Ethics statement

The study was conducted in close partnership with the Reproductive Health Directorate, MOH Malawi, and ethical approval to conduct this research was granted by the National Health Science Research Committee (NHSRC)–an independent international review board in Malawi with Federal-Wide Assurance (IRB00003905, FWA00005976). All study participants were asked to provide voluntary written informed consent to participate in this study prior to interview and were compensated for their participation in line with NHSRC policy. Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information Inclusivity in Global Research Questionnaire (S2 Text).

Methods, sampling and data collection

MOH Malawi and Clinton Health Access Initiative (CHAI) collaborated in 2021 to conduct this cross-sectional qualitative study. Specific outcomes of interest included: provider perspectives on enablers and barriers of integrating DMPA-SC intro their contraceptive counselling approach; client recall of, and perspectives on, the information received about DMPA-SC from providers during counselling sessions; client perspectives on the quality of training and support provided during SI training; as well as provider and client perspectives on the length of time counselling/training on DMPA-SC takes.

Study sites were six randomly-sampled public sector facilities in three districts (Nkhotakota, Mzimba South, Zomba)–one district from each of Malawi’s three regions. Districts and facilities were sampled randomly to minimize selection bias, however only public facilities that provided 10 or more DMPA-SC services per month were included in the sampling frame, to ensure enough injectable clients could be sampled. At each site, providers and injectable clients were purposively sampled according to inclusion criteria (for providers, this meant having been trained in DMPA-SC; for clients, this meant having used either a self-injected or provider-administered injectable contraceptive in the last nine months).

Data was collected using semi-structured in-depth interview guides. Several participatory activities were integrated to elicit detail about the provider-client counselling interaction. Firstly, providers were asked to role-play injectable contraceptive counselling and SI training with the data collectors acting as ‘clients’ interested in injectables. Providers were reassured that this exercise was purely to understand variations in approaches between providers, and that their responses would be anonymized, to try and minimize possible Hawthorne effect.

All data was collected in October 2021. Data for this study was collected during a period of inconsistent DMPA-SC stock in Malawi and other countries, due to global disruption in supply. Cognizant that method stockouts may affect how providers counsel on these methods [14] and may impact quality of contraceptive services [15], research assistants were trained to probe during role plays on whether and how providers’ self-reported counselling approaches may vary in cases of DMPA-SC stockouts.

Secondly, recognizing that some clients may not always critically appraise the quality of their care when they are unaware of the standards expected [16], injectable clients in this study were shown one of two videos to establish a standard against which they could assess the quality of the injectables counselling and SI training received:

1. Video 1 showed two actors demonstrating a best practice injectables counselling session between provider and client (S1 Text contains the script for the video). This video was created for the study and approved by the MOH for use for study purposes. It was shown to PA injectable clients who had chosen not to take up the SI option to help them critically compare with their own experience of counselling on injectables. It did not cover the SI training steps in detail, as most PA clients would not have proceeded with SI training after individual counselling. PA clients were interviewed on the same day that they received counselling, to minimize the chance of recall bias influencing results.
2. Video 2 was developed by PATH International [17] and explains the critical SI information and SI steps that a self-injecting client needs to know. This animated video was shown to current/recent SI clients to help them identify any gaps in their knowledge/recall. SI clients were often interviewed weeks or even months after receiving their original counselling on DMPA-SC, introducing the chance of recall bias in their recollections of individual counselling messages originally received about elements such as side effects and safe disposal. However, it was determined that they should still be able to recall the key SI steps, as successful independent self-injection is dependent on recall of these steps.

As Nkhotakota and Zomba are predominantly Chichewa-speaking districts, while Mzimba South is predominantly Tumbuka-speaking, all study tools and videos were translated or dubbed into both languages for study purposes.

The final sample size was based on theoretical saturation, which refers to the point at which no new ideas arise from data from a sample diverse in relevant characteristics and experiences [18]. Clear variation in themes emerging from the two DMPA client populations (PA and SI) during early data collection led to the decision to slightly expand sample sizes in those two groups to ensure saturation could be reached. No identifying information about participants was collected other than broad descriptors relating to basic demographics or cadre. Quantitative descriptors were collected on paper by the study team and manually entered into Excel for descriptive analysis. Qualitative data was collected by trained research assistants, audio-recorded, transcribed verbatim in Chichewa or Tumbuka and then translated into English for analysis.

Analysis

Data was coded deductively by three qualitative researchers using Dedoose software. To ensure alignment between coders, coding was conducted in three phases. Firstly, 20% (n = 8) client transcripts and 25% (n = 6) of provider transcripts were coded independently by all three members of the analysis team, then coded versions merged for comparison and discussion to generate a codebook. Then, a further 20% (n = 8) of the sample for client IDIs and 25% (n = 6) of the sample for provider IDIs were double-coded (i.e. coded by one member of the team and then checked by another) to ensure consistency and comprehensiveness of code application. Finally, and only once good agreement in coding between the three members of the team had been established, 60% (n = 24) of the sample of client IDIs and 50% (n = 12) of the sample for provider IDIs were single coded. Once data was fully coded, code reports (S1 Data contains code reports relevant to counselling/training) were exported from Dedoose for thematic analysis.

For some themes (for example, the counselling messages covered during provider role-plays), a ‘framework approach’ was used, charting the coded data into a matrix to allow comparability across in-depth interviews and against the recommended client counselling pathways in national protocols and in-service training content on DMPA-SC provided by MOH (Fig 1). Where relevant, sub-group analyses were conducted by splitting code reports up between provider-administered and self-injection client groups or between health surveillance assistants (HSAs) and facility-based provider groups, to note any variation in themes or opinions between the sub-groups.

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Fig 1. Client counselling pathways according to national protocols and provider in-service training content on DMPA-SC in Malawi.

https://doi.org/10.1371/journal.pgph.0002057.g001

Integrating self-injection into health education

All providers reported they had integrated high-level information on DMPA-SC and the SI option into their health education run-through of all the contraceptive methods (which most providers reportedly conducted as either a group session during a structured clinic or, for some HSAs, one-to-one with individual clients during home-based visits). Most providers said they still mentioned DMPA-SC and the SI option at this health education stage, even if they did not currently have DMPA-SC in stock, but advised that clients may need to receive PA options in the meantime until DMPA-SC was available again.

Some providers mentioned incorporating testimony from satisfied SI clients at the group health education stage, to demonstrate to other clients that it was possible for clients like them to SI. These providers felt this addition of peer testimonials was a powerful tool to support client confidence to SI.

Many providers reported emphasizing the benefits of SI at the health education stage; particularly that SI could reduce visits to facilities, which they felt would be the most appealing feature to clients. This is despite national protocol indicating both advantages and disadvantages of each method should be covered at group health education stage (Fig 1). One provider explained that the decision to focus on benefits was to pique client interest in DMPA-SC, knowing that the details of the method would be covered later in individual counselling:

“[In health education sessions]… we cannot focus on the bad side because she will not choose the method, but we should explain to her the advantages of the method. Then she understood [sic] and makes her choice. And then we train her on this method [later].”

–HSA, Nkhotakota

Echoing this practice, most PA injectable clients mentioned having first heard some high-level messages on SI during either a health education session and/or sometimes through other clients. For these clients, their level of recall was also typically limited to only the high-level benefits of SI, indicating that they had either not received or did not recall more in-depth information on disadvantages, mode of action, and side effects during health education nor through subsequent individual counselling on injectables:

“Yes, they [providers] told us that the injection is good, the self-injection. [Interviewer: Alright, did they say anything about the side effects of this injection? …] No, they did not say anything on that, they just explained about the benefits…”

–married PA client, 30–39 years, Zomba

A small group of PA injectable clients reported little or no awareness of even the high-level messages about SI, indicating they may have either not received or did not recall these messages from even a group health education session. These clients were mainly long-term DMPA-IM users who also reported that they tended to skip or not pay attention during group health education sessions and only spend a short time with providers one-on-one at their re-injection visits. They often cited satisfaction with DMPA-IM and lack of motivation to switch methods as their reasons for not paying attention to group health education:

“I can’t explain [about DMPA-SC] because I did not pay attention [during health education] … [Interviewer: Why didn’t you pay attention?] It’s because I don’t want to be convinced with a new method… I did not pay attention [be]cause the one [contraceptive method] I am using works well on me, so I don’t want to hear other methods.”

–married PA client, 30–39 years, Mzimba South

Integrating self-injection into individual method-specific counselling

If clients expressed interest in injectables after health education, providers then reported offering them in-depth individual counselling where they asked questions about contraceptive history, side effects and checked for contraindications, as well as presenting detailed information on all injectables options and exploring the client’s interest in the SI or PA options for mode of administration. This self-reported provider practice aligns with expected national protocol (Fig 1).

Most providers stressed the importance of having this one-to-one space with clients to tailor counselling to their needs. However, in a deviation from national protocol, a handful of providers reported grouping clients who expressed interest in a particular method to avoid repeating themselves and to save time–this practice included but did not seem to be exclusive to counselling on injectables. During stockouts of DMPA-SC, providers ranged in their approach with clients interested in SI at this stage: from encouraging clients to temporarily use other methods, to still proceeding with SI counselling/training but limiting clients’ opportunities to practice and/or their number of take-home doses, depending on stock availability.

During counselling role-plays, most providers interviewed demonstrated comprehensive counselling on DMPA-SC messages that aligned with national protocols and in-service training content, including proactively advising on re-injection dates, safe storage and disposal of the Unijects. Most providers were able to explain the benefits (for example, pregnancy prevention, reduced visits to facilities, discretion, etc.) and disadvantages/potential side effects (for example, menstrual changes, weight change, headaches, potential delayed return of fertility, etc.) of DMPA-SC, relative to other methods.

However, some messages from the national in-service training content that providers often missed during role-plays included advice on what clients should do:

• if they missed their re-injection window
• if they experienced any irritation or dimpling at the injection site
• to return unused units if they decided not to use them

In role-plays with research assistants, providers also shared their improvised techniques for familiarizing the concept of SI with clients early on. For example, some mentioned making comparisons between DMPA-SC and other needle-based concepts clients were familiar with–usually DMPA-IM, but also sometimes things like vaccines, malaria test kits, or insulin injections:

“…we also tell them that the needle is small comparing with Depo Provera [DMPA-IM]. When you show the… the two needles, they say this is long and this small and easy just like malaria test kit. When we counsel her, they understand although they might still be afraid.”

–HSA, Nkhotakota

Many providers noted the effectiveness of including elements that are typically associated with hands-on SI training (the next step for interested clients) into the individual counselling session early on–for example they had noticed that including a verbal/gestural description or visual of the SI steps into the information provided on DMPA-SC and/or showing clients the Uniject that this stage of the counselling was effective at alleviating concerns about the size of the needle or complexity of the SI process.

Some PA injectable clients were positive about the quality of individual counselling on injectables they received, even after comparing it to the best practice counselling session video (S1 Text). However, several others felt their own experience of counselling was less detailed than the session in the video:

“[Interviewer: Ah why have you not tried it [self-injection]?] because I was not trained properly, I did not receive the proper training … but they also did not explain that this is how you perform self-injection very well …they also did not talk about the consequences [side effects]”

–PA client, missing age and marital status, Zomba

For example, some PA clients picked up on topics covered in the best practice video that they felt had been missing (or not recalled) from their counselling, namely exactly how and where to self-inject, while others noted that they had not seen a visual aid/calendar that might have helped them remember the steps:

“The provider said we have three places where we can self-inject but, in the video, they have said we have only two places where we can self-inject.”

–married PA client, 30–39 years, Mzimba South

“…we were not given the calendar… it was a verbal calendar explaining that after 90 days you should do it…. But here [in the video] there is a calendar [with the job aid showing the SI steps] from washing hands to self-injecting.”

–married PA client, 40–49 years, Zomba,

From what they recalled from their original counselling on SI, most SI clients said the messages aligned with the key information covered in the PATH video. [17] Only a few SI clients reflected that the topic of possible side effects of DMPA-SC had been covered in more depth in the video than they recalled from their original counselling. A few others said they recalled receiving different disposal advice (for example, to throw used Unijects in a pit latrine) to the recommended advice mentioned in the video (i.e. to keep in a puncture-proof container and return to the facility):

“The training I received from my provider is different [from the video] because [in the video] they have said that some get fat, some menstruate, some [have] stomach ache and some headache. They did not explain this.”

–married SI client, 20–29 years, Nkhotakota

“[Interviewer: Anything else that you were not told that you have heard in the video?] … Oooh yes, we were told to throw the used injection in the toilets [pit latrine] whilst our friend [the client from the video] was told to through it in a Frozy bottle and bring it back to the facility.”

–married SI client, 20–29 years, Mzimba South

However, given most SI clients were interviewed weeks or months after their original counselling, these examples may be subject to recall bias.

All SI clients interviewed reported feeling reassured enough in their individual counselling to proceed to being trained in SI. By contrast, only a few PA clients reported that they had decided to proceed with training in SI after receiving counselling–the majority reported that they still had too many concerns about pain or doubt in their own ability to SI to even proceed with SI training.

Conducting self-injection training

After counselling on DMPA-SC, answering client questions, and establishing no contraindications, providers reported offering clients interested in DMPA-SC the opportunity to be trained on SI. Several providers commented that, if they had spent enough time addressing concerns during counselling (and especially if they had included a visualization or demonstration element of the Uniject and/or SI steps early) most clients would choose to be trained in SI, while only a few clients would request PA instead:

“…if you do the counselling very well, they do not have any concerns as long as they have understood every procedure on how they can self-inject and also know the next date to self-inject in doing so they will not forget.”

–Facility-based provider, Mzimba South

If they had not done so already, most providers reported first conducting some sort of visual demonstration of the Uniject and SI steps to kick off SI training. This typically involved using a visual aid (for example, posters, job aids or the visuals on the back of SI calendars) and/or gestures and demonstrations with a real Uniject–where DMPA-SC stock availability allowed. Many providers emphasized the importance of clients being able to visualize the SI steps to reassure them of the simplicity of it:

“…most people easily understand when they are able to see the things that they are being trained in, how it is operating…”

–HSA, Zomba

Providers were generally very positive about the DMPA-SC SI calendars used in Malawi (these include a visual reminder of the SI steps on the back), which they felt served multiple purposes– 1) acting as a visual aid during counselling/training, 2) serving as a reminder of the SI steps for clients at home, and 3) helping clients keep track of their re-injection dates:

“… calendars they are so helpful… It contains details on the steps on how self-injection should be done and also it has some pictures that help the clients to see the process. We also use the pictures when counselling clients … It helps especially when they are alone, they are able to refer to the instruction sheet.”

–HSA, Nkhotakota

During role plays, most providers showed good knowledge of the critical SI steps from national protocol/provider in-service training content. The critical SI steps most commonly mentioned by providers during the role plays included:

• the importance of shaking and activating the Uniject
• pinching the skin at the injection site
• injecting at a downward angle
• not rubbing the injection site after injecting
• disposing of the product safely in a closed container and returning it to a heath official

A few of the SI steps that were less commonly mentioned by providers included:

• Handwashing before self-injecting
• Checking expiration dates before self-injecting
• Removing the needle cap and not replacing it
• Pressing the reservoir for 5–7 seconds
• The specific sequencing of removing the needle and releasing the ‘pinched’ skin
• Calculating and noting down the date for the next injection

From the client side, there were understandable differences between the level of recall of critical SI steps between PA and SI clients. Most PA clients had not proceeded to SI training and therefore recalled only high-level information (typically only shaking and activating the Uniject and pinching the skin before injecting on the thigh or stomach) from their individual counselling. It was not always clear if this lower recall of the SI steps was due to providers omitting SI steps during counselling, or due to lack of PA client interest or absorption of the information at this stage.

By contrast, current/recent SI clients understandably showed the most detailed spontaneous recall for most of the critical SI steps, typically able to walk through most or all the steps from memory:

“This is how we hold Sayana [showing the interviewer using hands] then we shake it, after shaking it we press its neck and then the needle is pushed inside then we hold the place where we want to inject ourselves and then we inject the needle. The moment we realize that the needle is inside the skin then we press the medicine until all is finished then we start pulling out the needle little by little.”

–divorced/widowed SI client, 20–29 years, Nkhotakota

Most SI clients reported that the SI steps they recalled aligned mostly or completely with those covered in the PATH video: [17]

“… everything that we were trained [on] is in the video… After I watched the video and the training that I received from the providers… I can see that [I] am able to do everything in order and there is no problem and the providers trained us well”

–married SI client, 30–39 years, Zomba

After the visual demonstration, most providers reportedly then encouraged clients to practice with a Uniject. While national protocol/provider in-service training content suggests clients should practice first on inanimate objects, such as a condom filled with sugar, only a few providers talked about doing this in practice (and, if they did, they typically used cheaper materials than sugar, such as condoms filled with sand, or oranges or tomatoes). Most providers in this study instead reported encouraging clients to ‘practice’ SI directly for the first time on their thighs or stomachs, under supervision. The skipping of the practice on inanimate objects was said to be due to concerns about ‘wasting’ scarce DMPA-SC stock; provider time constraints; concerns about the cost of sugar; or because providers felt clients were not ‘convinced’ by practicing on inanimate materials:

“…most of the times the women are reluctant [they think] that this [condom filled with sugar] is not a real thing, and they want a demonstration on the actual body… so we don’t rely on it too much…”

–Facility-based provider, Zomba

Providers often noted that practice was the most challenging part of SI training, requiring observation and repeated feedback to ensure clients self-injected correctly. Some providers seemed to treat this step as something of an ‘exam’ for clients, using the terms ‘pass’ and ‘fail’ to denote if they were happy or unhappy with the client’s attempt:

“…we compare … how they are injecting themselves and see where they are doing wrong, and we help them to improve on that. And the ones who have passed [successfully self-injected], we congratulate them and tell them to continue at home. But for the ones who have failed, we tell them.”

–HSA, Nkhotakota

A few providers talked about revisiting demonstrations and training on SI over time (for example, over the course of several PA re-injection visits) to build the confidence of clients who had previously ‘failed’ practice sessions.

From the client perspective, SI clients were slightly more likely than their PA counterparts who had received SI training to mention having seen a visual demonstration of SI steps during SI training, while some SI clients said they had seen another client self-inject before being encouraged to ‘practice’ on themselves. By contrast, very few PA clients who proceeded to SI training mentioned seeing a visual demonstration of any kind, nor seeing other clients self-inject first before being asked to ‘practice’ on themselves. Reflecting the provider tendency to skip the practice on inanimate objects, very few clients in either the SI or PA group mentioned having practiced in this way–most said that their first ‘practice’ had been on their own thighs under provider observation:

“We were taught how to inject ourselves; we were asked if [we] would manage and I agreed and attempted to inject myself while the HSA was watching, she confirmed that I had done it well and could manage to do it on my own.”

–married SI client, 40–49 years, Zomba

“[Interviewer: Did they give you a chance to practice] Yes, they did [Interviewer: Did you self-inject? What did you use to practice?] They gave us a chance like me I practiced on my body”

–married PA client, under 20, Mzimba South

In general, SI clients reflected positively on their SI training and credited the visualizations, demonstrations and practice under observation with helping them build confidence and overcome initial fears:

“I had fears at first. But the fears went off because we were self-injecting under direct observation by the provider, they were instructing us on how to do it [Interviewer: What did you [do to] deal with the fears apart from providers being there for you?] It’s because of the counselling they gave us. When we started the procedure, everything was going as they had taught us, so this relieved us our fears.”

–married SI client, 20–29 years, Mzimba South

A few SI clients described how providers helped them overcome their fears and build their confidence over repeated PA visits, if they had initially been too afraid to try SI:

“Like for me I asked them to inject me because I was not confident. But I was told it [DMPA-SC] was meant for self-injection. During the second visit, they counselled us again and this time I understood and managed to self-inject”

–married SI client, 30–39 years, Mzimba South

When asked why they had not taken up SI after receiving SI training, the few PA clients who had received the SI training tended to blame themselves rather than the quality of their training–despite also reporting their training as ‘rushed’. For example, they were more likely to talk about struggling to overcome initial fears; lacking confidence in their own ability; or mirroring the providers’ language about having ‘failed’ their practice:

“I wanted to find out if I will be able to self-inject. If I will do it, I will be using that one. But I failed. [Interviewer: You failed?… How exactly did you fail?] I failed to open [activate the Uniject]. They say that for it to be opened [activated], it has to make a sound and I failed to do that. I was like ‘I will end up destroying this thing’.”

–married PA client, 30–39 years, Nkhotakota

A few PA clients also reported feeling pressure or judgment from providers to take up SI:

“[Interviewer: What was the nurse saying?] …[she] was saying, ‘Why do you still want us to inject you? Why are you not getting the self-injecting one?… Why are you not injecting yourself?’ … [Interviewer: So what did you say?] I said I have never taken the self-injecting type before.”

–married PA client, 20–29 years, Nkhotakota

Length and feasibility of comprehensive counselling and training

Most providers in this study reported that it takes between 15–20 minutes to counsel and then train a client on DMPA-SC SI. A few others said it could take more than 20 minutes and up to 45 minutes with some clients. Finding this additional time during busy days was not always easy for providers:

“To explain to the client [about DMPA-SC SI], you need to have uninterrupted time and also sometimes nurses are busy … you need to sit down and start explain[ing] all the procedures up until you are convinced that she can do it. So it’s not that difficult but you just need time to do it”

–Facility-based provider, Mzimba South

A few providers mentioned other factors that could influence the length of counselling/training. For example, many providers felt that counselling/training a client who had previously used an injectable would be quicker, as she had existing knowledge to draw on, while clients with less knowledge of contraception may be more difficult to counsel and train, as they would have more questions to address:

“Having previous experience [with injectables] does help, for instance, during counselling if we have clients who started the method some time [ago]… you will hear them commenting that they know the stuff … So … this makes the work simple because you know the counselling process will be easy and does not take a lot of time. Whilst if you have new clients it takes long to counsel them”

–HSA, Nkhotakota

Providers generally did not mention educational status of the client influencing counselling time, but they did mention age. Most providers felt that adolescents (under 20) required more time to counsel, just because they were more likely to be starting from a low baseline of information about contraception:

“Compared to an older woman, because older women already know the things, and maybe they have already heard the things from somebody else, but mostly the adolescents don’t know most of the information relating to family planning…”

–HSA, Zomba

However, a few providers said that it was actually quicker to counsel adolescents because they would pick up new ideas quickly:

“The understanding of adults is a bit complex… Hence it becomes difficult for them to grasp the information easily as such you have to say it again and again. It’s different from adolescents when you train them, they capture the info easily…”

–Facility-based provider, Nkhotakota

A few providers said adolescents’ anxiety about being seen at the facility was a factor in them wanting to avoid group health education sessions or in them asking for faster counselling:

“Most youth mostly don’t have time. It happens that sometimes the time we’re giving the talk, they’re rushing to do their own things and they sometimes try to avoid people … they think “If so and so sees me they will report them to their homes.”

–Facility-based provider, Zomba

Several providers described their role in counselling/training on SI becoming quicker and easier over time, as their own experience increased and awareness of DMPA-SC at community-level grew:

“…initially I think for the first three months … we would spend almost 45 minutes… 40 to 45 minutes… but after the first three months we spend 15 minutes”

–Facility-based provider, Zomba

Despite the time pressures, most providers took their responsibility for counselling and training clients in SI very seriously and felt that investing in longer counselling/training facilitated comprehensive understanding, uptake of SI, and reduced likelihood of SI clients encountering problems later. Many providers also clearly articulated that they believed investing that time would increase SI uptake and reduce their workload later, in terms of reducing visits by repeat PA clients:

“If the provider has counselled the clients so well in details, it becomes so easy for the clients when it comes for them to try to self-inject. But in cases where the provider does counsel the clients in a hurry without checking whether they are clear with the process, [then] it becomes a problem for them when doing the trial injection [practice].”

–HSA, Nkhotakota

“[once trained in SI] … they will just come and collect, and they will not show up again for an entire year. For them [not] to come back, it means [in] the gap they create we can be serving other clients…”

- HSA, Zomba

However, a minority of providers admitted that time pressures drove them to take shortcuts in counselling/training, most commonly turning to small-group method-specific counselling and small-group SI training approaches over individual approaches:

“During busy days, we do shortcuts (laughs)… We wait for at least the women to be 10 or 8 or 7, where you feel that this a good number. You just teach them in one kick [one group session] and then give them the methods. But for you to start one-on-one [counselling/training] and [it] being a busy day, it does not work.”

–HSA, Nkhotakota

On the clients’ side, SI clients were also more likely than their PA counterparts to say their training had taken a long time, even up to an hour, but typically they were satisfied with this length, as they felt it aided their understanding:

“[Interviewer: … Did you feel the provider spent enough time training you?] Yes. we spent a lot of time at that place. [Interviewer: you understood what they trained you?] I understood everything they trained me about.”

–married SI client, 20–29 years, Nkhotakota

Meanwhile most PA clients who had not taken up SI felt that the counselling and training time they received was too short to fully help them understand:

“[Interviewer: do you feel you received enough counselling [on DMPA-SC] from the provider?] no she was rushing she seemed to have other things to do”

–married PA client, 20–29 years, Mzimba South

Both PA and SI clients who reported having received at least some of their counselling and/or SI training in a small-group context did not explicitly note whether the group nature of this experience affected the quality of their counselling/training nor whether it influenced their decision to take up or not take up SI.