In total, 37 men participated in 4 FGDs in Mangochi and Thyolo. In Blantyre, Mangochi, and Thyolo, 64 providers (58 from public sector and 6 from private sector) participated in 9 FGDs and 4 interviews, and 30 female clients (12 from public and 18 from private sector) participated in interviews.

Participants of FGDs with men consisted of approximately half community leaders and half partners of DMPA-SC users. Their average age was 39 years, all had at least one child, and 38% had completed secondary school (Table 1). Almost 95% of the men’s partners had previously used the intramuscular version of DMPA (DMPA-IM), 62% had self-injected DMPA-SC, and 38% had ever received provider-administered DMPA-SC. For nearly half the men’s partners (49%), the most recently used family planning method was DMPA-SC self-injection.

Table 1 Sociodemographic characteristics of community leaders and partners of DMPA-SC users (FGDs with men)

Out of the 64 family planning providers, 3 worked in private pharmacies in Blantyre and 3 worked in private clinics in Mangochi and Thyolo districts (data not shown). Just over half of providers were men (52%) and their average age was 38 years. Most providers had been offering family planning for more than 4 years and DMPA-SC (both provider administered and self-injection) for more than 1 year. On average, since beginning to offer DMPA-SC, each provider had counseled 531 clients on DMPA-SC self-injection (range 1–4000) and trained 198 clients to self-inject (range 0–1500).

In terms of female clients, the average age was 30 years and all except one had at least one child (data not shown). Most were married (77%) or had a sexual partner (20%), and for most (76%), their partner knew they were using family planning. The most commonly used method was DMPA-IM (77% had ever used).

Men as family planning usersMen can and will offer participatory support

Participants discussed a variety of ways men had provided or could provide direct support to their partners to self-inject. As reported in the manuscript discussing the primary study objective [23], the main barrier to uptake of DMPA-SC self-injection was women’s fear of self-injecting. To address this concern, participants in 2 FGDs with men and 3 with providers discussed how men were attending or could attend counseling with their female partners to learn how to support her with the injection. For example, a participant from an FGD with men said:

We come together to the facility and we got counseled together such that when one day she failed to open the tube, I helped her.

Similarly, a participant from an FGD with providers said:

I think if we can deal a lot with involving men to escort their wives whereby they can also get trained on how they can be injecting their wives, with this the wives may be encouraged to select self-injection.

In men’s FGDs, participants whose partners had used DMPA-SC self-injection described helping to administer the actual injection when their wife got scared, helping their wife remember injection dates (e.g., by setting an alarm or marking the calendar), and assisting with DMPA-SC storage such as keeping the units out of children’s reach. For example, one participant said:

Sometimes she is afraid to inject herself and I usually take the responsibility of injecting her. I also take the same responsibility in reminding her on the date she is supposed to reinject herself and I normally ask her if she can remember her day.

Female clients were asked how their partners could support them if they decided to use DMPA-SC self-injection. Of the 30 female clients interviewed, 26 said that they would tell their partners if they decided to use DMPA-SC self-injection and 19 gave specific active ways their partner could or would support them. These included reminding them about when to re-inject and refilling the prescription when the units run out. About one-fifth of those who said they would tell their partner suggested that their partners could inject them. For example, one female client said:

He can help in injecting me when I become afraid to inject myself.

Men as supportive partners

Some providers and female clients and most participants in the men’s FGDs felt that partner support would help women adopt and successfully use self-injection. Most male participants held personally favorable opinions toward DMPA-SC self-injection.

Why men are supportive

In FGDs with men, participants whose partners had self-injected described being supportive because they felt that self-injection saved their wives time which could be used to do other things for themselves and the household (e.g., chores), saved money due to reduced transportation costs, and limited the need to make multiple clinic trips due to crowded facilities, unavailability of providers, or stock outs. For example, one participant described:

I see that it [self-injection] is a good thing as it alleviates the burden of movement and also it enables women to have ample time doing household chores, as it reduces time they spend in waiting for the service at the hospital.

Participants in the men’s FGDs said they liked that self-injection allowed them to better know the whereabouts of their partners. Fewer clinic visits, including reduced transportation to and from the facility and time away from home, reduced their “doubt” about their wives, such as fear of infidelity. To illustrate this point, a men’s FGD participant remarked:

Sometimes when they are coming here at hospital, one might think that she is not going to hospital but for a secret lover.

Of the 26 female clients who said they would tell their partner if they decided to use DMPA-SC self-injection, 24 said they believed their partner would be supportive, or reassuring, of this decision, as described by this client:

…as a schoolgirl there are a number of methods I follow to protect myself from unexpected pregnancy... So that method [DMPA-SC self-injection] is obvious that is used to protect from unwanted pregnancies hence he [my partner] will be in the forefront to make sure that I have completed my studies and if possible will get married and stay together.

Echoing the sentiment that men like that self-injection helps women stay at home, one of the female clients said:

Since most guys don’t like that women go to hospital for family planning, with privacy issues, he would prefer I self-inject here at home where it is convenient.

How men are supportive

Participants in all the FGDs with men described men’s actual or potential role of offering emotional support to their partners to encourage uptake and continuation of DMPA-SC self-injection. Participants whose partners had used DMPA-SC self-injection said their support included telling jokes to reduce fear during injection, providing general encouragement to “be bold” and self-inject, embracing family planning use in general, and buying special foods to reassure their partner on injection day. For example, one participant said:

What I liked most is that she told me that I should be reminding her if I feel like she will forget her reinjection dates, emphasizing that it is my duty to play a role in her use of DMPA-SC self-injection… I encouraged her to… make sure that if she feels that she will forget, she should hang the calendar on the wall and circle the reinjection dates clearly.

Participants whose partners had not self-injected believed that if they encouraged their wives to use DMPA-SC self-injection, then women would not fear self-injecting and might be more interested in the practice, as this male participant described:

We need just to encourage women that they should not be having fear because us men we have to support them when they want to self-inject. Therefore, this might make them to be bold to inject themselves.

Men as agents of changePartner opposition or support affects women’s use of self-injection

In response to the questions about why women would or would not choose to self-inject, men, providers, and female clients stated that men play a distinct role in women’s use of DMPA-SC self-injection. About half of providers, one-fifth of clients, and some men discussed partner opposition as a barrier to DMPA-SC self-injection uptake and use. Providers and clients noted that covert users may not be willing to self-inject for fear that their partner would not be supportive if he found the units at home. For example, one female client said:

For women who hide their use of contraceptives from their husbands because their husbands do not want them to be on it, self-injection might not be a good option for them, since they might feel that one day the injection units might bring disagreements in the family, which is different from provider administered where they just go to the facility, get injected, and come back without their husbands noticing about it.

Male FGD participants discussed the issue of men’s opposition to DMPA-SC self-injection. In one FGD, they said this could deter women from trying it or force them into covert use. In another FGD, men acknowledged that by not openly supporting women, they were, in fact, inhibiting women from using DMPA-SC self-injection. For example, one male FGD participant said:

[A] problem which women are facing is having fear to use this method of self-injecting at home because men are not supportive. Therefore, this makes women do it secretly.

Participants in all men’s FGDs discussed that women would be interested in self-injection because it would benefit their lives, and they viewed women as being even more inclined to use DMPA-SC self-injection if their male partners and/or community leaders encouraged them to do so, as seen in the following discussion between 2 participants in a men’s FGD:

Participant 1: Men are the reasons why women would opt for self-injection if we are to encourage them to do so since some of the women are afraid of injecting themselves. As men, we should make sure that we are in the forefront on encouraging women on the benefits of self-injection.

Participant 2: I feel that if these women are fed with proper and right information from their community leaders and service providers, they would be opting for this method.

Men’s role in shifting norms

To increase men’s acceptability of self-injection, participants in one men’s FGD suggested that men whose wives self-inject should talk to other men about the practice. In another men’s FGD, participants suggested that male partners of self-injectors could disseminate messages to youth, with the aim of shifting norms for future generations. For example, one participant said:

We have community youth clubs that move around in the communities disseminating various messages. Men are present in such gatherings, and I think that can be one of the platforms where we can introduce this method to them. Later, these men can carry these messages to their homes, and they would help to encourage women to opt for this method.

Other participants from provider and men’s FGDs mentioned involving men in the development and dissemination of messaging in other fora, as well as making educational leaflets available in communities so that men could learn about DMPA-SC self-injection on their own time. Participants in all the men’s FGDs felt that women would be more inclined to self-inject if encouraged by male partners and/or community leaders. They suggested that expanding community involvement by educating village chiefs and husbands would work towards normalizing self-injection because men could help to change misconceptions in the community and promote an enabling environment. For example, one participant from a men’s FGD explained:

If the HSAs would be invited in meetings which chiefs conduct with their subjects and give a talk on this section… In due course, men would be reminded frequently, hence they can be transformed with the passing of time.

Similarly, providers urged community outreach and advocacy to encourage greater male involvement and subsequent uptake of DMPA-SC self-injection. More than half of providers were of the opinion that community involvement, particularly community leadership and male heads of household, would reinforce messaging around DMPA-SC self-injection. For instance, one provider said:

As men are the head of the houses, we should involve them. We will not have problems. We should also do sensitization and health talks… Even the village heads should be told about DMPA-SC so that we can remove misconceptions in the villages.

Engaging men in social and behavioral change (SBC)

SBC efforts can play a role in increasing men’s support of contraceptive use through promotion of accurate knowledge of and favorable attitudes toward family planning and DMPA-SC. However, participants in all of the men’s FGDs reported that men do not receive enough messaging about DMPA-SC self-injection or family planning in general. One participant explained:

The problem is that the women come on their own to collect the method without the men’s knowledge, leading to misunderstanding since men do have their own ideas. As such, men need to be involved.

Most of the men’s FGD participants had positive views about DMPA-SC and self-injection. However, in all 4 men’s FGDs, participants also cited misconceptions, such as that women’s use of DMPA-SC affected men’s own physical and sexual health, including having reduced “sexual power.” For example, one participant stated:

But the majority believe that when women, more especially my wife, when she takes this method of Sayana and it happens that I have slept with her, I do feel that something has entered in my body. Because when you went to bed, you do just fall asleep, and in my case… I don’t perform during sex as before. And even when I went to the farm [to work], I feel pain when I bend my waist.

These myths were also reflected in provider and female client perceptions of how men viewed DMPA-SC, particularly, as one client described:

Men feel that injectable contraceptive weakens their manhood power.

Although providers and clients also noted that men ascribed to those myths about contraception in general and not exclusively DMPA-SC. One provider explained:

For men, they think every family planning method weakens them. They say they do not perform in their homes sexually. They say they just do one round and they fall asleep.

Providers also mentioned community-wide misconceptions, held by both men and women, such as DMPA-SC leading to female infertility, as this provider described:

There were some rumors loitering around [the community] that when you inject yourself DMPA-SC on the stomach, the uterus gets burnt and you will never give birth.

The majority of providers expressed the importance of engaging men in SBC in order to diminish misconceptions and increase user demand. They recommended engaging people in a number of ways, including community engagement with both men and women present, engaging men specifically, and counseling couples together. For example, one provider suggested:

On misconceptions, we can encourage them, say they should be coming as couples when a wife wants to start taking the contraceptives, so that you should explain to both of them together.