requiring researchers to take additional steps during data analysis to avoid making incorrect causal statements. Using longitudinal data from a recent pilot study of DMPA-SC self-injection, we explored the relationship between reproductive empowerment and the desire to continue using DMPA-SC self-injection. These constructs are theoretically endogenous, and their relationship cannot be assessed through traditional association analyses. We used a two-stage regression approach to predict desire for continuation with an instrument for empowerment, controlling for other variables.\u003c/p\u003e\n\u003cp\u003eWe found that participants in this pilot study had high reproductive empowerment scores at both enrollment and the 3-month follow-up visit, and we observed nonsignificant differences in scores over time. The study population may have been highly empowered to begin with (at least according to the measure of empowerment we used) because they all agreed to join our study and try self-injection\u0026mdash;a new method being offered in their communities. Since scores were high to begin with there was not much room in the scale for the scores to increase over a 3-month period and this \u0026ldquo;ceiling effect\u0026rdquo; likely prevented us from observing differences over time. At least in this highly empowered population, we did not find evidence of self-care use affecting empowerment. This analysis should be replicated with a population with lower initial empowerment. For example, future studies should examine this relationship for those that are eligible for but decide not to try self-injection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe explored models for change in empowerment from baseline as well as for endline empowerment to identify suitable instrumental variables. The variables found to be associated with endline reproductive empowerment but not with desire to continue\u0026nbsp;with DMPA-SC self-injection were selected as instruments. These included religion, employment status and postsecondary school attendance, and are consistent with previous research that did not find women\u0026rsquo;s sociodemographic factors associated with the risk of discontinuation of DMPA-SC.(5)\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur final model did not identify a significant relationship between reproductive empowerment, either at baseline or at follow-up using the instruments, and desire to continue using DMPA-SC self-injection. While advocates of self-care describe self-injection as empowering, our findings do not support this conclusion. At the same time, we only measured a change in reproductive empowerment over a short time frame (3-months, only one reinjection) but perhaps changes take longer to occur. This warrants further research with longer follow-up. Also, we specifically explored reproductive empowerment and measured it through a specific measure. There are several scales available that measure reproductive empowerment-related concepts which cover different domains.(23)\u0026nbsp;If we had used another measure of reproductive empowerment, we might have found a different outcome. Also, as noted in the background section, empowerment is a broad concept with many related constructs. It is possible that self-injection, and perhaps self-care more broadly, are not related to reproductive empowerment but rather other types of empowerment. While the test of exogeneity did not meet our prespecified threshold for significance, it is\u0026nbsp;marginally significant and the constructs theoretically endogenous and as such, we still recommend future research investigate\u0026nbsp;this relationship\u0026nbsp;using appropriate methodology beyond single equation models. In addition, measurement of latent constructs pose additional challenges. Other measures of acceptability\u0026nbsp;of self-injection may be more clearly endogenous. In either case, previous research examining simple associations are methodologically flawed and researchers should always approach this question first with an analysis addressing endogeneity. After testing and confirming no\u0026nbsp;endogeneity in a particular analysis,\u0026nbsp;researchers could\u0026nbsp;then modify their models.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe factors that we found significantly associated with desire to continue self-injection\u0026mdash;participants\u0026rsquo; experience of side effects and the health facility where they were enrolled into the study\u0026mdash;are consistent with previous studies.(26-28)\u0026nbsp;Compared to participants who did not experience any side effects, those who did experience them and reported increasing levels of interference in their everyday life, were significantly less interested in continuing to use DMPA-SC self-injection in the future. The association with health facility may be related to differences in the (unmeasured) characteristics of participants attending the different health facilities or may be related to variations in provider counseling and training on DMPA-SC self-injection. This site-level effect warrants further investigation to ensure that counseling and training are high-quality and empathy-based across all health facilities.\u003c/p\u003e\n\u003cp\u003eLike other studies, we found that comfort and confidence to self-inject increased over time.(7, 29)\u0026nbsp;Interestingly, we found no change in comfort level from pre- to post-training, but we did see a significant increase in participants\u0026rsquo; comfort after re-injection 3-months after training. It appears that users begin to feel more comfortable with this method after having injected themselves once on their own. This suggests that it is important for providers to focus on helping adopters through the first injection. We found that participants\u0026rsquo; confidence significantly increased over time from the first injection to the 3-month re-injection, and towards future self-injections. Only 4% of participants who re-injected at 3-months were not very confident in their ability to self-inject in the future. These results indicate that there may be further gains in constructs related to empowerment over a longer period of time. Exploring measures of self-confidence and self-efficacy may be of interest in future research on this topic.\u003c/p\u003e\n\u003ch2\u003eLimitations\u003c/h2\u003e\n\u003cp\u003eAs a secondary analysis, we were limited by the study design and data that were collected to answer the primary research question. The two main outcomes in this analysis are conceptually endogenous,\u0026nbsp;as described in the introduction. Our analysis\u0026nbsp;attempted\u0026nbsp;to address the endogeneity concern, but it is affected by the data (measurement and design) as well as the potential for some misspecification (important confounders, appropriate instruments). Other study designs and inclusion of different subgroups could mitigate the endogeneity concerns by controlling for who chooses to participate in self-care, by design. On the other hand, our analysis is strengthened by the use of longitudinal data, which is rarely available. Further, our analysis uses robust methods to appropriately disentangle the endogeneity in our outcomes, offering more valid conclusions than naive regression analysis. Both better data and appropriate modelling addressing the endogeneity of these outcomes, are needed.\u0026nbsp;Importantly, endogeneity should not be ignored.\u003c/p\u003e\n\u003cp\u003eAnother limitation of this study is that our measures of comfort with self-injection post-training and after re-injection 3-months later were measured at the same time, during the 3-month follow up visit. However, it is reassuring that despite the two measures being taken at the same time, the responses to these questions varied which is an indication that the participants were engaged during the survey and increases our confidence in the validity of their responses.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo our knowledge this the first analysis examining the relationship between reproductive empowerment and a contraceptive self-care intervention that used a modelling technique to better address the endogeneity problem that is rooted in the nature of these constructs. We also attempted to assess the directionality between the two constructs\u0026mdash;a pressing question in the family planning self-care space. We did this through two models: \u0026nbsp;the first assessed the change in empowerment after participants\u0026rsquo; first self-injection and the second assessed the effect of empowerment on potential future use self-injection. Though the data we had available to us in this secondary data analysis had limitations, through this analysis we shine a light on the serious issue of endogeneity inherent in answering this question and offered a strategy for how to appropriately answer it in future studies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eCI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.84615384615384%\" valign=\"top\"\u003e\n \u003cp\u003eConfidence interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.84615384615384%\" valign=\"top\"\u003e\n \u003cp\u003eNot applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eSd\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.84615384615384%\" valign=\"top\"\u003e\n \u003cp\u003eStandard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.84615384615384%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-injection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eDMPA-SC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.84615384615384%\" valign=\"top\"\u003e\n \u003cp\u003eSubcutaneous depot medroxyprogesterone acetate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.84615384615384%\" valign=\"top\"\u003e\n \u003cp\u003eReference group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.84615384615384%\" valign=\"top\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Ethiopian Public Health Institute Institutional Review Board, FHI 360\u0026rsquo;s Protection of Human Subjects Committee and PSI\u0026rsquo;s Research Ethics Board. All participants provided written informed consent to participate.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to organizational policy but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research was funded by the Children\u0026rsquo;s Investment Fund Foundation.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eKMA and HMB secured funding and HMB conceptualized the study. HMB, MML and MC designed the methodology. AA, TM and TT led data collection, MML, AA, TM and TT managed and coordinated the study and HMB and KMA provided supervision support. MML led analysis and visualization with support from MC. MML and HMB led manuscript development, with contributions from MC, and all authors reviewed and edited the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors would like to acknowledge Dr. Meseret Zelalem, Professor Mirkuzi Wolde, and Dr. Zerihun Bogale of the Federal Ethiopian Ministry of Health, along with Abaynesh Ahmed of the Addis Ababa Health Bureau and Fikreselassie Getachew of the Ethiopia Public Health Institute for their support of this research and the Children\u0026rsquo;s Investment Fund Foundation for their financial support to conduct the pilot study. We thank Carter Crew for verifying the results and Donna McCarraher for her review of the paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. WHO guideline on self-care interventions for health and well-being, 2022 revision. WHO Consolidated Guideline on Self-Care Interventions for Health: Sexual and Reproductive Health and Rights. WHO Guidelines Approved by the Guidelines Review Committee. Geneva, Switzerland: World Health Organization; 2022.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. WHO Consolidated Guideline on Self-Care Interventions for Health. WHO Consolidated Guideline on Self-Care Interventions for Health: Sexual and Reproductive Health and Rights. WHO Guidelines Approved by the Guidelines Review Committee. Geneva: World Health Organization\u0026copy; World Health Organization 2019.; 2019.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"3\"\u003e\n\u003cli\u003eLerma K, Goldthwaite LM. Injectable contraception: emerging evidence on subcutaneous self-administration. Curr Opin Obstet Gynecol. 2019;31(6):464-70.\u003c/li\u003e\n\u003cli\u003eBurke HM, Packer C, Buluzi M, Healy E, Ngwira B. Client and provider experiences with self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) in Malawi. Contraception. 2018;98(5):405-10.\u003c/li\u003e\n\u003cli\u003eBurke HM, Chen M, Buluzi M, Fuchs R, Wevill S, Venkatasubramanian L, et al. Factors Affecting Continued Use of Subcutaneous Depot Medroxyprogesterone Acetate (DMPA-SC): A Secondary Analysis of a 1-Year Randomized Trial in Malawi. Global Health: Science and Practice. 2019;7(1):54.\u003c/li\u003e\n\u003cli\u003eBurke HM, Mueller MP, Packer C, Perry B, Bufumbo L, Mbengue D, et al. Provider acceptability of Sayana\u0026reg; Press: results from community health workers and clinic-based providers in Uganda and Senegal. Contraception. 2014;89(5):368-73.\u003c/li\u003e\n\u003cli\u003eBurke HM, Chen M, Buluzi M, Fuchs R, Wevill S, Venkatasubramanian L, et al. Women's satisfaction, use, storage and disposal of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) during a randomized trial. Contraception. 2018;98(5):418-22.\u003c/li\u003e\n\u003cli\u003eBurke HM, Chen M, Packer C, Fuchs R, Ngwira B. Young Women's Experiences With Subcutaneous Depot Medroxyprogesterone Acetate: A Secondary Analysis of a One-Year Randomized Trial in Malawi. J Adolesc Health. 2020;67(5):700-7.\u003c/li\u003e\n\u003cli\u003eBurke HM, Chen M, Buluzi M, Fuchs R, Wevill S, Venkatasubramanian L, et al. Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomised controlled trial. Lancet Glob Health. 2018;6(5):e568-e78.\u003c/li\u003e\n\u003cli\u003eBrady M, Drake JK, Namagembe A, Cover J. Self-care provision of contraception: Evidence and insights from contraceptive injectable self-administration. Best Pract Res Clin Obstet Gynaecol. 2020;66:95-106.\u003c/li\u003e\n\u003cli\u003eDMPA-SC Access Collaborative. Looking back, thinking forward, and scaling up: Insights from the DMPA-SC Access Collaborative DMPA-SC Resource Library2021 [updated April 2021. Available from: https://fpoptions.org/resource/webinar-ac-insights/.\u003c/li\u003e\n\u003cli\u003eBurke HM, Ridgeway K, Murray K, Mickler A, Thomas R, Williams K. Reproductive empowerment and contraceptive self-care: a systematic review. Sex Reprod Health Matters. 2021;29(2):2090057.\u003c/li\u003e\n\u003cli\u003eEdmeades J, Hinson L, Sebany M, Murithi L. A conceptual framework for reproductive empowerment: empowering individuals and couples to improve their health. Washington DC: International Center for Research on Women. 2018.\u003c/li\u003e\n\u003cli\u003eZohra S. Lassi, Komal Abdul Rahim, Alexandra Maria Stavropoulos, Lareesa Marie Ryan, Jyoti Tyagi, Bisi Adewale, et al. Use of contraceptives, empowerment and agency of adolescent girls and young women: a systematic review and meta-analysis. BMJ Sexual \u0026amp;amp;amp; Reproductive Health. 2024:bmjsrh-2023-202151.\u003c/li\u003e\n\u003cli\u003eLe Bourdonnec K, Samieri C, Tzourio C, Mura T, Mishra A, Tr\u0026eacute;gou\u0026euml;t D-A, et al. Addressing unmeasured confounders in cohort studies: Instrumental variable method for a time-fixed exposure on an outcome trajectory. Biometrical Journal. 2024;66(1):2200358.\u003c/li\u003e\n\u003cli\u003eEthiopian Public Health Institute, ICF. Ethiopia Mini Demographic and Health Survey 2019: Key Indicators. Rockville, Maryland, USA: EPHI and ICF; 2019.\u003c/li\u003e\n\u003cli\u003eCentral Statistical Agency, ICF. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville Maryland, USA: CSA and ICF; 2016.\u003c/li\u003e\n\u003cli\u003eBurke HM, Mueller MP, Perry B, Packer C, Bufumbo L, Mbengue D, et al. Observational study of the acceptability of Sayana\u0026reg; Press among intramuscular DMPA users in Uganda and Senegal. Contraception. 2014;89(5):361-7.\u003c/li\u003e\n\u003cli\u003eCover J, Ba M, Lim J, Drake JK, Daff BM. Evaluating the feasibility and acceptability of self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA) in Senegal: a prospective cohort study. Contraception. 2017;96(3):203-10.\u003c/li\u003e\n\u003cli\u003eCover J, Namagembe A, Tumusiime J, Lim J, Drake JK, Mbonye AK. A prospective cohort study of the feasibility and acceptability of depot medroxyprogesterone acetate administered subcutaneously through self-injection. Contraception. 2017;95(3):306-11.\u003c/li\u003e\n\u003cli\u003eMandal M, Albert LM. Reproductive Empowerment Scale: Psychometric Validation in Nigeria. Chapel Hill, NC, USA: MEASURE Evaluation, University of North Carolina; 2020.\u003c/li\u003e\n\u003cli\u003eMandal MT-K, S.; Mejia, C. . Validating Measures of Reproductive Empowerment in Kenya. Chapel Hill, NC, USA: MEASURE Evaluation, University of North Carolina; 2020.\u003c/li\u003e\n\u003cli\u003eBurke HM, Thomas R. Thematic Analysis and Mapping of Reproductive Empowerment Scales: A Tool for Family Planning Self-Care Programming and Research. Global Health: Science and Practice. 2022;10(3):e2100794.\u003c/li\u003e\n\u003cli\u003eReproductive Empowerment Scale: MEASURE Evaluation; 2020 [Available from: https://www.measureevaluation.org/resources/publications/tl-20-81/at_download/document.\u003c/li\u003e\n\u003cli\u003eStataCorp. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC; 2019.\u003c/li\u003e\n\u003cli\u003eMacLachlan E, Atuyambe LM, Millogo T, Guiella G, Yaro S, Kasasa S, et al. Continuation of subcutaneous or intramuscular injectable contraception when administered by facility-based and community health workers: findings from a prospective cohort study in Burkina Faso and Uganda. Contraception. 2018;98(5):423-9.\u003c/li\u003e\n\u003cli\u003eCover J, Namagembe A, Tumusiime J, Nsangi D, Lim J, Nakiganda-Busiku D. Continuation of injectable contraception when self-injected vs. administered by a facility-based health worker: a nonrandomized, prospective cohort study in Uganda. Contraception. 2018;98(5):383-8.\u003c/li\u003e\n\u003cli\u003eCover J, Ba M, Drake JK, MD ND. Continuation of self-injected versus provider-administered contraception in Senegal: a nonrandomized, prospective cohort study. Contraception. 2019;99(2):137-41.\u003c/li\u003e\n\u003cli\u003eKohn JE, Simons HR, Della Badia L, Draper E, Morfesis J, Talmont E, et al. Increased 1-year continuation of DMPA among women randomized to self-administration: results from a randomized controlled trial at Planned Parenthood. Contraception. 2018;97(3):198-204.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Self-care, empowerment, DMPA-SC, subcutaneous depot medroxyprogesterone acetate, self-injection, endogeneity, instrumental variable model","lastPublishedDoi":"10.21203/rs.3.rs-4360966/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4360966/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Self-care interventions, including contraceptive self-injectables such as subcutaneous depot medroxyprogesterone acetate (DMPA-SC), are hypothesized to be empowering to users. It is also believed that those who are empowered are more likely to use self-care. Though critical for ensuring equity of these interventions, evidence for the relationship between empowerment and contraceptive self-care is scant. However, studying this relationship is challenging. In addition to the potential reversed causality between these two constructs, empowerment is determined by similar factors as the motivation for using self-care, contributing to an endogeneity problem. If not addressed, endogeneity can lead to incorrect causal assertions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Using data from a study of 400 women from six public health facilities in Addis Ababa, Ethiopia who opted to self-inject DMPA-SC, we assessed the directionality between the two constructs through two models: the first assessed the change in empowerment after participants’ first self-injection and the second assessedthe effect of empowerment on potential future use of self-injection. To address potential endogeneity, we identified instrumental variables of empowerment and then applied a two-stage regression approach to predict desire to continue self-injecting at follow-up with an instrument for empowerment, controlling for other variables.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Empowerment scores among the 343 women who were followed-up were high and did not significantly change from baseline to endline. Most women (78%) wanted to continue self-injecting. The following variables were associated with endline empowerment, but not with desire to continue and were therefore used as instruments: religion, employment status and postsecondary school attendance. The final model did not identify a significant relationship between desire to continue self-injecting and empowerment. The test of exogeneity was marginally significant (p=0.08).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eWe did not find evidence of a significant relationship between reproductive empowerment and desire to continue self-injecting. Though there are limitations to this secondary data analysis, we recommend future research investigate this relationship using the methodology we demonstrate to address endogeneity inherent in answering this critical question about self-care interventions.\u003c/p\u003e","manuscriptTitle":"Examining the relationship between reproductive empowerment and contraceptive self-injection: tackling the endogeneity problem","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-10 20:52:23","doi":"10.21203/rs.3.rs-4360966/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8e041a00-e908-4e7a-82fb-19ca961905ce","owner":[],"postedDate":"May 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-29T09:46:38+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-10 20:52:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4360966","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4360966","identity":"rs-4360966","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}