How do pro-social tendencies and provider biases affect service delivery? Evidence from the rollout of self-injection of DMPA-SC in Nigeria
Abstract Background Inconsistent provision of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) for self-injection (SI) undermines efforts to improve women’s reproductive health agency and access to self-care. In Nigeria, providers feel pro-social responsibility as frontline health workers to...
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| Format: | Article |
| Language: | English |
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BMC
2025-03-01
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| Series: | BMC Women's Health |
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| Online Access: | https://doi.org/10.1186/s12905-025-03613-6 |
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| author | Calvin Chiu Aminat Tijani Madeline Griffith Emily Himes Sneha Challa Chioma Okoli Shakede Dimowo Ayobambo Jegede Jenny X. Liu |
| author_facet | Calvin Chiu Aminat Tijani Madeline Griffith Emily Himes Sneha Challa Chioma Okoli Shakede Dimowo Ayobambo Jegede Jenny X. Liu |
| author_sort | Calvin Chiu |
| collection | DOAJ |
| description | Abstract Background Inconsistent provision of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) for self-injection (SI) undermines efforts to improve women’s reproductive health agency and access to self-care. In Nigeria, providers feel pro-social responsibility as frontline health workers to support their clients’ wellbeing. However, their pronatalist beliefs censure premarital sexual activity and inhibit access to contraceptives for young, unmarried women. How pro-social tendencies and provider biases interact to affect service delivery is a critical but underexplored question. Methods We conducted a mixed-methods study comparing stated pro-social tendencies and intentions to dispense DMPA-SC for SI (N = 81 in-depth interviews (IDIs)) with actual dispensing behavior during mystery client (MC) visits (N = 162 post-interaction surveys) across private and public facilities in Lagos, Enugu and Plateau. Qualitative analysis of providers’ pro-social tendencies, biases, and reasons for not offering DMPA-SC for SI complemented quantitative analysis exploring the associations between pro-social tendencies and dispensing behavior. Results Providers showed substantial levels of both pro-social tendencies and bias against young, unmarried women. High levels of stated intentions to dispense in IDIs (91% to older, married women vs 78% to young, unmarried women) did not translate to actual willingness to dispense in MC visits (30% to older, married women vs 27% to young, unmarried women). Young, unmarried actors were twice as likely to perceive differential treatment from providers (33%) relative to older, married women actors (17%). From IDIs, providers expressed biases about the appropriateness of family planning and SI specifically based on a client’s age, marital status, parity, and covert use. In some cases, pro-social tendencies reinforced bias when providers sought to uphold social norms as a gatekeeper; in other cases, pro-social tendencies on self-defined client needs helped overcome bias. Providers described other factors that deterred them from dispensing DMPA-SC for SI, including elements of self-care that posed risks to their practice or business. Conclusions Provider biases may limit provision of DMPA-SC for SI, which could affect contraceptive equity and women’s control over their own fertility, especially for younger, unmarried women. Targeted interventions that effectively address provider biases against young, unmarried women, potentially leveraging providers’ underlying pro-social tendencies, may help ensure equity in client access to contraceptive self-care. |
| format | Article |
| id | doaj-art-d9bda00241a44dbba9bb91b0f563bfc0 |
| institution | OA Journals |
| issn | 1472-6874 |
| language | English |
| publishDate | 2025-03-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Women's Health |
| spelling | doaj-art-d9bda00241a44dbba9bb91b0f563bfc02025-08-20T01:57:27ZengBMCBMC Women's Health1472-68742025-03-0125S111610.1186/s12905-025-03613-6How do pro-social tendencies and provider biases affect service delivery? Evidence from the rollout of self-injection of DMPA-SC in NigeriaCalvin Chiu0Aminat Tijani1Madeline Griffith2Emily Himes3Sneha Challa4Chioma Okoli5Shakede Dimowo6Ayobambo Jegede7Jenny X. Liu8Institute for Health & Aging, University of California San FranciscoAkenaPlus HealthInstitute for Health & Aging, University of California San FranciscoInstitute for Health & Aging, University of California San FranciscoInstitute for Health & Aging, University of California San FranciscoAkenaPlus HealthAkenaPlus HealthAkenaPlus HealthInstitute for Health & Aging, University of California San FranciscoAbstract Background Inconsistent provision of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) for self-injection (SI) undermines efforts to improve women’s reproductive health agency and access to self-care. In Nigeria, providers feel pro-social responsibility as frontline health workers to support their clients’ wellbeing. However, their pronatalist beliefs censure premarital sexual activity and inhibit access to contraceptives for young, unmarried women. How pro-social tendencies and provider biases interact to affect service delivery is a critical but underexplored question. Methods We conducted a mixed-methods study comparing stated pro-social tendencies and intentions to dispense DMPA-SC for SI (N = 81 in-depth interviews (IDIs)) with actual dispensing behavior during mystery client (MC) visits (N = 162 post-interaction surveys) across private and public facilities in Lagos, Enugu and Plateau. Qualitative analysis of providers’ pro-social tendencies, biases, and reasons for not offering DMPA-SC for SI complemented quantitative analysis exploring the associations between pro-social tendencies and dispensing behavior. Results Providers showed substantial levels of both pro-social tendencies and bias against young, unmarried women. High levels of stated intentions to dispense in IDIs (91% to older, married women vs 78% to young, unmarried women) did not translate to actual willingness to dispense in MC visits (30% to older, married women vs 27% to young, unmarried women). Young, unmarried actors were twice as likely to perceive differential treatment from providers (33%) relative to older, married women actors (17%). From IDIs, providers expressed biases about the appropriateness of family planning and SI specifically based on a client’s age, marital status, parity, and covert use. In some cases, pro-social tendencies reinforced bias when providers sought to uphold social norms as a gatekeeper; in other cases, pro-social tendencies on self-defined client needs helped overcome bias. Providers described other factors that deterred them from dispensing DMPA-SC for SI, including elements of self-care that posed risks to their practice or business. Conclusions Provider biases may limit provision of DMPA-SC for SI, which could affect contraceptive equity and women’s control over their own fertility, especially for younger, unmarried women. Targeted interventions that effectively address provider biases against young, unmarried women, potentially leveraging providers’ underlying pro-social tendencies, may help ensure equity in client access to contraceptive self-care.https://doi.org/10.1186/s12905-025-03613-6Provider biasPro-social tendenciesSelf-injectionSelf-care |
| spellingShingle | Calvin Chiu Aminat Tijani Madeline Griffith Emily Himes Sneha Challa Chioma Okoli Shakede Dimowo Ayobambo Jegede Jenny X. Liu How do pro-social tendencies and provider biases affect service delivery? Evidence from the rollout of self-injection of DMPA-SC in Nigeria BMC Women's Health Provider bias Pro-social tendencies Self-injection Self-care |
| title | How do pro-social tendencies and provider biases affect service delivery? Evidence from the rollout of self-injection of DMPA-SC in Nigeria |
| title_full | How do pro-social tendencies and provider biases affect service delivery? Evidence from the rollout of self-injection of DMPA-SC in Nigeria |
| title_fullStr | How do pro-social tendencies and provider biases affect service delivery? Evidence from the rollout of self-injection of DMPA-SC in Nigeria |
| title_full_unstemmed | How do pro-social tendencies and provider biases affect service delivery? Evidence from the rollout of self-injection of DMPA-SC in Nigeria |
| title_short | How do pro-social tendencies and provider biases affect service delivery? Evidence from the rollout of self-injection of DMPA-SC in Nigeria |
| title_sort | how do pro social tendencies and provider biases affect service delivery evidence from the rollout of self injection of dmpa sc in nigeria |
| topic | Provider bias Pro-social tendencies Self-injection Self-care |
| url | https://doi.org/10.1186/s12905-025-03613-6 |
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