Improving contraceptive agency through peer social support: findings from a longitudinal qualitative evaluation of the I-CAN intervention in Uganda

Abstract

Background: Sexual and reproductive health organizations have been advocating for a human rights-based approach to contraceptive programming for many years, but progress has been slow. Peer social support shows promise to address structural and social barriers limiting women's agency to make and act on decisions related to contraception, but evidence-based models are lacking. Informed by Social Support Theory and the Contraceptive Agency Framework, we used human-centered design to develop “I-CAN”, a community-based peer mentorship intervention in which experienced contraception users in Uganda provide tailored support to peers to promote agency and self-efficacy to use self-injectable contraception among women interested in this method. We conducted a six-month pilot of I-CAN and report here on qualitative findings from a longitudinal study exploring I-CAN's social support mechanisms. Methods: We conducted serial in-depth interviews with n = 25 women who received mentorship at baseline, three months, and six months in 2023. We conducted parallel interviews with a comparison group (n = 15) without the intervention. Women were purposefully sampled for diversity in contraceptive use, district, and age. We analyzed interviews using a codebook informed by I-CAN's theory of action. Results: We identified two primary ways in which I-CAN peer social support appeared to improve mentee agency more than existing social support in the control group: (1) improved contraceptive knowledge, particularly allaying side effect concerns, and (2) improved ability to act on contraceptive preferences via communication with unsupportive partners, covert use, or accessing contraceptive services or products. Less prominent changes compared to the control included improved self-efficacy to self-inject and perceived control over and consciousness of the right to contraceptive choice. Conclusions: Underpinned by a human rights-based approach to contraception, the I-CAN intervention, shows promise that locally tailored peer social support models can effectively improve contraceptive agency, particularly related to knowledge and partner communication.