WHO Guideline on Self-Care Interventions for Health and Well-Being

Publication date: 2021

WHO Guideline on Self-Care Interventions for Health and Well-Being WHO Guideline on Self-Care Interventions for Health and Well-Being WHO guideline on self-care interventions for health and well-being This publication is the update of the Guidelines published in 2019 entitled “WHO consolidated guideline on self-care interventions for health: sexual and reproductive health and rights”. This publication also expands the scope of the 2019 Guidelines. ISBN 978-92-4-003090-9 (electronic version) ISBN 978-92-4-003091-6 (print version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. https://creativecommons.org/licenses/by-nc-sa/3.0/igo http://www.wipo.int/amc/en/mediation/rules/ https://creativecommons.org/licenses/by-nc-sa/3.0/igo http://apps.who.int/iris http://www.who.int/about/licensing iii Contents CONTENTS Preface vi Foreword vii Acknowledgements viii Acronyms and Abbreviations x Document Overview and Navigation Tools xi Executive summary xii 1. Introduction 1 1.1 Background 2 1.2 Objectives 7 1.3 Living guideline approach 7 1.4 Definition of self-care and self-care interventions 8 1.5 Scope 9 1.6 Target audience 11 1.7 Values and preferences 11 1.8 Guideline development and compilation process 12 2. Essential strategies for creating and maintaining an enabling environment for self-care 14 2.1 Background 16 2.2 People-centred approach for health and well-being 17 2.3 Key principles 17 2.4 Safe and supportive enabling environment 19 2.5 Characteristics of the enabling environment 22 2.6 Places of access to self-care interventions 24 2.7 Accountability 24 3. Recommendations and key considerations 28 3.1 Improving antenatal, intrapartum and postnatal care 30 3.2 Providing high-quality services for family planning, including infertility services 40 3.3 Eliminating unsafe abortion 46 3.4 Combating sexually transmitted infections (including HIV), reproductive tract infections, cervical cancer and other gynaecological morbidities 47 3.5 Promoting sexual health 50 3.6 Noncommunicable diseases, including cardiovascular diseases and diabetes 55 4. Implementation and programmatic considerations for self-care interventions 64 4.1 Background 66 4.2 Human rights, gender equality and equity considerations 67 4.3 Financing and economic considerations 69 4.4 Training needs of health workers 72 4.5 Population-specific implementation considerations 78 4.6 Digital health interventions 84 4.7 Environmental considerations 86 iv WHO Guideline on Self-Care Interventions for Health and Well-Being Cover: © UNICEF/Patricia Willocq, © Shutterstock/AJR_photo, © Shutterstock/Mila Supinskaya Glashchenko, © Jonathan Torgovnik, © istock/Alessandro Biascioli Chapter 1: © Photoshare/Hari Fitri Putjuk, © Images of Empowerment/Getty © Images/Paula Bronstein Chapter 2: Elmvh CC BY-SA 3, © WHO/Blink Media – Nikolay Doychinov Chapter 3: © UNICEF/Mani, © UNICEF/Shehzad Noorani Chapter 4: © Shutterstock/Rawpixel, © Getty Images/Images of Empowerment/Paula Bronstein Chapter 5: © Richard Liblanc, © Julia Fiedler Chapter 6: © Adobe Stock/poco_bw, © WHO/Ploy Phutpheng Pg v: © UNICEF/Njiokiktjien Pg 63: © Shutterstock/Tooykrub Pg 95: © WHO/Tania Habjouqa Pg 111: © WHO/Anne Sturm Guerrand Pg 117: © Shutterstock/Anton_Ivanov The Web Annex, containing the summary tables of the evaluations of the evidence for this guideline, is available at https://apps.who.int/iris/bitstream/handle/10665/342654/9789240031326-eng.pdf. The interactive web-based version of this living guideline is available at https://app.magicapp.org/#/guideline/Lr21gL. SMART Guidelines on self-care interventions for antenatal care, family planning, HIV and other topics is available under: https://www.who.int/teams/digital-health-and-innovation/smart-guidelines PHOTOGRAPHER CREDITS 5. Developing the research agenda for self-care interventions 96 5.1 Research on self-care and self-care interventions contributing to the World Health Organization’s triple-billion goals 98 5.2 Towards an appropriate approach to research on self-care interventions 98 5.3 Specific research considerations to strengthen the evidence base 99 5.4 Centring human rights and equity in self-care interventions 99 5.5 Ensuring the meaningful engagement of communities in research 102 5.6 Knowledge translation for self-care interventions 102 6. Dissemination, applicability and updating of the guideline and recommendations 112 6.1 Dissemination 114 6.2 Applicability 115 6.3 Updating the guideline 116 Annexes 118 Annex 1. External experts and WHO staff involved in the preparation of this guideline 118 Annex 2. Methodology: guideline development process 126 Annex 3. Scoping review: WHO self-care definitions 133 Annex 4. Glossary 135 Annex 5. Summary of declarations of interest and the management of conflicts of interest 145 Annex 6. Priority questions and outcomes 147 Annex 7. Published reviews 152 Annex 8. Guideline Development Group judgements on new recommendations 153 https://apps.who.int/iris/bitstream/handle/10665/342654/9789240031326-eng.pdf https://app.magicapp.org/#/guideline/Lr21gL https://www.who.int/teams/digital-health-and-innovation/smart-guidelines v Photographer credits vi WHO Guideline on Self-Care Interventions for Health and Well-Being PREFACE I am driven by the conviction that everyone has a right to health. But today, at least half the world’s population has no access to essential health services. The provider-to- client model that is at the heart of health systems must be complemented with a self-care model through which people are enabled to make active, informed health decisions to promote health, prevent disease, maintain health and cope with illness and disability with or without the support of a health worker. Many health issues can already be diagnosed and managed through self-care interventions, and the list continues to grow. People have been practising self-care for millennia, and new diagnostics, medicines, and interventions, including digital technologies, are changing how health services can be delivered. Self-care and self-care interventions have also played a critical role in individual, community and national responses to the COVID-19 pandemic. In the context of overstretched health systems and shortages of qualified health workers, self-care interventions, prioritized by the World Health Organization (WHO), have contributed to improving health and well-being. Self-care must work as an extension of the health system, so that while people are using self-care interventions, they can also access the health system and community support for further assistance when needed. It is also important that self-care occurs in a safe and supportive environment, to avoid the stigma, violence and negative health outcomes that can often occur when seeking care in isolation. This guideline on self-care interventions is based on the core principles of universal health coverage, including a people-centred approach to health that views people as active decision-makers in their own health, not merely passive recipients of health services. People-centred approaches to healthcare also support health literacy, including digital literacy, so that people can take charge of their own health with evidence-based self-care interventions. This guideline can play an important role in helping people both to access safe and effective self-care interventions and to avoid ones that may be dangerous or otherwise unhelpful. The partnerships and experts who have contributed to the development of this guideline will also be important for its dissemination and implementation, particularly among underserved and marginalized populations who may have trouble accessing formal health systems. I hope you will join me to promote this important guideline and support the efforts of WHO to implement self-care interventions for health. Dr Tedros Adhanom Ghebreyesus Director-General World Health Organization vii Foreword FOREWORD S elf-care interventions are playing a more prominent role in today’s world with greater access through avenues such as digital technologies and the availability of over- the-counter medicines and diagnostics via pharmacies. The development of normative guidance from the World Health Organization (WHO) on self-care interventions acknowledges the important roles of individuals and communities in their own healthcare and the shift away from solely accessing health services through traditional health centres. Further data and rigorous research continue to be needed to ensure a strong evidence base to promote the introduction, use and scale-up of self-care interventions. We urgently need to identify innovative research methodologies to better understand self-care and how it fits into individual, community and national- level healthcare. This need is in large part due to the challenges in collecting information on health practices at home. Research is the foundation for learning, and monitoring, evaluating and improving these interventions, to ensure we are reaching the most underserved and marginalized communities with the right information and services, and positively impacting their health and well-being. Meaningful community engagement, including qualitative research methodologies to capture experiences and lived realities, can further strengthen the evidence base. Building on the exciting momentum for self-care globally, there is an opportunity to expand the research in this field. Research has an important role in the implementation and scale-up of health programmes and interventions, including self-care. Partnerships will be instrumental in carrying out this research and using the information to inform and enhance self-care interventions. By leveraging the framework, recommendations and good practices within this guideline, we can implement quality interventions and design research methodologies to support and further this rapidly growing field. This will be imperative to driving a sustainable pathway to achieving health for all. Dr Soumya Swaminathan Chief Scientist World Health Organization viii WHO Guideline on Self-Care Interventions for Health and Well-Being ACKNOWLEDGEMENTS T he World Health Organization (WHO) gratefully acknowledges the contributions of many individuals and organizations to the development of this consolidated guideline. WHO extends sincere thanks to the members of the Guideline Development Group: Kaosar Afsana, Hera Ali, Elham Atalla, Martha Brady, Elizabeth Bukusi, Laura Ferguson, Anita Hardon (co-chair), Jonathan Hopkins, Hussain Jafri, Mukesh Kapila, Po-Chin Li, Carmen Logie, Kevin Moody, Daniella Munene, Lisa Noguchi, Gina Ogilvie, Ash Pachauri, Michelle Remme, Jayalakshmi Shreedhar, Leigh Ann van der Merwe, Sheryl van der Poel and Allen Wu (co-chair); and to the members of the External Review Group: Faysal Al Kak, Jack Byrne, Georgina Caswell, Tyler Crone, Eva Deplecker, Austen El-Osta, Joanna Erdman, Mariangela Freitas da Silveira, Patricia Garcia, Roopan Gill, James Hargreaves, Rei Haruyama, Denis Kibira, Amy Knopf, Oswaldo Montoya, Ulysses Panisset, Michael Tan, Viroj Tangcharoensathien, Tarek Turk, Julián Vadell Martinez, Sten Vermund and Zawora Rita Zizien. The institutional affiliations of these and other contributors are in Annex 1 of this guideline. Special thanks are due to the external contributors who led the systematic reviews – Caitlin Kennedy and Ping Teresa Yeh, with support from Kaitlyn Atkins, Shannon King, Jingjia (Cynthia) Li, and Dong Keun Rhee (Johns Hopkins Bloomberg School of Public Health) – and to the guideline methodologist, Nandi Siegfried. We acknowledge the following external partners: Harriet Birungi (Population Council), Jennifer Drake (PATH), Catherine Duggan (International Pharmaceutical Federation), Christine Galavotti (Bill & Melinda Gates Foundation) and Saumya Ramarao (Population Council); and the following representatives from United Nations agencies: Pascale Allotey (United Nations University – International Institute for Global Health, Maribel Almonte (International Agency for Research on Cancer), Layal Barjoud (The Defeat-NCD Partnership hosted at the United Nations Institute for Training and Research), Rueben Brouwer (Office of the United Nations High Commissioner for Human Rights), Luisa Cabal and Emily Christie (Joint United Nations Programme on HIV/AIDS), Kenechukwu Esom (United Nations Development Programme), Shaffiq Essajee (United Nations Children’s Fund), Petra ten Hoope-Bender (United Nations Population Fund), Etienne Langlois (Partnership for Maternal, Newborn and Child Health hosted at WHO), Sameera Maziad Al Tuwaijri (World Bank), Tim Sladden (United Nations Population Fund), Damilola Walker (United Nations Children’s Fund) and David Wilson (World Bank). The following WHO staff members contributed as members of the WHO Guideline Steering Group, which managed the guideline development process: Katthyana Aparicio Reyes (Department of Integrated Health Services), the late Islene Araujo de Carvalho (Department of Maternal, Newborn, Child and Adolescent Health and Ageing), Rachel Baggaley (Department of Global HIV, Hepatitis and Sexually Transmitted Infections), Nathalie Broutet (Department of Sexual and Reproductive Health and Research [SRH]), Maurice Bucagu (Department of Maternal, Newborn, Child and Adolescent Health and Ageing), Giorgio Cometto and Siobhan Fitzpatrick (Health Workforce Department), Dina Gbenou (WHO Country Office, Burkina Faso), Karima Gholbzouri (WHO Regional Office for the Eastern Mediterranean), Rodolfo Gomez Ponce de Leon (Pan American Health Organization/WHO Regional Office for the Americas), Lianne Gonsalves (Department of Global Coordination and Partnership on Antimicrobial Resistance), Nilmini Hemachandra (WHO Regional Office for the Eastern Mediterranean), Bianca Hemmingsen (Department of Noncommunicable Diseases), Naoko Ishikawa (WHO Regional Office for the Western Pacific), Oleg Kuzmenko (WHO Regional Office for Europe), the late Ramez Mahaini (WHO Regional Office for the Eastern Mediterranean), Garrett Mehl (Department of Digital Health and Innovation), Manjulaa Narasimhan (Department of SRH), Léopold Ouedraogo (WHO Regional Office for Africa), Ulrika Rehnström Loi (Department of SRH), Bharat Rewari (WHO Regional Office for South-East Asia), Lisa Rogers (Department of Nutrition and Food Safety), Petrus Steyn, Tigest Tamrat and Özge Tunçalp (Department of SRH), Meera Upadhyay (WHO Regional Office for South-East Asia), Cherian Varghese (Department of Noncommunicable Diseases) and Adriana Velazquez Berumen (Department of Health Product Policy and Standards); and the WHO consultants: Briana Lucido and Marta Schaaf (Department of SRH). ix Acknowledgements We are also grateful to the following WHO staff, who provided input at various stages of the guideline’s development: Onyema Ajuebor (Health Workforce Department), Moazzam Ali, Avni Amin and Ian Askew (Department of SRH), Chilanga Asmani (WHO Regional Office for Africa), Anshu Banerjee (Department of Maternal, Newborn, Child and Adolescent Health and Ageing), Nino Berdzuli (WHO Regional Office for Europe), James Campbell (Health Workforce Department), Diarmid Campbell-Lendrum (Department of Environment, Climate Change and Health), Venkatraman Chandra-Mouli (Department of SRH), Paata Chikvaidze (WHO Country Office, Afghanistan), Shona Dalal (Department of Global HIV, Hepatitis and STIs Programmes), Fahdi Dkhimi (Department of Health Systems Governance and Financing), Tarun Dua (Department of Mental Health and Substance Use), Hayfa Elamin (WHO Regional Office for Africa), Mario Festin (previously in the Department of SRH), Mary Lyn Gaffield, Bela Ganatra and Claudia Garcia Moreno (Department of SRH), Geetha Krishnan Gopalakrishna Pillai (Department of Integrated Health Services), Veloshnee Govender (Department of SRH), John Grove (Department of Quality Assurance of Norms and Standards) Suzanne Rose Hill (previously in the Department of Essential Medicines and Health Products), Chandani Anoma Jayathilaka (WHO Regional Office for South-East Asia), Cheryl Johnson (Department of Global HIV, Hepatitis and STIs Programmes), Rita Kabra (Department of SRH), Edward Talbott Kelley (previously in the Department of Integrated Health Services), Rajat Khosla (previously in the Department of SRH), James Kiarie (Department of SRH), Hyo Jeong Kim (Department of Health Emergency Interventions), Loulou Kobeissi and Antonella Lavelanet (Department of SRH), Arno Muller and Carmem Pessoa Da Silva (Department of Surveillance, Prevention and Control), Michaela Pfeiffer (Department of Environment, Climate Change and Health), Marina Plesons (Department of SRH), Vladimir Poznyak (Department of Mental Health and Substance Use), Michelle Rodolph (Department of Global HIV, Hepatitis and STIs Programmes), Ritu Sadana (Department of Maternal, Newborn, Child and Adolescent Health and Ageing), Diah Saminarsih (Office of the Director-General), Anita Sands (Department of Regulation and Prequalification), Lale Say (Department of SRH), Elisa Scolaro (Department of Health and Multilateral Partnerships), Olive Sentumbwe-Mugisa (WHO Country Office, Uganda), Agnes Soucat (Department of Health Systems Governance and Financing), Anna Thorson and Igor Toskin (Department of SRH), Reinhilde Van De Weerdt (Department of Health Emergency Interventions), Isabelle Wachsmuth (Department of Integrated Health Services), Tana Wuliji (Health Workforce Department), Souleymane Zan (WHO Country Office, Cotonou, Benin), Qi Zhang (Department of Integrated Health Services); and the WHO consultants: Michalina Drejza (previously in the Department of SRH), Carmen Figueroa (Department of Global Tuberculosis Programme) and Megha Rathi (Department of Environment, Climate Change and Health). Special thanks to the WHO Guidelines Review Committee and in particular to its Secretariat, Susan Norris and Rebekah Thomas Bosco for their valuable feedback at every stage of the guideline development process. WHO writing support was provided by Briana Lucido, WHO administrative support was provided by Jane Werunga-Ndanareh and Michael Tabiszewski and WHO communications support was provided by Catherine Hamill, Sarah Kessler, Christine Meynent and Elizabeth Noble all from the WHO Department of SRH. Editing and proofreading was provided by Green Ink, United Kingdom of Great Britain and Northern Ireland. Overall coordination of the guideline development process was provided by Manjulaa Narasimhan (WHO Department of SRH). Funding for the development of the guideline was provided by the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, and the Children’s Investment Fund Foundation. x WHO Guideline on Self-Care Interventions for Health and Well-Being Apgar appearance, pulse, grimace, activity and respiration CHW community health worker COMET Core Outcome Measures in Effectiveness Trials COVID-19 coronavirus disease 2019 CSE comprehensive sexuality education DALY disability-adjusted life year DMPA-IM intramuscular depot medroxyprogesterone acetate DMPA-SC subcutaneous depot medroxyprogesterone acetate EC emergency contraception ERG External Review Group GAH gender-affirming hormone GDG Guideline Development Group GRADE Grading of Recommendations Assessment, Development and Evaluation GRC Guidelines Review Committee GVPS Global Values and Preferences Survey HELLP haemolysis, elevated liver enzymes and low platelet count HIV human immunodeficiency virus HPV human papillomavirus HRP UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction IPCHS Integrated People-Centred Health Services framework NCD noncommunicable disease OCP oral contraceptive pill OHCHR Office of High Commission for Human Rights OTC over the counter PHC primary healthcare LMICs low- and middle-income countries PICO population, intervention, comparator, outcome PrEP pre-exposure prophylaxis PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses RCT randomized controlled trial SDG Sustainable Development Goal SMART standards-based, machine-readable, adaptive, requirements-based and testable SMBG self-monitoring of blood glucose SMBP self-monitoring of blood pressure SRH sexual and reproductive health SRHR sexual and reproductive health and rights STI sexually transmitted infection UHC universal health coverage UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organization ACRONYMS AND ABBREVIATIONS xi Document Overview and Navigation Tools Arrow buttons – jump directly to different pages, sections, and external resources. Home icon – jump to this Overview page. Document Overview and Navigation Tools HOW TO NAVIGATE THIS DOCUMENT: 1. 2. 3. 4. 5. 6. People- centredness Throughout this document, icons will be located next to text denoting cross-cutting themes for implementation considerations of self-care interventions. Gender equality Human rights Health financing Health workforce WHO GUIDELINE ON SELF-CARE INTERVENTIONS FOR HEALTH AND WELL-BEING Introduction Essential strategies for creating and maintaining an enabling environment for self-care Recommendations and key considerations Implementation and programmatic considerations for self-care interventions Developing the research agenda for self-care interventions Dissemination, applicability and updating of the guideline and recommendations Executive summary xii WHO Guideline on Self-Care Interventions for Health and Well-Being EXECUTIVE SUMMARY BACKGROUND Self-care interventions are among the most promising and exciting approaches to improve health and well-being, both from a health systems perspective and for the users of these interventions. Self-care interventions hold the promise to be good for everyone and to move us closer to realizing universal health. Self-care interventions have the potential to increase choice and autonomy when they are accessible, acceptable and affordable. They represent a significant push towards greater self-determination, self-efficacy, autonomy and engagement in health for self- carers and caregivers. While risk and benefit calculations may be different in different settings and for different populations, with appropriate normative guidance and a safe and supportive enabling environment, self-care interventions promote the active participation of individuals in their healthcare and are an exciting way forward to reach improved health outcomes by addressing various aspects of healthcare, as seen in Fig. 1. A global shortage of an estimated 18 million health workers is anticipated by 2030, a record 130 million people are in need of humanitarian assistance, and there is the global threat of pandemics such as COVID-19. At least 400 million people worldwide lack access to the most essential health services, and every year 100 million people are plunged into poverty because they have to pay for healthcare out of their own pockets. There is, therefore, an urgent need to find innovative strategies that go beyond the conventional health-sector response. These interventions are also relevant for all three areas of the Thirteenth General Programme of Work of the World Health Organization (WHO), as illustrated in Fig. 2. WHO recommends self-care interventions for every country and economic setting as critical components on the path to reaching universal health coverage (UHC), promoting health, keeping the world safe and serving the vulnerable. Primary healthcare, universal health coverage and other global initiatives Self-care interventions are increasingly being acknowledged in global initiatives, including for advancing primary healthcare. The three main elements of primary healthcare described in the 2018 Declaration of Astana are: • Meeting people’s needs through comprehensive and integrated health services (including promotive, protective, preventive, curative, rehabilitative and palliative) throughout the entire life course, prioritizing primary care and essential public health functions; • Systematically addressing the broader determinants of health (including social, economic and environmental factors as well as individual characteristics and behaviours) through evidence-informed policies and actions across all sectors; and • Empowering individuals, families and communities to optimize their health as advocates of policies that promote and protect health and well-being, as co- developers of health and social services and as self- carers and caregivers. Primary healthcare is a fundamental component to achieving UHC, which will need a paradigm shift in health service delivery – and self-care interventions can Improved outcomes Increased coverage and access Reduced health disparities and increased equity Increased quality of services Improved health, human rights and social outcomes Reduced cost and more efficient use of healthcare resources and services FIG. 1. IMPROVED OUTCOMES ASSOCIATED WITH SELF-CARE INTERVENTIONS Executive summary xiii Executive summary contribute substantially to making that shift. Self-care in support of UHC in turn supports target 3.8 of Sustainable Development Goal 3 (to ensure healthy lives and promote well-being for all at all ages). Improving health and well-being Health promotion enables people to increase their control over their own health. It covers a wide range of social and environmental interventions designed to benefit and protect individual people’s health and quality of life by addressing and preventing the root causes of ill health, not just focusing on treatment and cure. WHO recommends a range of self-care interventions for health promotion (see Fig. 3), including better nutrition and physical activity – but also essential enablers such as health literacy that provide a basis for health promotion. Pandemics and humanitarian settings In settings affected by conflict and humanitarian crises, existing health systems can rapidly become overstretched and there is often an unprecedented demand on individuals and communities to manage their own health. When quality self-care interventions are provided within the recommended framework or “enabling environment” (as described in Chapter 2), individuals and communities can benefit. During pandemics like COVID-19, self-care measures such as physical distancing, wearing masks and good hygiene are recommended and practised globally as an essential part of the response. Self-care interventions are shifting the way healthcare is perceived, understood and accessed, and adding to the many medicines, diagnostics and other technologies available for people to use themselves. Definition of self-care and self-care interventions Self-care is 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. The scope of self-care in this definition includes health promotion, disease prevention and control, self-medication, giving care to dependent people, seeking hospital, specialist or primary care when needed, and rehabilitation, including palliative care. Self-care interventions are tools that support self-care. These include evidence-based, high-quality drugs, devices, diagnostics and/or digital interventions that can be provided fully or partially outside formal health services and be used with or without a health worker. Purpose and objectives of the guideline The purpose of this guideline is to provide evidence- based normative guidance that will support individuals, communities and countries with quality health services FIG. 2. STRATEGIC PRIORITIES AND TRIPLE-BILLION GOALS FROM THE WHO THIRTEENTH GENERAL PROGRAMME OF WORK UN IV ER SA L HEALTH COVERAGE HEALTH EMERGENC IES HEALTH AND WE LL -B EI NG One billion more people benefiting from One billion more people enjoying better One billion more people better protected from Executive summary xiv WHO Guideline on Self-Care Interventions for Health and Well-Being and self-care interventions based on primary healthcare strategies, comprehensive and essential service packages and people-centredness. The specific objectives of this guideline are to provide: • evidence-based recommendations on key public health self-care interventions, including for advancing sexual and reproductive health and rights (SRHR), with a focus on underserved populations and settings with limited capacity and resources in the health system; • good practice statements on key programmatic, operational and service-delivery issues that need to be addressed to promote and increase the safe and equitable access, uptake and use of self-care interventions, including for advancing SRHR; and • key considerations on specific topics to guide future research and guidelines processes. Conceptual framework for self-care interventions The conceptual framework provides a starting point for tackling the evolving field of self-care and identifying self-care interventions for future updates. The conceptual framework (see Fig. 4) illustrates core elements from both the “people-centred” and “health systems” approaches, which can support the introduction, uptake and scale-up of self-care interventions. The people-centred approach to health and well-being lies at the core of this framework. This guideline is grounded in and advocates a strengthened, comprehensive, people-centred approach to health and well-being, including for SRHR. This approach is underpinned by the key principles of human rights, ethics and gender equality. People-centredness requires taking an holistic approach to the care of each person, taking account of their individual circumstances, needs and desires across their whole life course, and taking account of the environment within which they live. Self-care interventions, if situated in an environment that is safe and supportive, are an opportunity to help to increase people’s active participation in their own health, including patient engagement. A safe and supportive enabling environment is essential to facilitate access to and the uptake of products and interventions that can improve the health and well-being of underserved and marginalized populations. Assessing and ensuring an enabling environment in which self-care interventions can be made available in safe and appropriate ways must be a key initial piece of any strategy to introduce or scale up these interventions. This should be informed by the profile of potential users, the services on offer to them, and the broader legal and policy environment, and structural supports and barriers. FIG. 3. SELF-CARE IN THE CONTEXT OF INTERVENTIONS LINKED TO HEALTH SYSTEMS HEALTH SYSTEMS EVERYDAY LIFE SELF-MANAGEMENT Self-medication, self-treatment, self-examination, self-injection, self-administration, self-use SELF-TESTING Self-sampling, self-screening, self-diagnosis, self- collection, self-monitoring SELF-AWARENESS Self-help, self-education, self-regulation, self- efficacy, self-determination SELF-CARE Executive summary xv Executive summary Scope of this guideline This guideline brings together new and existing WHO recommendations, good practice statements and key considerations on self-care interventions for health. The recommendations relate to specific health-related interventions (see Chapter 3) while the good practice statements relate to implementation considerations and more generally to creating and maintaining an enabling environment, particularly for underserved populations (see Chapter 4, which also contains two additional recommendations). This document builds on the 2019 guidance, which was the first such guideline published by WHO. The new recommendations in this guideline focus on self-care interventions that are considered to be in transition from provision by facility-based health workers to delivery using a self-care approach. Where current WHO guidance exists, this document refers users to those other publications for further information, and to other relevant WHO tools and documents on programme activities. Places of access Key principles Enabling environment Individual accountability Education Health financing Private sector accountability Trained health workforce Commodity security Psychosocial support Health sector accountability Donor accountability Government accountability Home Information Community Holistic Caregivers Pharmacies Ethics Life course Gender equality Human rights Supportive laws and policies Digital technologies and platforms Protection from violence, coercion, stigma and discrimination Traditional medicine and sociocultural practices Economic empowerment (e.g. housing, food security, ability to pay for healthcare) Social accountability Health services Access to justice Accountability Self-care for health and well-being Regulated quality products and interventions Health literacy FIG. 4. CONCEPTUAL FRAMEWORK FOR SELF-CARE INTERVENTIONS Source: adapted with permission from Narasimhan et al. (doi:10.1136/bmj.l688). Executive summary xvi WHO Guideline on Self-Care Interventions for Health and Well-Being Access, use and uptake of self-care interventions for underserved populations Health inequities are endemic to every region of the world, with rates of disease significantly higher among the poorest and most marginalized individuals and communities. The vulnerabilities of underserved individuals and communities might increase in many settings because of factors such as older age, which could lead to social isolation, or poverty, which could lead to people living in environments that are harmful to health. Not all individuals and communities, therefore, require the same level of support for access to and the uptake and use of self-care interventions. Safe and strong linkages between independent self-care and access to quality healthcare services for people who want or need them are critically important to avoid harm. Where self-care is not a positive choice but is prompted by fear or a lack of alternatives, it can increase vulnerabilities. The use and uptake of self-care interventions is organic and the shift in responsibility – between full responsibility of the user and full responsibility of the health worker (or somewhere along that continuum) – can also change over time for each intervention and for different population groups. Ensuring the full implementation of human rights- based laws and policies through SRHR programmes is fundamental to health and human rights. Target audience The primary target audience for this guideline is national and international policy-makers, researchers, programme managers, health workers (including pharmacists), donors and civil society organizations responsible for making decisions or advising on the delivery or promotion of self-care interventions. The secondary target audience is product developers. This new guideline is also expected to support the people affected by the recommendations: those who are taking care of themselves, and caregivers. Health services and programmes in low-resource settings will benefit most from the guidance presented here, as they face the greatest challenges in providing services tailored to the needs and rights of underserved populations. However, this guideline is relevant for all settings and should, therefore, be considered as global guidance. In implementing these globally relevant recommendations, WHO regions and countries can adapt them to the local context, taking into account the economic conditions and the existing health services and healthcare facilities. Guideline development process This guideline has been developed according to WHO standards and requirements for guideline development, and with the oversight of the WHO Guidelines Review Committee. All of the recommendations in this guideline have been developed by the Guideline Development Group (GDG) and facilitated by the guideline methodologist using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). Annex 2 of this document provides the full details of the methodology. In particular, section 2.4 of Annex 2 describes how the issues to be addressed and the specific recommendations and good practice statements to be included in this guideline were determined. Developing the research agenda Future research in self-care can be conceptualized under two broad areas: (i) the development of self-care interventions and (ii) the delivery of self-care interventions. Underpinning the focus of research on efficacy, safety, implementation and delivery will be the perspectives of individuals, collectives, communities and health workers, and/or systems perspectives. As such, attention needs to be given to matching the selection of outcomes to be measured with the relevant perspective. The same is true for studies of costs and cost-effectiveness. The increasing adoption of digital health and digital therapeutics in self-care offers new opportunities to generate real-world evidence in real time. However, it demands that privacy, security and identity management are integral to the conduct of ethical self-care research. Transparency, a culture of trust, and mutual benefit for the people who participate in research and those who conduct it are paramount to creating a sustainable research environment. During the guideline development process and in-person GDG meeting, the GDG members identified important knowledge gaps that needed to be addressed through further primary research. Chapter 5 of the guideline discusses the limitations of the existing evidence base, presents illustrative research questions relevant to the enabling environment for self- care for SRHR, lists questions to address the identified research gaps related to the new recommendations in this guideline, and illustrative research questions on self-care interventions relevant to several outcome domains for measuring human rights and equity. Executive summary xvii Executive summary Implementation, applicability, and monitoring and evaluation of the guideline The effective implementation of the recommendations, good practice statements and key considerations in this guideline is likely to need the reorganization of care and the redistribution of healthcare resources, particularly in low- and middle-income countries. The potential barriers are reviewed in Chapter 6. Various strategies will be applied to ensure that the people-centred approach and the key principles that underpin this guideline are operationalized, and to address barriers in a range of settings to facilitate the implementation of the guidance. The implementation and impact of these recommendations will be monitored at the health-service, regional and country levels, based on existing indicators. Given the private space in which self-care is practised, though, alternative ways to assess the impact of the interventions need to be developed, with the engagement of the affected communities, and with a particular emphasis on the uptake and use by underserved populations. Updating of the guideline The recommendations, good practice statements, and key considerations published here represent a subset of prioritized self-care interventions for health. This guidance will be updated and expanded as new evidence becomes available and also depending on the progress in policies and programmes. This guideline is considered a “living guideline”, which will allow the continual review of new evidence and information, so that appropriate guidance can be issued in a timely manner and adopted and implemented by countries and programmes. Summary of the recommendations, good practice statements and key considerations Table 1 presents the new and existing recommendations and the new key considerations on self-care interventions, covering the following topics: (i) improving antenatal, intrapartum and postnatal care; (ii) providing high-quality services for family planning, including infertility services; (iii) eliminating unsafe abortion; (iv) combating sexually transmitted infections (including HIV), reproductive tract infections, cervical cancer and other gynaecological morbidities; (v) promoting sexual health; and (vi) noncommunicable diseases, including cardiovascular disease and diabetes. Table 2 presents the new and existing good practice statements and two new recommendations on self-care interventions, covering the following topics: (i) human rights, gender equality and equity considerations; (ii) financing and economic considerations; (iii) the training needs of health workers; (iv) population-specific implementation considerations; (v) digital health interventions; and (vi) environmental considerations. Where the recommendations, good practice statements or key considerations are new, this is noted. Interventions Recommendations and key considerationsa Improving antenatal, intrapartum and postnatal care Non-clinical interventions targeted at women to reduce caesarean sections Recommendation 1 Health education for women is an essential component of antenatal care. The following educational interventions and support programmes are recommended to reduce caesarean births only with targeted monitoring and evaluation. (Context-specific recommendation; low certainty evidence) Recommendation 1a Childbirth training workshops (content includes sessions about childbirth fear and pain, pharmacological pain-relief techniques and their effects, non-pharmacological pain-relief methods, advantages and disadvantages of caesarean sections and vaginal delivery, indications and contraindications of caesarean sections, among others). (Low to moderate certainty evidence) TABLE 1. RECOMMENDATIONS AND KEY CONSIDERATIONS FOR SELF-CARE INTERVENTIONS Executive summary xviii WHO Guideline on Self-Care Interventions for Health and Well-Being Interventions Recommendations and key considerationsa Recommendation 1b Nurse-led applied relaxation training programme (content includes group discussion of anxiety and stress-related issues in pregnancy and purpose of applied relaxation, deep breathing techniques, among other relaxation techniques). (Low to moderate certainty evidence) Recommendation 1c Psychosocial couple-based prevention programme (content includes emotional self- management, conflict management, problem-solving, communication and mutual support strategies that foster positive joint parenting of an infant). “Couple” in this recommendation includes couples, people in a primary relationship or other close people. (Low to moderate certainty evidence) Recommendation 1d Psychoeducation (for women with fear of pain; comprising information about fear and anxiety, fear of childbirth, normalization of individual reactions, stages of labour, hospital routines, birth process, and pain relief [led by a therapist and midwife], among other topics). (Low to moderate certainty evidence) Self-administered interventions for common physiological symptoms Recommendation 2 When considering the educational interventions and support programmes, no specific format (e.g. pamphlet, videos, role play education) is recommended as more effective. Interventions for nausea and vomiting Recommendation 3 Ginger, chamomile, vitamin B6 and/or acupuncture are recommended for the relief of nausea in early pregnancy, based on a woman’s preferences and available options. Interventions for heartburn Recommendation 4 Advice on diet and lifestyle is recommended to prevent and relieve heartburn in pregnancy. Antacid preparations can be offered to women with troublesome symptoms that are not relieved by lifestyle modification. Interventions for leg cramps Recommendation 5 Magnesium, calcium or non-pharmacological treatment options can be used for the relief of leg cramps in pregnancy, based on a woman’s preferences and available options. Interventions for low back and pelvic pain Recommendation 6 Regular exercise throughout pregnancy is recommended to prevent low back and pelvic pain. There are a number of different treatment options that can be used, such as physiotherapy, support belts and acupuncture, based on a woman’s preferences and available options. Interventions for constipation Recommendation 7 Wheat bran or other fibre supplements can be used to relieve constipation in pregnancy if the condition fails to respond to dietary modification, based on a woman’s preferences and available options. Interventions for varicose veins and oedema Recommendation 8 Non-pharmacological options, such as compression stockings, leg elevation and water immersion, can be used for the management of varicose veins and oedema in pregnancy, based on a woman’s preferences and available options. Executive summary xix Executive summary Interventions Recommendations and key considerationsa Self-administered pain relief for prevention of delay in the first stage of labour Recommendation 9 Pain relief for preventing delay and reducing the use of augmentation in labour is not recommended. (Conditional recommendation; very low certainty evidence) Iron and folic acid supplements Recommendation 10a (new) WHO recommends making the self-management of folic acid supplements available as an additional option to health worker-led provision of folic acid supplements for individuals who are planning pregnancy within the next three months. (Strong recommendation; very low certainty evidence) Recommendation 10b (new) WHO recommends making the self-management of iron and folic acid supplements available as an additional option to health worker-led provision of folic acid supplements for individuals during pregnancy. (Strong recommendation; very low certainty evidence) Recommendation 10c (new) WHO recommends making the self-management of iron and folic acid supplements available as an additional option to health worker-led provision of iron and folic acid supplements for individuals during the postnatal period. (Strong recommendation; very low certainty evidence) Self-monitoring of blood pressure during pregnancy Recommendation 11 (new) WHO suggests making the self-monitoring of blood pressure during pregnancy available as an additional option to clinic blood pressure monitoring by health workers during antenatal contacts only, for individuals with hypertensive disorders of pregnancy. (Conditional recommendation; very low certainty evidence) Self-testing for proteinuria during pregnancy Key consideration 1 (new) For pregnant individuals with non-proteinuric hypertension, there may be some benefit of home- based urine self-testing compared with inpatient care to detect proteinuria, but clinicians need to balance this with the additional burden placed on the individual. Self-monitoring of blood glucose during pregnancy Recommendation 12 (new) WHO recommends making self-monitoring of glucose during pregnancy available as an additional option to clinic blood glucose monitoring by health workers during antenatal contacts, for individuals diagnosed with gestational diabetes. (Strong recommendation; very low certainty evidence) Women-held case notes to improve the utilization and quality of antenatal care Recommendation 13 WHO recommends that each pregnant woman carries their own case notes during pregnancy to improve the continuity and quality of care and their pregnancy experience. Providing high-quality services for family planning, including infertility services Self-administration of injectable contraception Recommendation 14 Self-administered injectable contraception should be made available as an additional approach to deliver injectable contraception for individuals of reproductive age. (Strong recommendation; moderate certainty evidence) Executive summary xx WHO Guideline on Self-Care Interventions for Health and Well-Being Interventions Recommendations and key considerationsa Self-management of contraceptive use with over-the-counter oral contraceptive pills Recommendation 15 Over-the-counter oral contraceptive pills (OCPs) should be made available without a prescription for individuals using OCPs. (Strong recommendation; very low certainty evidence) Over-the-counter availability of emergency contraception Recommendation 16 (new) WHO recommends making over-the-counter emergency contraceptive pills available without a prescription to individuals who wish to use emergency contraception. (Strong recommendation; moderate certainty evidence) Self-screening with ovulation predictor kits for fertility regulation Recommendation 17 Home-based ovulation predictor kits should be made available as an additional approach to fertility management for individuals attempting to become pregnant. (Strong recommendation; low certainty evidence) Condom use Recommendation 18 The consistent and correct use of male and female condoms is highly effective in preventing the sexual transmission of HIV; reducing the risk of HIV transmission both from men to women and women to men in serodiscordant couples; reducing the risk of acquiring other STIs and associated conditions, including genital warts and cervical cancer; and preventing unintended pregnancy. Recommendation 19 The correct and consistent use of condoms with condom-compatible lubricants is recommended for all key populations to prevent sexual transmission of HIV and STIs. (Strong recommendation; moderate certainty evidence) Recommendation 20a Provide up to one year’s supply of pills, depending on the woman’s preference and anticipated use. Recommendation 20b Programmes must balance the desirability of giving women maximum access to pills with concerns regarding contraceptive supply and logistics. Recommendation 20c The resupply system should be flexible, so that the woman can obtain pills easily in the amount and at the time she requires them. Pregnancy self-testing Recommendation 21 (new) WHO recommends making self-testing for pregnancy available as an additional option to health worker-led testing for pregnancy, for individuals seeking pregnancy testing. (Strong recommendation; very low certainty evidence) Eliminating unsafe abortion Self-management of the medical abortion process in the first trimester Recommendation 22 Self-assessing eligibility for medical abortion is recommended within the context of rigorous research. Executive summary xxi Executive summary Interventions Recommendations and key considerationsa Recommendation 23 Managing the mifepristone and misoprostol medication without the direct supervision of a health worker is recommended in specific circumstances. We recommend this option in circumstances where women have a source of accurate information and access to a health worker should they need or want it at any stage of the process. Recommendation 24 Self-assessing the completeness of the abortion process using pregnancy tests and checklists is recommended in specific circumstances. We recommend this option in circumstances where both mifepristone and misoprostol are being used and where women have a source of accurate information and access to a health worker should they need or want it at any stage of the process. Post-abortion hormonal contraception initiation Recommendation 25 Self-administering injectable contraceptives is recommended in specific circumstances. We recommend this option in contexts where mechanisms to provide the woman with appropriate information and training exist, referral linkages to a health worker are strong, and where monitoring and follow-up can be ensured. Recommendation 26 For individuals undergoing medical abortion with the combination mifepristone and misoprostol regimen or the misoprostol-only regimen who desire hormonal contraception (oral contraceptive pills, contraceptive patch, contraceptive ring, contraceptive implant or contraceptive injections), we suggest that they be given the option of starting hormonal contraception immediately after the first pill of the medical abortion regimen. Combating sexually transmitted infections (including HIV), reproductive tract infections, cervical cancer and other gynaecological morbidities Human papillomavirus (HPV) self-sampling Recommendation 27 HPV self-sampling should be made available as an additional approach to sampling in cervical cancer screening services for individuals aged 30–60 years. (Strong recommendation; moderate certainty evidence) Self-collection of samples for STI testing Recommendation 28 Self-collection of samples for Neisseria gonorrhoeae and Chlamydia trachomatis should be made available as an additional approach to deliver STI testing services. (Strong recommendation; moderate certainty evidence) Recommendation 29 Self-collection of samples for Treponema pallidum (syphilis) and Trichomonas vaginalis may be considered as an additional approach to deliver STI testing services. (Conditional recommendation; low certainty evidence) HIV self-testing Recommendation 30 HIV self-testing should be offered as an additional approach to HIV testing services. (Strong recommendation; moderate certainty evidence) Self-efficacy and empowerment for women living with HIV Recommendation 31 For women living with HIV, interventions on self-efficacy and empowerment around sexual and reproductive health and rights should be provided to maximize their health and fulfil their rights. (Strong recommendation; low certainty evidence) Executive summary xxii WHO Guideline on Self-Care Interventions for Health and Well-Being Interventions Recommendations and key considerationsa Pharmacy access to pre-exposure prophylaxis (PrEP) for HIV prevention Key consideration 2 (new) Pharmacy initiation and continuation of PrEP: • WHO recommends offering oral PrEP and the dapivirine vaginal ring to individuals at substantial risk of HIV infection. • Equitable access to and the availability of PrEP, plus information about its use are imperative to ensure increased uptake. • Providing PrEP through pharmacies may present a unique opportunity for expanding access to PrEP in the community setting. • Any model of PrEP delivery through pharmacies should ensure adherence to WHO suggested procedures for initiating and maintaining PrEP, including HIV testing, creatinine testing and other tests and counselling as appropriate. • The decision to offer PrEP in pharmacies will require alignment with local laws and regulations, appropriate health system linkages and community engagement. Promoting sexual health Lubricant use for sexual health Recommendation 32 (new) WHO recommends making lubricants available for optional use during sexual activity, among sexually active individuals. (Strong recommendation; moderate certainty evidence) Self-administration of gender-affirming hormones for transgender and gender-diverse individuals Key consideration 3 (new) • The principles of gender equality and human rights in the delivery of quality gender-affirming hormones are critical to expanding access to this important intervention and reducing discrimination based on gender identity. • Transgender and gender-diverse people live within social, legal, economic and political systems that place them at high risk of discrimination, exclusion, poverty and violence. • Research is urgently needed to support evidence-driven guidance. Noncommunicable diseases, including cardiovascular disease and diabetes Cardiovascular disease Self-measurement to monitor blood pressure Recommendation 33 Self-measurement to monitor blood pressure is recommended for the management of hypertension in appropriate patients where the affordability of the technology has been established. (Strong recommendation; low certainty evidence) Self-monitoring of blood coagulation Recommendation 34 Self-monitoring of blood coagulation is recommended for appropriate patients treated with oral anticoagulation agents, where the affordability of the technology has been established. (Weak recommendation; moderate certainty evidence) Recommendation 35 Self-monitoring of blood coagulation and self-augmentation of dosage in patients receiving oral anticoagulation agents is recommended if affordable, and according to an agreed action plan with a health professional. (Conditional recommendation; moderate certainty evidence) Executive summary xxiii Executive summary Interventions Recommendations and key considerationsa Diabetes Self-monitoring of blood glucose Recommendation 36 The use of self-monitoring of blood glucose in the management of patients with type 2 diabetes not on insulin is not recommended at the present time because there is insufficient evidence to support such a recommendation. (Conditional recommendation; moderate certainty evidence) Recommendation 37 People with type 1 and type 2 diabetes on insulin should be offered self-monitoring of blood glucose based on individual clinical need. (Conditional recommendation; low certainty evidence) Interventions Recommendations and good practice statements Human rights, gender equality and equity considerations Good practice statement 1 (new) All self-care interventions for health must be accompanied by accurate, understandable and actionable information, in accessible formats and languages, about the intervention itself and how to link to relevant community- or facility-based healthcare services, and the opportunity to interact with a health worker or a trained peer supporter to support decisions around, and the use of, the intervention. Good practice statement 2 (new) The provision of self-care interventions for health should increase clients’ options about when and how they seek healthcare, including offering flexibility in the choice of interventions and in the degree and manner of the engagement with health services. Good practice statement 3 (new) Self-care interventions for health and their delivery mechanisms should be designed to accommodate the needs of all people across the gender spectrum, recognizing that there may be differences in the barriers that individuals and communities face accessing quality interventions, in their needs and priorities, in the nature of support they need, and in their preferred points of access. Good practice statement 4 (new) Countries should review and, where necessary, revise laws, policies and regulations to ensure that quality self-care interventions are made widely available in the community, that they are accessible to all without discrimination, through public, private and community-based health workers, and that they are acceptable to users. a The strength of the recommendation and/or the certainty of the evidence are not specified for some of the existing recommendations because they were developed prior to the systematic use of GRADE methodology. When respective guidelines are updated using the GRADE framework, we will update the wording accordingly. TABLE 2. RECOMMENDATIONS AND GOOD PRACTICE STATEMENTS ON THE IMPLEMENTATION AND PROGRAMMATIC CONSIDERATIONS OF SELF-CARE INTERVENTIONS Executive summary xxiv WHO Guideline on Self-Care Interventions for Health and Well-Being Interventions Recommendations and good practice statements Financing and economic considerations Good practice statement 5 Good-quality health services and self-care interventions should be made available, accessible, affordable and acceptable to underserved and marginalized populations, based on the principles of medical ethics; the avoidance of stigma, coercion and violence; non- discrimination; and the right to health. Training needs of health workers Good practice statement 6 (adapted) Health workers should receive appropriate recurrent education to ensure that they have the competencies, underpinned by the required knowledge, skills and attitudes, to provide self-care interventions based on the right to health, confidentiality and non-discrimination. Rational delegation of tasks and task sharing Good practice statement 7 Countries, in collaboration with relevant stakeholders, including patient groups and the community, should consider implementing and/or extending and strengthening the rational delegation of tasks to individuals, carers and communities, as members of the health team, in effective ways that lead to equitable health outcomes. Good practice statement 8 Self-carers and caregivers who are not trained health workers can be empowered to manage certain aspects of healthcare under the responsibility of a health worker, particularly in relation to self-care and the use of self-care interventions, where appropriate and within the context of safe, supportive health systems. Competency-based training of health workers Good practice statement 9 (adapted) Countries should adopt a systematic approach to harmonized, standardized and competency- based training that is needs-driven and accredited so that health workers are equipped with the appropriate competencies for: • engaging in and supporting self-care practices that promote emotional resilience, health and well-being; • determining the extent to which an individual wishes to, and is able to, self-monitor and self- manage healthcare; • promoting access to and the correct use and uptake of self-care interventions; and • educating individuals for preparing and self-administering medications or therapeutics. Population-specific implementation considerations Implementation considerations during humanitarian and pandemic crises Recommendation 38 WHO recommends prioritizing digital health services, self-care interventions, task sharing and outreach to ensure access to medicines, diagnostics, devices, information and counselling when facility-based provision of sexual and reproductive health services is disrupted. Recommendation 39 WHO recommends maximizing occupational health and staff safety measures, including providing mental healthcare and psychosocial support and promoting self-care strategies. Life-course approach Good practice statement 10 Sensitization about self-care interventions should be tailored to people’s specific needs across the life course and across different settings and circumstances, and should recognize their right to sexual and reproductive health across the life course. Executive summary xxv Executive summary Interventions Recommendations and good practice statements Implementation considerations of underserved and marginalized populations Good practice statement 11 (adapted) People from underserved and marginalized populations should be able to experience full, pleasurable sex lives and have access to a range and choice of reproductive health options. Good practice statement 12 (adapted) Countries should work towards implementing and enforcing anti-discrimination and protective laws, derived from human rights standards, to eliminate stigma, discrimination and violence against underserved and marginalized populations. Good practice statement 13 (new) Transgender and gender-diverse individuals who self-administer gender-affirming hormones require access to evidence-based information, quality products and sterile injection equipment. Digital health interventions Good practice statement 14 (adapted) Digital health interventions offer opportunities to promote, offer information about and provide discussion forums for self-care interventions. Good practice statement 15 (adapted) Client-to-provider telemedicine to support self-care interventions can be offered to complement face-to-face health services. Good practice statement 16 (adapted) Digital targeted client communication by health workers on the use of self-care interventions can help to implement monitor and evaluate health outcomes. Environmental considerations Good practice statement 17 Safe and secure disposal of waste from self-care products should be promoted at all levels. Good practice statement 18 Countries, donors and relevant stakeholders should work towards environmentally preferable purchasing of self-care products by selecting supplies that are less wasteful, can be recycled or produce less-hazardous waste products, or by using smaller quantities. This living guideline is also available in one user-friendly and easy-to-navigate online platform, which will allow for continual review of new evidence and information. The interactive web-based version of this living guideline is available at https://app.magicapp.org/#/guideline/Lr21gL. SMART Guidelines (Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable) on self-care interventions for antenatal care, family planning, HIV and other topics is available under: https://www.who.int/teams/ digital-health-and-innovation/smart-guidelines. A LIVING GUIDELINE https://app.magicapp.org/#/guideline/Lr21gL https://www.who.int/publications/i/item/9789240020306 https://www.who.int/publications/i/item/9789240029743 https://www.who.int/teams/digital-health-and-innovation/smart-guidelines https://www.who.int/teams/digital-health-and-innovation/smart-guidelines Chapter 3 xxvi WHO Guideline on Self-Care Interventions for Health and Well-Being 3 Introduction1. Chapter 3 1 Chapter 3: Recommendations and key considerations This chapter provides key background information about self-care and self-care interventions and an overview of the guideline, including brief summaries of how it was developed, the way it should be used and the scope of the guideline. At a Glance1. Chapter Return to Overview 1 p. 2 p. 7 p. 7 p. 8 p. 9 p. 11 p. 11 p. 12 Background Objectives Living guideline approach Definitions of self-care and self-care interventions Scope Target audience Values and preferences Guideline development and compilation process Chapter 1 2 WHO Guideline on Self-Care Interventions for Health and Well-Being 1.1 BACKGROUND Self-care interventions are among the most promising and exciting new approaches to improving health and well-being, both from a health systems perspective and for the users of these interventions. Self-care interventions hold the promise of being good for everyone and moving us closer to realizing universal health. They have the potential to increase choice and autonomy when they are accessible, acceptable and affordable. People practise many forms of self-care, often learning from health professionals and applying medical and/or traditional treatments themselves. This has become especially important for everyone, everywhere in global health emergencies such as the COVID-19 pandemic and is especially important for individuals and communities whose health-seeking behaviour is constrained by costs or limited access to health facilities (1). For example, in rural north-east Thailand, 80% of self-reported uterus-related (mot luuk) complaints, such as vaginal discharge and pelvic pain, were self-treated, often with small doses of antibiotics bought from markets after seeing advertisements promoting branded tetracycline for these complaints (2). It is important, therefore, to have evidence-based normative guidance to ensure that quality self-care interventions can provide more opportunities for individuals to make informed decisions regarding their health and healthcare. Self-care interventions represent a significant push towards greater self-determination, self-efficacy, autonomy and engagement in health for self-carers and caregivers. While calculations of risks and benefits may be different in different settings and for different populations, with appropriate normative guidance and a safe and supportive enabling environment, self-care interventions can promote the active participation of individuals in their health, and are an exciting way forward to reach improved health outcomes via a number of mechanisms, as shown in Fig. 1.1. 1.1.1 THE ROLE OF SELF-CARE INTERVENTIONS TO SUPPORT HEALTH SYSTEMS A shortage of 18 million health workers is anticipated globally by 2030 (3), and a record 130 million people are in need of assistance under global threats that include humanitarian crises and pandemics such as COVID-19. At least 400 million people worldwide lack access to the most essential health services, and every year 100 million people are plunged into poverty because they have to pay for healthcare out of their own pockets (4). There is, therefore, an urgent need to find innovative strategies that go beyond the conventional health sector response. Self-care interventions are also relevant to all three areas of the Thirteenth General Programme of Work of the World Health Organization (WHO) (5), as illustrated in Fig. 1.2. WHO recommends self-care interventions for every country and economic setting as a critical component of the path to reach universal health coverage (UHC), promote health, keep the world safe and serve the vulnerable. Improved outcomes Increased coverage and access Reduced health disparities and increased equity Increased quality of services Improved health, human rights and social outcomes Reduced cost and more efficient use of healthcare resources and services FIG. 1.1. IMPROVED OUTCOMES ASSOCIATED WITH SELF-CARE INTERVENTIONS Chapter 1 3 Chapter 1: Introduction 1.1.2 PRIMARY HEALTHCARE, UNIVERSAL HEALTH COVERAGE AND OTHER GLOBAL INITIATIVES Self-care interventions are increasingly being acknowledged in global initiatives, including to advance primary healthcare (6, 7). The Astana Declaration calls for the mobilization of all stakeholders – healthcare professionals, academics and researchers, patients, civil society, local and international partners, agencies and funds, the private sector, faith-based organizations – to focus their efforts around the three main elements of primary healthcare: 1. Meeting people’s needs through comprehensive and integrated health services (including promotive, protective, preventive, curative, rehabilitative and palliative) throughout the entire life course, prioritizing primary care and essential public health functions; 2. Systematically addressing the broader determinants of health (including social, economic and environmental factors, and individual characteristics and behaviours) through evidence-informed policies and actions across all sectors; and 3. Empowering individuals, families and communities to optimize their health – as advocates of policies that promote and protect health and well-being, as co-developers of health and social services and as self-carers and caregivers. 1 Available at https://www.who.int/universal-health-coverage/compendium/database Table 1.1 outlines some examples of global initiatives in which self-care interventions play an important role. Primary healthcare is a fundamental component to achieve UHC. Its achievement needs a paradigm shift in health service delivery, and self-care interventions can contribute substantially to making that shift. Self-care as part of primary healthcare represents a cornerstone of a sustainable health system in support of UHC, which is the target 3.8 of Sustainable Development Goal 3 (SDG 3) – to ensure healthy lives and promote well-being for all at all ages. To assist countries in making progress towards UHC, WHO has developed the UHC Compendium – a website and database of health services and intersectoral interventions. This provides a strategic way to organize and present information and creates a framework for thinking about health services and health interventions (8). The database1 spans the full spectrum of promotive, preventive, resuscitative, curative, rehabilitative and palliative services, plus a full complement of intersectoral interventions, including self-care. FIG. 1.2. WHO STRATEGIC PRIORITIES AND THE TRIPLE-BILLION GOALS IN THE THIRTEENTH GENERAL PROGRAMME OF WORK UN IV ER SA L HEALTH COVERAGE HEALTH EMERGENC IES HEALTH AND WE LL -B EI NG One billion more people benefiting from One billion more people enjoying better One billion more people better protected from https://www.who.int/universal-health-coverage/compendium/database Chapter 1 4 WHO Guideline on Self-Care Interventions for Health and Well-Being Initiative Interventions Web address Global action plan for the prevention and control of noncommunicable diseases, 2013–2020 Self-care strategies for improving health conditions such as cardiovascular disease and diabetes https://www.who. int/publications/i/ item/9789241506236 Global health sector strategy on HIV, 2016–2021 HIV self-testing to improve the coverage of testing for individuals and their partners https://apps.who.int/iris/ bitstream/handle/10665/246178/ WHO-HIV-2016.05-eng.pdf Global health sector strategy on sexually transmitted infections, 2016–2021 Self-collection of samples for the testing of sexually transmitted infections to improve testing and treatment, particularly for gonorrhoea, syphilis and chlamydia https://www.who.int/ reproductivehealth/publications/ rtis/ghss-stis/en Global strategy to accelerate the elimination of cervical cancer as a public health problem Self-sampling for human papillomavirus testing, to reach goals on cervical cancer screening and treatment https://www.who. int/publications/i/ item/9789240014107 TABLE 1.1. EXAMPLES OF GLOBAL INITIATIVES THAT INCLUDE SELF-CARE INTERVENTIONS 1.1.3 IMPROVING HEALTH AND WELL-BEING Health promotion enables people to increase their control over their own health. It covers a wide range of social and environmental interventions that address and prevent the root causes of ill health rather than just focusing on treatment and cure (9). WHO promotes a range of self-care interventions for health promotion (see Fig. 1.3), including better nutrition and physical activity – but also essential enablers, such as health literacy, that are foundational to health promotion. FIG. 1.3. HEALTH-PROMOTION TIPS FOR SELF-CARE PRACTICES https://www.who.int/publications/i/item/9789241506236 https://www.who.int/publications/i/item/9789241506236 https://www.who.int/publications/i/item/9789241506236 https://apps.who.int/iris/bitstream/handle/10665/246178/WHO-HIV-2016.05-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/246178/WHO-HIV-2016.05-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/246178/WHO-HIV-2016.05-eng.pdf https://www.who.int/reproductivehealth/publications/rtis/ghss-stis/en https://www.who.int/reproductivehealth/publications/rtis/ghss-stis/en https://www.who.int/reproductivehealth/publications/rtis/ghss-stis/en https://www.who.int/publications/i/item/9789240014107 https://www.who.int/publications/i/item/9789240014107 https://www.who.int/publications/i/item/9789240014107 Chapter 1 5 Chapter 1: Introduction 1.1.4 HUMANITARIAN CRISES In settings affected by conflict and humanitarian crises, the existing health system can become rapidly overstretched and there is often an unprecedented demand on individuals and communities to manage their own health. When quality self-care interventions are provided within the recommended framework or an enabling environment (as described in Chapter 2), individuals and communities can benefit. During pandemics, such as the COVID-19 one, self-care measures such as physical distancing, wearing masks and good hygiene have been recommended and are practised globally as an essential part of the response (see Fig. 1.4). FIG. 1.4. EXAMPLE OF A WHO-RECOMMENDED SELF-CARE PRACTICE DURING THE COVID-19 PANDEMIC – HAND HYGIENE Self-care interventions are shifting the way healthcare is perceived, understood and accessed, and adding to the many medicines, diagnostics and other technologies available for people to use themselves. 1.1.5 SUSTAINABLE DEVELOPMENT GOALS The SDGs – particularly SDG 3 on health and well- being, SDG 4 on quality education and SDG 5 on gender equality – embrace a vision for leaving no one behind and, in doing so, call for us to reach out first to those who are furthest behind, including in terms of both the coverage of quality essential services, and related financial risk protection. In addition, SDG 9 on industry, innovation and infrastructure, and SDG 12 on responsible consumption and production encompass innovation and sustainability, and, in the context of self-care interventions, oblige us to anticipate an increase in the development, distribution and disposal of self-care products. The management of the related production, consumption and waste will need to be environmentally responsible. SDG 10 on reduced inequalities is of particular relevance to the key principles of ethics and human rights that underpin this guideline and inform the recommendations. Finally, SDG 16 on peace, justice and strong institutions emphasizes the importance of transparency, accountability and access to justice – all crucial aspects of an enabling environment for safe and effective health services, including self-care interventions. Box 1.1 lists the SDGs and targets relevant to this guideline. Chapter 1 6 WHO Guideline on Self-Care Interventions for Health and Well-Being SDG 3: Ensure healthy lives and promote well-being for all at all ages • Target 3.7: By 2030, ensure universal access to sexual and reproductive healthcare services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes • Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all SDG 4: Ensure inclusive and equitable quality education and promote life-long learning opportunities for all • Target 4.5: By 2030, eliminate gender disparities in education and ensure equal access to all levels of education and vocational training for the vulnerable, including persons with disabilities, indigenous peoples and children in vulnerable situations • Target 4.6: By 2030, ensure that all youth and a substantial proportion of adults, both men and women, achieve literacy and numeracy SDG 5: Achieve gender equality and empower all women and girls • Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action, and the outcome documents of their review conferences SDG 9: Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation • Target 9.5: Enhance scientific research, upgrade the technological capabilities of industrial sectors in all countries, in particular developing countries, including, by 2030, encouraging innovation and substantially increasing the number of research and development workers per 1 million people, and public and private research and development spending SDG 10: Reduce inequality within and among countries • Target 10.3: Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory laws, policies and practices and promoting appropriate legislation, policies and action in this regard • Target 10.4: Adopt policies, especially fiscal, wage and social protection policies, and progressively achieve greater equality SDG 12: Ensure sustainable consumption and production patterns • Target 12.7: Promote public procurement practices that are sustainable, in accordance with national policies and priorities • Target 12.a: Support developing countries to strengthen their scientific and technological capacity to move towards more sustainable patterns of consumption and production SDG 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels • Target 16.6: Develop effective, accountable and transparent institutions at all levels Source: United Nations (10). BOX 1.1. RELEVANT SUSTAINABLE DEVELOPMENT GOALS AND TARGETS Chapter 1 7 Chapter 1: Introduction The self-care SDG logo (Fig. 1.5) was developed to promote this WHO guideline and related WHO/United Nations partner tools to support the implementation of self-care interventions for health. People-centredness is inherent in the concept of self-care, and this logo symbolizes placing power over health and well-being in the hands of people in their roles as self-carers and/ or caregivers. The image encompasses all the elements of the guideline reflected in the framework for self-care interventions (see Chapter 2). 1.2 OBJECTIVES The purpose of this guideline is to provide evidence- based normative guidance that will support individuals, communities and countries with quality health services and self-care interventions based on primary healthcare strategies, comprehensive essential service packages and people-centredness. The specific objectives of this guideline are to provide: • evidence-based recommendations on key public health self-care interventions, including for advancing health, with a focus on underserved populations and settings with limited capacity and resources in the health system; • good practice statements on key programmatic, operational and service-delivery issues that need to be addressed to promote and increase safe and equitable access, and the uptake and use of self-care interventions for health; and • key considerations on specific topics to guide future research and guidelines processes. 1.3 LIVING GUIDELINE APPROACH In a fast-moving field, a “living guideline” approach allows for continual review of new evidence to inform further versions of the guideline. This guideline will be updated frequently, on a rolling basis, and will be posted on a dynamic, user-friendly and easy-to-navigate web-based platform. The recommendations, good practice statements and key considerations presented in this publication build on the guideline published in 2019 and represent a subset of prioritized self-care interventions for health. Over time, in subsequent versions, WHO aims for this guideline to gradually include a broader set of self-care interventions. This living guideline approach also facilitates the updating of existing recommendations as new evidence becomes available, and the inclusion of additional health domains that may not yet be reflected. Future guidance on self-care interventions in additional health areas will build on existing tools and guidance. For instance, a WHO package of essential noncommunicable disease interventions for primary healthcare in low-resource settings includes far-reaching recommendations, including the use of self-testing and measurement, and self-adjustment of dosages. These recommendations also point to the importance of group education and user-friendly, valid and reliable online information. Section 6.3 offers more detail about the living guideline approach. FIG. 1.5. WHO SELF-CARE LOGO INCORPORATING THE SUSTAINABLE DEVELOPMENT GOALS Chapter 1 8 WHO Guideline on Self-Care Interventions for Health and Well-Being 1.4 DEFINITION OF SELF-CARE AND SELF-CARE INTERVENTIONS 1.4.1 SELF-CARE Self-care is 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 (11). The scope of self-care thus includes health promotion, disease prevention and control, self-medication, providing care to dependent people, seeking hospital/specialist/ primary care if needed, and rehabilitation, including palliative care (12). This definition of self-care is based on a scoping review of WHO definitions of self-care (see Annex 3). It includes a range of self-care practices and approaches, as shown in Fig. 1.6. 1.4.2 SELF-CARE INTERVENTIONS Self-care interventions are tools that support self-care. These include evidence-based, high-quality drugs, devices, diagnostics and/or digital interventions that can be provided fully or partially outside formal health services and can be used with or without the direct supervision of healthcare personnel. People can have good knowledge of some interventions, and feel comfortable using them independently from the outset. For other interventions, people need more guidance and support before they can accept and use them independently. Self-care interventions for health that need initiation by health workers, or their support, should be linked to the health system and supported by it (see Fig. 1.6). Self-care interventions also support a continuum of care, as shown in Fig. 1.7, and a people-centred approach to health. This continuum of care applies to the users of self-care health interventions as individuals, but also to people in the role of caregiver. People might choose these interventions for positive reasons, which may include convenience, cost, empowerment or a better fit with values or daily lifestyles, or because the intervention may provide the desired options and choice. There might also be negative reasons, though – they might opt for self-care health interventions to avoid the health system, because of a lack of quality (e.g. discrimination from health workers) or lack of access (e.g. in humanitarian settings). While not ideal in these situations, self-care health interventions fulfil a particularly important role, as the alternative might be that people have no access at all. FIG. 1.6. SELF-CARE IN THE CONTEXT OF INTERVENTIONS LINKED TO HEALTH SYSTEMS HEALTH SYSTEMS EVERYDAY LIFE SELF-MANAGEMENT Self-medication, self-treatment, self-examination, self-injection, self-administration, self-use SELF-TESTING Self-sampling, self-screening, self-diagnosis, self- collection, self-monitoring SELF-AWARENESS Self-help, self-education, self-regulation, self- efficacy, self-determination SELF-CARE Source: adapted with permission from Narasimhan et al. (13). Chapter 1 9 Chapter 1: Introduction 1.4.3 CLASSIFICATION OF SELF-CARE INTERVENTIONS The WHO classification of self-care interventions categorizes the different ways in which they are used to support people’s needs and health system challenges (14). Even though many self-care interventions directly target individuals and caregivers and offer alternative means of seeking and obtaining care, they often operate at the broader health system level. As such, this classification is primarily health- system focused, analysing how self-care interventions can be applied as strategies to meet health system challenges. In turn, the system responses to these strategies help to meet people’s self-care needs by supporting and improving the health of individuals downstream. Targeted primarily at public health audiences, this classification provides a structure with the objective of promoting an accessible and bridging language for researchers, policy-makers, donors and health programme planners to articulate the functionalities of the implementation of self-care interventions. 1.5 SCOPE 1.5.1 SCOPE OF THIS GUIDELINE Building on the 2019 guideline, this guideline brings together new and existing WHO recommendations, key considerations and good practice statements on self-care interventions for health. These relate either to specific health-related interventions (see Chapter 3) or to creating and maintaining an enabling environment, particularly for underserved populations (see Chapter 4). The new recommendations focus on self-care interventions that are considered to be in transition from provision by facility-based health workers to delivery using a self-care approach. Where current WHO guidance exists, this document refers readers to those other publications for further information, and to other relevant WHO tools and documents on programme activities. All of the new and existing recommendations in this guideline are summarized in the summary tables in the executive summary and described in detail in Chapters 3 and 4. 1.5.2 ACCESS, USE AND UPTAKE OF SELF- CARE INTERVENTIONS FOR UNDERSERVED POPULATIONS Health inequities are endemic to every region of the world, with rates of disease significantly higher among the poorest and most marginalized individuals and communities. The vulnerabilities of underserved individuals and communities can lead to social isolation, poverty and people living in environments that are harmful to health. Not all individuals and communities require the same level of support for access, use and uptake of self-care interventions. Safe and strong linkages between independent self-care and access to quality healthcare for people who want or need it are important to avoid harm. Where self-care is not a positive choice, but prompted by fear or a lack of alternatives, this can increase any vulnerabilities. FIG. 1.7. CONTINUUM OF CARE FOR SELF-CARE PERSONAL DETERMINANTS • Knowledge • Health literacy • Daily choices (hygiene, safe sex, risk avoidance, nutrition/diet, work-life balance, adherence to treatment) SITUATIONAL, ECONOMIC, EMOTIONAL AND SOCIAL DETERMINANTS • Peer-to-peer actions • Support • Counselling • Engagement in health decisions HEALTH SYSTEMS DETERMINANTS • Identify opportunities to promote self-care • Provide written or visual materials • Support development of action/calendar/follow-up plan with increased severity of health condition • Promote tools, interventions, information for improved autonomy • Support caregivers PERSON COMMUNITY HEALTH WORKERS SELF- CARE Chapter 1 10 WHO Guideline on Self-Care Interventions for Health and Well-Being Furthermore, not all interventions are situated in the same space between users themselves and health workers. The use and uptake of self-care interventions is organic, and the shift in responsibility – between full responsibility for the user and full responsibility for the health worker (or somewhere along that continuum) – can change over time for each intervention and for different population groups. Informal consultations are taking place at the regional level to examine the current situation of self-care interventions at the national levels, and to determine the factors that will facilitate the uptake of this guideline. 1.5.3 SELF-CARE FOR SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS Within the framework of WHO’s definition of health, as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity” (15), sexual and reproductive health addresses sexuality and sexual relationships as well as the reproductive processes, functions and system at all stages of life. Ensuring the full implementation of human rights-based laws and policies through sexual and reproductive health programmes is fundamental to health and human rights. Table 1.2 outlines the key components of a human rights approach to self- care interventions. TABLE 1.2. HUMAN RIGHTS APPROACH TO SELF-CARE INTERVENTIONS Human rights standard Relevance to self-care interventions for sexual and reproductive health and rights The right to health, including the availability, accessibility, acceptability and quality of information, goods and services The ability of the user to engage in self-care interventions with information and products that are available, accessible, acceptable and of good quality is a core component of promoting and protecting their right to health The right to participation The active, fully informed participation of individuals in decision-making processes that affect them extends to matters relating to health The right to equality and non- discrimination This right highlights the particular challenges faced by people who may be marginalized or face discrimination and stigma, and it helps to ensure that relevant regulatory frameworks, laws, policies and practices conform to human rights principles The right to information The right to information has implications for how the provision of information is regulated, including determinations about where the liability falls for inaccurate or false information The right to informed decision- making The availability of accurate, accessible, clear and user-friendly information framed in non-discriminatory terminology is central to informed decision-making around self- care interventions The right to privacy and confidentiality Guarantees of privacy and confidentiality may need additional consideration where self-care interventions are accessed outside the health system The right to accountability Accountability includes that of the health sector as a whole, and regulation of the private sector, and encompasses the legal and policy environment more broadly. It also includes a system of redress that promotes access to justice in cases where rights related to self-care interventions may be neglected or violated Chapter 1 11 Chapter 1: Introduction The comprehensive approach to SRHR endorsed by WHO Member States in the 2004 Global Reproductive Health Strategy covers five key areas (see Fig. 1.8) – plus several cross-cutting areas such as gender-based violence (16). While self-care is important in all aspects of health, it is particularly important – and particularly challenging to manage – for populations negatively affected by gender, political, cultural and power dynamics and for underserved people (e.g. people with disabilities). This is true for self-care interventions for SRHR, since many people are unable to exercise autonomy over their bodies and are unable to make decisions around sexuality and reproduction. 1.6 TARGET AUDIENCE Primary target audience: • national and international policy-makers, researchers, programme managers, health workers (including pharmacists), donors and civil society organizations responsible for making decisions or advising on the delivery or promotion of self-care interventions. Secondary target audience: • product developers. This new guideline is also expected to support: • people affected by the recommendations, i.e. people taking care of themselves, and caregivers. Health services and programmes in low-resource settings will benefit most from the guidance presented here, as they face the greatest challenges in providing services tailored to the needs and rights of underserved populations. However, this guideline is relevant for all settings and should, therefore, be considered as global guidance. In implementing these globally relevant recommendations and good practice statements, WHO regions and countries can adapt them to the local context, taking into account the economic conditions and the existing health services and healthcare facilities. 1.7 VALUES AND PREFERENCES Building on the best practice of assessing end-user values and preferences – as used for the 2017 WHO Consolidated guideline on sexual and reproductive health and rights of women living with HIV (17) – a global survey on self- care interventions ran online. Available in English, French FIG. 1.8. SCOPE OF SELF-CARE INTERVENTIONS FOR SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) HEALTH “A state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.” SRHR Self-care for underserved and marginalized populations who may require additional information or support to make informed decisions about uptake and use of self-care interventions Improving antenatal, delivery, postpartum and newborn care For SRHR, the following five key aspects are highlighted in the Global Reproductive Health Strategy Providing high-quality services for family planning, including infertility services Promoting sexual health Eliminating unsafe abortion Combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer and other gynaecological morbidities Chapter 1 12 WHO Guideline on Self-Care Interventions for Health and Well-Being and Spanish, this Global Values and Preferences Survey (GVPS), was available from October 2020 to May 2021. A total of 1350 people from 113 countries responded to the survey, including health workers (36% of respondents). There was good regional representation: 26% of respondents were in Africa, 18% in South Asia, 27% in Europe, 23% in the Americas and 13% in the Western Pacific. The respondents ranged in age from 18 to 70 years and had a diverse range of backgrounds, including individuals of diverse sexual orientation and gender identity and expression (18%), young people between 18 and 29 years of age (46%), and people aged 50 years and older (16%). The limitations of the GVPS included that the survey was most likely to reach people who were able to locate and access it online, and it was accessible only to people who could read English, French or Spanish. The strengths of the survey included the wide range of global responses from every region, which provided a snapshot into differential access, and the inclusion of qualitative responses, highlighting a range of perspectives on self- care interventions. The GVPS results were presented at the Guideline Development Group (GDG) meeting. The GDG took the findings of the GVPS into account in the process of developing the new recommendations for this guideline (just as they also took into account the findings of literature reviews on values and preferences). 1.8 GUIDELINE DEVELOPMENT AND COMPILATION PROCESS This guideline has been developed according to WHO standards and requirements for guideline development, based on the WHO handbook for guideline development, second edition (18), and with the oversight of the WHO Guideline Review Committee. All of the recommendations in this guideline have been developed by the GDG, facilitated by the guideline methodologist using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (19). See Annex 2, and section A2.4 in particular, which describes how the issues to be addressed and the specific recommendations and good practice statements to be included in this guideline were determined. In the remainder of this document, Chapter 2 describes the essential strategies for creating and maintaining an enabling environment for self-care. Chapter 3 presents the recommendations, and Chapter 4 provides the good practice statements relating to implementation considerations. Chapter 5 offers a list of research gaps and priorities, as identified by the GDG, that need further study. Finally, Chapter 6 describes the plans for the dissemination, application, monitoring and evaluation, and updating of the guideline and recommendations. 1. Hardon A, Pell C, Taqueban E, Narasimhan M. Sexual and reproductive self care among women and girls: insights from ethnographic studies. BMJ. 2019;365:l1333. doi:10.1136/bmj.l1333. 2. Boonmongkon P, Nichter M, Pylypa J. Mot luuk problems in Northeast Thailand: why women’s own health concerns matter as much as disease rates. Soc Sci Med. 2001;53:1095–1112. doi:10.1016/S0277- 9536(00)00404-4. REFERENCES FOR CHAPTER 1 This living guideline is also available in one user-friendly and easy-to-navigate online platform, which will allow for continual review of new evidence and information. The interactive web-based version of this living guideline is available at https://app.magicapp.org/#/guideline/Lr21gL. BOX 1.2 A LIVING GUIDELINE https://app.magicapp.org/#/guideline/Lr21gL Chapter 1 13 Chapter 1: Introduction 3. Working for health and growth: investing in the health workforce. Report of the High-Level Commission on Health Employment and Economic Growth. Geneva: World Health Organization; 2016 (http://apps.who.int/ iris/bitstream/10665/250047/1/9789241511308-eng.pdf, accessed 13 March 2021). 4. Half the world lacks access to essential health services, 100 million still pushed into extreme poverty because of health expenses. Washington (DC) and Geneva: World Bank and World Health Organization; 2017 (https:// www.worldbank.org/en/news/press-release/2017/12/13/ world-bank-who-half-world-lacks-access-to-essential- health-services-100-million-still-pushed-into-extreme- poverty-because-of-health-expenses, accessed 19 March 2021). 5. Director-General of the World Health Organization. Thirteenth general programme of work 2019−2023 (draft 5 April). Seventy-first World Health Assembly. Geneva: World Health Organization; 2018 (A71/4; https://www.who.int/about/what-we-do/thirteenth- general-programme-of-work-2019---2023, accessed 24 May 2021). 6. 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Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. Global strategy adopted by the 57th World Health Assembly. Geneva: World Health Organization; 2004 (http://www.who.int/ reproductivehealth/publications/general/RHR_04_8/en, accessed 13 March 2021). 17. Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva: World Health Organization; 2017 (https://www.who.int/ reproductivehealth/publications/gender_rights/srhr- women-hiv/en, accessed 13 March 2021). 18. WHO handbook for guideline development, second edition. Geneva: World Health Organization; 2014 (https://apps.who.int/iris/handle/10665/145714, accessed 21 April 2021). 19. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org, accessed 1 April 2021). http://apps.who.int/iris/bitstream/10665/250047/1/9789241511308-eng.pdf http://apps.who.int/iris/bitstream/10665/250047/1/9789241511308-eng.pdf https://www.worldbank.org/en/news/press-release/2017/12/13/world-bank-who-half-world-lacks-access-to-essential-health-services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses https://www.worldbank.org/en/news/press-release/2017/12/13/world-bank-who-half-world-lacks-access-to-essential-health-services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses https://www.worldbank.org/en/news/press-release/2017/12/13/world-bank-who-half-world-lacks-access-to-essential-health-services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses https://www.worldbank.org/en/news/press-release/2017/12/13/world-bank-who-half-world-lacks-access-to-essential-health-services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses https://www.worldbank.org/en/news/press-release/2017/12/13/world-bank-who-half-world-lacks-access-to-essential-health-services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses https://www.who.int/about/what-we-do/thirteenth-general-programme-of-work-2019---2023 https://www.who.int/about/what-we-do/thirteenth-general-programme-of-work-2019---2023 https://www.who.int/primary-health/conference-phc/declaration https://www.who.int/primary-health/conference-phc/declaration https://www.who.int/publications/almaata_declaration_en.pdf https://www.who.int/publications/almaata_declaration_en.pdf https://www.who.int/universal-health-coverage/compendium https://www.who.int/universal-health-coverage/compendium https://www.who.int/news-room/q-a-detail/health-promotion https://www.who.int/news-room/q-a-detail/health-promotion https://sustainabledevelopment.un.org/sdgs http://apps.searo.who.int/PDS_DOCS/B5084.pdf https://www.who.int/about/governance/constitution https://www.who.int/about/governance/constitution http://www.who.int/reproductivehealth/publications/general/RHR_04_8/en http://www.who.int/reproductivehealth/publications/general/RHR_04_8/en https://www.who.int/reproductivehealth/publications/gender_rights/srhr-women-hiv/en https://www.who.int/reproductivehealth/publications/gender_rights/srhr-women-hiv/en https://www.who.int/reproductivehealth/publications/gender_rights/srhr-women-hiv/en https://apps.who.int/iris/handle/10665/145714 http://gradeworkinggroup.org Chapter 3 14 WHO Guideline on Self-Care Interventions for Health and Well-Being 3 Essential strategies for creating and maintaining an enabling environment for self-care 2. 14 Chapter 3 15 Chapter 3: Recommendations and key considerations This chapter describes the core elements of the WHO conceptual framework for self-care interventions and their importance in supporting the introduction, access, uptake and scale-up of self-care interventions. At a Glance2. Chapter Return to Overview 15 p. 17 p. 24 p. 19 p. 22 p. 24 p. 17 Key principles Accountability Safe and supportive enabling environment Characteristics of an enabling environment Places to access and/or deliver self-care interventions People-centred approach for health and well-being Chapter 2 16 WHO Guideline on Self-Care Interventions for Health and Well-Being 2.1 BACKGROUND Ensuring that the environment in which self-care interventions can be made available is safe and appropriate must be key to any strategy for introducing and/or scaling- up these interventions. These strategies should be informed by the profile of potential users, the services on offer to them, and the broader legal and policy environment, and structural supports and barriers. The conceptual framework informing this guideline is designed to draw systematic attention to the key areas for creating and maintaining an enabling environment for self-care to ensure that self-care interventions reach users with all the necessary checks and balances in place to support their rights and needs. The conceptual framework presented in Fig. 2.1 illustrates core elements from both people-centred and health systems approaches that can support the introduction, access, uptake and scale-up of self-care interventions for health (1). The people-centred approach to health and well- being lies at the core of this framework (green circle) and is underpinned by key principles (pink ring). The framework then shows key places of access to, and delivery of, self- care interventions (mustard ring), the key elements of a safe and supportive enabling environment (red ring), and accountability at different levels (blue ring). Places of access Key principles Enabling environment Individual accountability Education Health financing Private sector accountability Trained health workforce Commodity security Psychosocial support Health sector accountability Donor accountability Government accountability Home Information Community Holistic Caregivers Pharmacies Ethics Life course Gender equality Human rights Supportive laws and policies Digital technologies and platforms Protection from violence, coercion, stigma and discrimination Traditional medicine and sociocultural practices Economic empowerment (e.g. housing, food security, ability to pay for healthcare) Social accountability Health services Access to justice Accountability Self-care for health and well-being Regulated quality products and interventions Health literacy FIG. 2.1. CONCEPTUAL FRAMEWORK FOR SELF-CARE INTERVENTIONS Source: adapted with permission from Narasimhan et al. (1). Chapter 2 17 Chapter 2: Essential strategies for creating and maintaining an enabling environment for self-care 2.2 PEOPLE-CENTRED APPROACH FOR HEALTH AND WELL-BEING This guideline is grounded in, and advocates, a strengthened, comprehensive, people-centred approach to health and well-being, including for sexual and reproductive health and rights (SRHR) and noncommunicable diseases (NCDs). People-centredness means taking a holistic approach to the care of each person, and taking account of the environment in which they live and their individual circumstances, needs and desires across their whole life course. People-centred health services are delivered using an approach to healthcare that consciously adopts the perspectives of individuals, families and communities. A people-centred approach (2, 3): • sees individuals as active participants in, as well as beneficiaries of, trusted health systems that respond to their needs, rights and preferences in humane and holistic ways; • emphasizes the promotion of gender equality as central to the achievement of health for all and promotes gender-transformative health services that examine harmful gender norms and support gender equality; • ensures that people are empowered – through education and support – to make and enact decisions in all aspects of their lives, including in relation to sexuality and reproduction; • calls for strategies that promote people’s participation in their own healthcare; • recognizes the strengths of individuals as active agents in their health and not merely passive recipients of health services; and • is organized around the health needs and priorities of people themselves rather than disease management and control. The framework for integrated people-centred health services calls for a fundamental shift in the way health services are funded, managed and delivered (2). The framework’s vision is that “all people have equal access to quality health services that are co-produced in a way that meets their life- course needs, are coordinated across the continuum of care and are comprehensive, safe, effective, timely, efficient and acceptable; and all carers are motivated, skilled and operate in a supportive environment” (2). The World Health Organization (WHO) recommends five interwoven strategies that need to be implemented to achieve the framework. Application of the approach can build robust and resilient health services, which are critical for progress towards universal health coverage (UHC) and fulfilling the Sustainable Development Goals (2). 2.3 KEY PRINCIPLES A systematic consideration of the key principles outlined in this section, in the context of a well-functioning health system and a safe and supportive enabling environment, will help to ensure better health for all in the provision of self-care interventions. This guideline’s key principles are designed to draw systematic attention to key areas of potential concern, to inform actions that might militate against these negative impacts and ensure a supportive and responsive health system and broader enabling environment. 2.3.1 HOLISTIC APPROACH A holistic approach to health encompasses issues that go beyond simple access to biomedical interventions and their uptake. Adopting a holistic approach to health means working at multiple levels from the individual, the family and the community, to the broader health system and the overarching enabling environment. In this way, not only is every aspect of the individual’s health considered, but also the different pieces of the environment within which the individual lives – all of which influence individual health and care-seeking. Within a people-centred approach, a holistic view of health demands that attention is given beyond a specific disease or health condition. Health is interrelated with nature and nurture and evolves over time, so ensuring a holistic approach to it can better reflect its complex and dynamic elements (4). A holistic approach to self-care interventions is thereby one that is relevant to a range of health topics, including SRHR and NCDs, infectious diseases and noncommunicable diseases, including mental health. 2.3.2 ETHICAL CONSIDERATIONS Health ethics add the dimension of value-orientated considerations, such as equity and its impact on healthcare delivery for underserved populations. Leveraging an ethical framework emphasizes well-being and not just the absence of disease. An ethical framework can help us to better understand how user autonomy could promote or challenge one or more dimensions of well-being. It can help us to assess, for instance, criteria on the capacity of individuals to make health decisions or to use a self-care intervention (5). Chapter 2 18 WHO Guideline on Self-Care Interventions for Health and Well-Being An ethical approach should inform all decisions about self-care interventions, underpinned by the principles of fairness and equity (6). This includes respect for medical ethics within health services, and goes beyond doing so, to ensuring an ethical approach anywhere that self- care interventions are accessed and used outside the health system. The enabling environment to support the introduction of self-care interventions must be ethical by making sure that healthcare optimizes the risk–benefit ratio in all interventions, respects individuals’ rights to make autonomous and informed decisions, safeguards privacy, protects the most underserved, and ensures equitable distribution of resources. 2.3.3 LIFE-COURSE APPROACH Socioeconomic conditions throughout people’s lives shape health outcomes, disease risk, health-seeking behaviour and needs, and influence people’s use and uptake of self-care interventions (6). Healthy people often maintain their health and well-being at home and engage or re-engage with the health system at discrete stages of their lives. Self-care interventions should meet the health needs and aspirations of potential users at all stages of the life course. This helps to ensure that the needs of different age groups are considered and that people’s health needs and priorities over time are taken into account for access to and the use of self-care interventions. The benefits of considering such a life-course approach include increased delivery efficiency, decreased overall costs, improved equity in the uptake of services, better health literacy and self-care, increased satisfaction with care, improved relationships between patients and health workers, and an improved ability to respond to healthcare crises. As each stage in a person’s life exerts influence on the next stage, it is important to use self-care interventions at all stages (7). 2.3.4 HUMAN-RIGHTS AND GENDER- EQUALITY APPROACHES An integrated approach based on human rights and gender equality lies at the heart of ensuring the dignity and well-being of individuals. Laws, policies and interventions should address gender inequalities, including harmful gender norms and stereotypes, unequal power in intimate relationships, and women’s and gender-diverse individuals’ relative lack of access to and control over resources. All these inequalities exacerbate people’s vulnerability, affect their access to and experience of health services and create barriers that prevent them from fully exercising their health-related rights. The promotion of gender equality is central to facilitating access to self-care interventions for all people who might benefit from them. The protection of human rights is fundamental to this guideline. Human rights relating to sexual and reproductive health (SRH) include the rights of all people to have pleasurable and safe sexual experiences, free of coercion, discrimination and violence, the right to be informed of and have access to the safe, effective, affordable and acceptable method of fertility regulation of their choice, and the right of access to appropriate health services that will enable individuals to go safely through pregnancy and childbirth and provide individuals and partners with the best chance of having a healthy infant (6). The United Nations Committee on Economic, Social and Cultural Rights has defined the right to SRH as an “integral part of the right to health enshrined in Article 12 of the International Covenant on Economic, Social and Cultural Rights” (8). It says the right to SRH entails a set of entitlements, including unhindered access to a whole range of healthcare facilities, goods, services and information (8). These ensure – for all people – the full enjoyment of the right to SRH under Article 12. Showing respect for individual dignity and for physical and mental integrity includes giving each person the opportunity to make autonomous reproductive choices (9–11). The principle of autonomy, expressed through free, full and informed decision- making, is a central theme in medical ethics and is embodied in human rights law (12). This holds particular relevance in the context of self-care interventions, as people may rely on publicly available information rather than healthcare professionals to make appropriate decisions when selecting and using self-care interventions. Furthermore, Article 27 of the Universal Declaration of Human Rights states that everyone has the right freely “to share in scientific advancement and its benefits” (13). The programme of action of the 1994 International Conference on Population and Development highlighted SRH issues within a human rights framework (14). It defined reproductive rights as follows. Chapter 2 19 Chapter 2: Essential strategies for creating and maintaining an enabling environment for self-care Reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents (14, paragraph 7.3). Since then, international and regional human rights standards and jurisprudence related to SRHR have evolved considerably. There is a growing consensus that SRH cannot be achieved and maintained without respect for and protection of certain human rights. The application of existing human rights to sexuality and SRH constitutes sexual rights. Sexual rights protect all people’s rights to fulfil and express their sexuality and enjoy SRH, with due regard for the rights of others and within a framework of protection against discrimination (15). WHO has recognized certain human rights to be particularly integral to the promotion and protection of SRHR (16). As such, these human rights are equally applicable to self-care interventions for SRHR. Centred around the user, Table 1.2 in Chapter 1 outlines the relevance of these human rights standards to the adoption and provision of self-care interventions. These human rights standards and principles are critical to ensuring the appropriate roll-out of self-care interventions (17). SRHR outcomes are not equal for people throughout the world, neither across nor within countries. Many of these disparities, which are rooted in underlying social determinants, are avoidable and unacceptable (18). 2.4 SAFE AND SUPPORTIVE ENABLING ENVIRONMENT A safe and supportive enabling environment is essential to facilitate access to and uptake of products and interventions that can improve the health and well-being of marginalized and underserved populations. The successful introduction and/or scale-up of self-care interventions therefore requires systematic attention to all aspects of the health system, and to the broader environment within which self-care interventions are delivered (6). Self-care interventions must be an adjunct to, rather than a replacement for, direct interaction with the health system, and this may need the boundaries of the health system to be reconceptualized. Users’ experiences of self-care interventions are shaped, in part, by the health system. To be safe and effective and to reach individuals who may not be able to access healthcare, self-care interventions may need more – not less – support from the health system (17). Drawing on the WHO health system framework (19), every health system building block (see Fig. 2.2) needs to be adapted to ensure its adequacy for effective self-care interventions. System building blocks Overall goals/ outcomes Improved health (level and equity) Social and financial risk protection Improved efficiency Responsiveness SERVICE DELIVERY INFORMATION LEADERSHIP/GOVERNANCE HEALTH WORKFORCE FINANCING MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES ACCESS QUALITY COVERAGE SAFETY FIG. 2.2. WHO HEALTH SYSTEM FRAMEWORK Source: WHO (19). Chapter 2 20 WHO Guideline on Self-Care Interventions for Health and Well-Being In addition, there will be an increased need to reach out to communities to ensure that people have appropriate information about self-care interventions to make informed choices in using them, and to ensure that they seek support from health workers when needed. This is further explored in section 2.4.7, with the potential users of self- care interventions placed at the centre of all considerations of how the health system might have to respond. 2.4.1 SERVICE DELIVERY Service delivery is a direct function of the inputs into the health system, such as the health workforce, procurement/ supplies and financing; increased inputs should lead to improved service delivery and enhanced access to services. Ensuring the availability of and access to health services that meet or exceed the minimum quality standards is a key function of a health system (20). Services are organized around the person’s needs and preferences, not the disease or the person’s ability to pay. Users perceive health services as being responsive and acceptable to them (or not), and this promotes an approach where people are active partners in their own healthcare. Service delivery is organized to provide an individual with a continuity of care across the network of services, health conditions and levels of care, and over the life course. 2.4.2 THE HEALTH WORKFORCE The WHO global competency and outcomes framework for UHC is relevant to the provision of health interventions across promotive, preventative, curative, rehabilitative and palliative health services, and it can be used by health workers at the primary healthcare level with a pre-service training pathway of 12–48 months (21). The framework focuses on the competencies (integrated knowledge, skills and behaviours) needed to provide interventions, and has relevance to both pre-service and in-service education and training. To maximize the opportunities to promote and facilitate self-care interventions, it is important that training for health workers incorporates communication to enable informed decision-making; the clarification of values; collaborative practice; and empathetic and compassionate approaches to care (21). The delivery of care and health services should be accomplished in a people-centred and non-judgemental way, allowing everyone, when they are willing and able, to lead the decision-making about their own care in an informed and supported fashion. Self-care interventions, even if accessed and used outside health services, demand some engagement with the health system, and, as such, it is critical that the attitudes and behaviours of health workers are inclusive and non- stigmatizing and that they promote safety, including patient safety and equality. Health workers and managers of healthcare facilities – whether in the public or the private sector – are responsible for delivering services appropriately and meeting standards based on professional ethics and internationally agreed human rights principles. Health workers and health services need to include the role that people take up when practising self-care outside of any initiation by the health system – acknowledging self-care when developing and supporting a holistic, health management plan. 2.4.3 INFORMATION Health information and services must be available and accessible at the time and place they are needed, and they must also be acceptable and of high quality (6). With self-care interventions available outside the health system, potential users must have access to reliable, useful, quality information that is consistent with the needs of the individual and the community. Pictures and other visual materials are useful in overcoming language barriers and literacy issues. Mobile phones, tablets and other information and communications technologies offer new opportunities to deliver health information. Health information should be available to and used by health workers to address the clinical and non-clinical aspects of self-care. Information should be reliable and accurate, and it needs to be trusted by individuals, who rely on it to support their informed decision-making about their health and well-being and their interactions with the health system. Patient information leaflets, for example, are a legal requirement in many countries, and they must be designed to ensure that patients can make informed decisions about the safe and effective use of the products and interventions they describe. Capturing information about self-care interventions may require the expansion of health management information systems beyond the traditional confines of the health system. 2.4.4 MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES The sequence of processes to guarantee access to appropriate and safe medical products, vaccines and technologies includes health technology regulation, assessment and management (see Fig 2.3) (22). The national regulatory authorities (i.e. the government) determine which medical products, vaccines and Chapter 2 21 Chapter 2: Essential strategies for creating and maintaining an enabling environment for self-care technologies can enter the local market. The uninterrupted delivery of services and of the implementation of interventions must be enabled by the availability of all the necessary medical products and technologies; this includes supplies that might be accessed outside traditional health services (e.g. through pharmacies or online). Even though most self-care interventions are likely to be used outside the healthcare setting, the quality of the products and technologies must be appropriately regulated (see section 2.4.6). The security of reproductive health commodities exists when every person is able to choose, obtain and use quality contraceptives and other essential reproductive health products whenever they need them. As demand for reproductive health supplies increases, countries are under increasing pressure to establish and maintain secure systems for procuring reproductive health commodities and managing their delivery. Ensuring this security involves planning, implementation, and the monitoring and evaluation of supply chain processes at the programme level. It also demands broader policy advocacy, the management of procurement issues, devising costing strategies, multi-sectoral coordination and addressing contextual considerations. Enabling and strengthening in-country capacity for the security of reproductive health commodities is an essential step in guarding against shortfalls in much-needed reproductive health supplies (24). 2.4.5 FINANCING Using self-care approaches and technologies to deliver certain healthcare interventions could affect (i) how much societies pay for delivering these interventions (and producing the associated health outcomes), (ii) who pays for these interventions, and (iii) who accesses them (25). Budgetary allocations and financing strategies need to be recognized for the critical role they play in creating the enabling environment for people to use self-care interventions to help achieve good health outcomes, contributing to UHC and promoting cost-effective service delivery. Health systems must also consider the potential savings that may result from earlier diagnosis and treatment due to self-care, and include these in the financial equation. 2.4.6 LEADERSHIP AND GOVERNANCE – THE REGULATORY ENVIRONMENT With self-care interventions encompassing many different products and places of access, the regulation of a wide range of actors is necessary. It is likely that, as self-care interventions become increasingly available through the private sector and online, informal and/or unregulated vendors might supply products of unknown quality, safety and performance (26). Regulation is key in this context, and it is critical that this balances ensuring quality and safety against ensuring access. The detection and correction of any undesirable trends and distortions – any negative impacts or unintended uses of self-care interventions – is also important. The regulatory system also has a role in identifying and preventing the spread of counterfeit products. Finally, transparent, accessible and effective accountability mechanisms must be put in place; these may operate alongside other social accountability mechanisms, but there must be avenues for remedy, redress and access to justice through the health system (27, 28). FIG. 2.3. PROCESSES TO GUARANTEE ACCESS TO APPROPRIATE, SAFE AND QUALITY SELF-CARE INTERVENTIONS Source: adapted from WHO (23). Appropriate, safe and quality self-care interventions HEALTH TECHNOLOGY REGULATION • Safety, performance and quality • Access and availability HEALTH TECHNOLOGY ASSESSMENT • Clinical effectiveness • Ethics • Social issues • Organizational factors HEALTH TECHNOLOGY MANAGEMENT • Procurement • Selection • Training • Use Chapter 2 22 WHO Guideline on Self-Care Interventions for Health and Well-Being 2.4.7 LINKS BETWEEN HEALTH SYSTEMS AND COMMUNITIES To ensure the safe and effective provision of self-care interventions, mechanisms must be put into place to overcome any barriers to service uptake and use, and any barriers to continued engagement with the health system. These barriers occur at the individual, interpersonal, community and societal levels. They may include challenges such as, among others, social exclusion and marginalization, criminalization, stigma, and gender-based violence and gender inequality. Strategies are needed across health system building blocks (see Fig. 2.2) to improve the availability, accessibility, acceptability, affordability, uptake, equitable coverage, quality, effectiveness and efficiency of self-care interventions as well as links to services. If barriers to such improvements are left unaddressed, they could undermine health, even where self-care interventions are available; removing them is a critical part of creating an enabling environment for self-care interventions. In the context of self-care interventions, bridges between health systems and communities take on particular importance for ensuring safe, informed and appropriate use of these interventions. This should include outreach to provide information on the traditional options available as well as on the self-care interventions, and how and where to seek support from health services whenever needed, including outreach to communities that may be unaware of new technological advances in self-care products. 2.5 CHARACTERISTICS OF THE ENABLING ENVIRONMENT The environment around the health system and the individual plays a crucial role in shaping a person’s access to and use of health services as well as their health outcomes (see Fig. 2.4). The importance of, for example, the social determinants of SRHR, as manifested in the laws, institutional arrangements and social practices that prevent individuals from effectively enjoying their SRHR, is well documented (9). The importance of the enabling environment is particularly true for self-care interventions, since these are mostly accessed and/or used outside formal health services. This environment must, therefore, be conducive to the realization of health and well-being. FIG. 2.4. CHARACTERISTICS OF THE ENABLING ENVIRONMENT AFFECTING SELF-CARE INTERVENTIONS Commodity security Psychosocial support Supportive laws and policies Health literacy Access to justice Economic empowerment Education Health financing Regulated quality products and interventions Trained health workforce Protection from violence, coercion, stigma and discrimination Information ENABLING ENVIRONMENT These factors determine individuals’ access to and use of health services and their health outcomes Chapter 2 23 Chapter 2: Essential strategies for creating and maintaining an enabling environment for self-care 2.5.1 ACCESS TO JUSTICE Policies and procedures are needed to ensure that all people can safely report, seek redress for, and prevent further rights violations such as discrimination, violations of medical confidentiality, and denial of health services. Programmes should facilitate the same level of access to justice for individuals using self-care interventions. The primary considerations in facilitating access to justice must include safety, confidentiality, and choice and autonomy in terms of whether or not an individual wants to report a violation. Users should be able to access a functional system of remedy; in the case of rights violations (e.g. discrimination), such a system provides a way to seek legal redress, by which users can hold duty-bearers, including health workers, accountable for their actions or inactions. A system could also provide other forms of redress and accountability, as formal legal systems may present too high a barrier for an individual seeking redress and prevention of further harm. Where appropriate, health workers can facilitate access to justice by offering to support clients who want to report violations to the police. Access to justice, redress and the prevention of further harm may take different forms, in particular for communities and individuals who face marginalization and criminalization. 2.5.2 ECONOMIC EMPOWERMENT Livelihood insecurity, poverty and a lack of resources to meet key needs and expenses contribute to greater vulnerability and poor health outcomes. Socioeconomic vulnerabilities can make it difficult for people to exercise their human rights, such as in situations where individuals are dependent on violent or abusive partners or transactional sex to ensure that their own and/or their dependants’ basic needs are met. There is a risk that self-care interventions shift the costs of care from the health system to the individual (see section 2.4.5), which could exacerbate access inequities. Interventions focused on economic empowerment, poverty reduction and resource access, such as housing and food support, therefore have the potential to improve access to healthcare and to improve health outcomes for all. 2.5.3 EDUCATION Education, particularly secondary education, is important for empowering people in their health and well-being, and has repeatedly been found to be associated with a wide range of better health outcomes as well as improved knowledge of how to maintain good health (29, 30). The central role of comprehensive sexuality education (CSE), for example, in empowering young people to take responsible and informed decisions about their sexuality and relationships is well documented (31). Ensuring access to education, including CSE, for all will support informed decision-making about care-seeking and self-care interventions. 2.5.4 PROTECTION FROM VIOLENCE, COERCION, STIGMA AND DISCRIMINATION Violence can take various forms, including physical aggression, forced or coerced sexual contact, psychological abuse, and controlling behaviours by an intimate partner (32). Multiple structural factors influence vulnerability to violence, including discriminatory or harsh laws and policing practices, and cultural and social norms that legitimize stigma and discrimination (32, 33). Violence may undermine people’s ability to make and enact health- promoting decisions in their sexual and reproductive life, or to access and use SRH services, including self-care interventions. Further, the negative psychological outcomes of violence may inhibit self-care (34). The risks of violence that may be affecting people must be considered and mitigated when self-care interventions are used. Efforts to address violence in this context must involve other sectors along with the health sector. While appropriate action around violence could help to improve SRHR for everyone, special attention should be paid to people who may be more vulnerable to stigma, exclusion and violence, including people living with HIV, transgender and gender-diverse individuals, sexually diverse persons, people who use drugs, and people engaged in sex work. Stigma and discrimination, both enacted and perceived, can create barriers to accessing SRH services, with important implications for health-seeking behaviours and outcomes. This can be true for certain SRH services in particular, such as abortion, and for specific populations, such as adolescents, transgender and gender-diverse individuals, and people with disabilities. Protecting against such stigma and discrimination is a critical part of the enabling environment for self-care interventions, to ensure equitable access to services for all who need them, without fear of reprisals for seeking information or connecting with health services. This may need intervention at multiple levels, from individuals to communities as well as people working in health facilities and services. Chapter 2 24 WHO Guideline on Self-Care Interventions for Health and Well-Being 2.5.5 PSYCHOSOCIAL SUPPORT Early, adequate and tailored psychosocial support (see the definition in Annex 4) helps individuals and communities to heal psychological wounds and rebuild social structures after an emergency or a critical event. It can help to change people into active survivors rather than passive victims. Early and adequate psychosocial support can (i) prevent distress and suffering developing into something more severe, (ii) help people to cope better and become reconciled to everyday life, (iii) help people to resume their regular lives, and (iv) meet community-identified needs (35). 2.5.6 SUPPORTIVE LAWS AND POLICIES The legal and policy environment shapes the availability of health services and programmes, and the degree to which they are responsive to individuals’ needs and aspirations. Laws and public policies are also key tools with which to influence the social and economic context; they can reinforce positive social determinants and begin the process of addressing those social norms or conditions that exacerbate health inequity (36). The barriers created by, for example, the criminalization of adult same-sex consensual sexual conduct and other behaviours, should be addressed. If these barriers persist, linkage to health services following the use of self-care interventions will continue to be impeded. In addition, the regulation needed to promote access to self-care interventions without compromising quality or safety is a critical area for action to realize SRHR. 2.5.7 HEALTH AND DIGITAL LITERACY Health literacy is essential to make the most informed choices regarding health for self-carers and caregivers. Improving health literacy in populations provides the foundation on which citizens are enabled to play an active role in improving their own health, to engage successfully with community action for health, and to push governments to meet their responsibilities for health and health equity. Improving people’s health literacy can allow them to better interpret, understand and act on health information for better self-care. Health literacy also helps individuals to distinguish between incorrect and correct information. Ideally, a health-literate individual is able to seek and assess the health information they need; to understand and follow instructions for self-care, including administering complex daily medical regimens; to plan and achieve the lifestyle adjustments needed to improve their health; to make informed, positive health decisions; to know how and when to access healthcare when this is needed; and to share health-promoting activities with others, and address health issues in the community and society (37). When digital platforms are used for self-care interventions, digital literacy – proficiency in operating digital devices and platforms – needs to be considered. The uptake of self-care interventions delivered though digital channels may be affected by different levels of digital literacy. Some populations, such as adolescents and youth, may have higher levels, so self-care interventions delivered though digital or mobile devices may be more appealing to them (38, 39). 2.6 PLACES OF ACCESS TO SELF- CARE INTERVENTIONS Increasingly, people access health information, products and services outside formal health facilities (6). Self-care interventions can be accessed through several avenues, giving individuals more choice and improving individual autonomy. Much self-care is done at home, and self-care interventions are often accessed through pharmacies or via digital platforms (such as telehealth or through mobile applications). The places of access to these interventions also include health facilities (such as hospitals, specialized clinics or care homes) and delivery can also be via the community, caregivers or traditional health practitioners (see Fig. 2.5). 2.7 ACCOUNTABILITY From a human rights perspective, accountability means ensuring the fulfilment of the obligations of government policy-makers and other duty bearers to the rights holders who are affected by their decisions and actions. From an ethics perspective, accountability is about answerability, liability, and the expectation that blameworthy individuals or organizations will be held accountable for their actions (6). Accountability for self-care interventions is shared among several different sectors and should be considered at all levels – local, national, regional and global. The enabling environment to support self-care interventions must be governed through shared accountability to ensure quality of care and better health outcomes. Self-care interventions require accountability across several fronts of the health system for their fully ethical and appropriate provision (6). Self-care interventions should not be stand-alone products or cause further health system fragmentation but should rather be linked to the health system and supported by it (6). This ensures that the health system remains accountable and can determine how to appropriately interact with and support the implementation of self-care interventions (6). Chapter 2 25 Chapter 2: Essential strategies for creating and maintaining an enabling environment for self-care ACCESS TO SELF-CARE INTERVENTIONS Increasingly people are getting health information, products and services through several ways Family/partner Home Traditional medicine and sociocultural practices Community Caregivers Pharmacies Health facilities Digital technologies and platforms FIG. 2.5. PLACES OF ACCESS TO SELF-CARE INTERVENTIONS 1. Narasimhan M, Allotey P, Hardon A. Self-care interventions to advance health and well-being: developing a conceptual framework to inform normative guidance. BMJ. 2019;365:l688. doi:10.1136/bmj.l688. 2. WHO Secretariat. Framework on integrated, people- centred health services. Sixty-ninth World Health Assembly. Provisional agenda item 16.1. Geneva: World Health Organization; 2016 (A69/39; https://apps. who.int/gb/ebwha/pdf_files/WHA69/A69_39-en.pdf, accessed 25 March 2021). 3. WHO global strategy on people-centred and integrated health services: interim report. Geneva: World Health Organization; 2015 (WHO/HIS/SDS/2015.6; https:// apps.who.int/iris/handle/10665/155002, accessed 23 June 2021). 4. Pourbohloul B, Kieny M-P. Complex systems analysis: towards holistic approaches to health systems planning and policy. Bull World Health Organ. 2011;89:242. doi:10.2471/BLT.11.087544. 5. Global health ethics: key issues. Geneva: World Health Organization; 2015 (https://www.afro.who.int/ sites/default/files/2017-06/9789240694033_eng.pdf, accessed 19 March 2021). 6. World Health Organization meeting on ethical, legal, human rights and social accountability implications of self-care interventions for sexual and reproductive health: 2–14 March 2018, Brocher Foundation, Hermance, Switzerland: summary report. Geneva: World Health Organization; 2018 (https://apps.who.int/ iris/bitstream/handle/10665/273989/WHO-FWC-18.30- eng.pdf, accessed 24 May 2021). 7. A life-course approach to health and sustainable development. Geneva: World Health Organization; 2019 (https://www.who.int/life-course/publications/life- course-brief/en, accessed 19 March 2021). 8. Committee on Economic, Social and Cultural Rights. General Comment No. 22 (2016) on the right to sexual and reproductive health (Article 12 of the International Covenant on Economic, Social and Cultural Rights). New York (NY): United Nations Economic and Social Council; 2016 (E/C.12/GC/22; https://tbinternet. ohchr.org/_layouts/treatybodyexternal/Download. aspx?symbolno=E/C.12/GC/22&Lang=en, accessed 19 March 2021). 9. General recommendation No. 24 (20th session): Article 12 of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) – women and health. In: Report of the Committee on the Elimination of Discrimination against Women, Fifty-fourth session of the General Assembly, Supplement No. 38 (Chapter I). New York (NY): United Nations; 1999: paragraph 22 (A/54/38/Rev.1, https://www.un.org/womenwatch/daw/ cedaw/reports/21report.pdf, accessed 19 March 2021). 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Backman G, Hunt P, Khosla R, Jaramillo-Strouss C, Fikre BM, Rumble C, et al. Health systems and the right to health: an assessment of 194 countries. Lancet. 2008;372(9655):2047–85. doi:10.1016/S0140- 6736(08)61781-X. 28. Gruskin S, Ahmed S, Bogecho D, Ferguson L, Hanefeld  J, MacCarthy S, et al. Human rights in health systems frameworks: what is there, what is missing and why does it matter? Glob Public Health. 2012;7(4):337– 51. doi:10.1080/17441692.2011.651733. 29. Svanemyr J, Amin A, Robles OJ, Greene ME. Creating an enabling environment for adolescent sexual and reproductive health: a framework and promising approaches. J Adolesc Health. 2015;56:S7–S14. doi:10.1016/j.jadohealth.2014.09.011. 30. Lloyd CB. The role of schools in promoting sexual and reproductive health among adolescents in developing countries. In: Malarcher S, editor. Social determinants of sexual and reproductive health: informing future research and programme implementation. 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Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations – 2016 update. Geneva: World Health Organization; 2016: slide 17 (http://apps.who.int/iris/bitstre am/10665/246200/1/9789241511124-eng.pdf, accessed 19 March 2021). 34. Orza L, Bewley S, Chung C, Crone ET, Nagadya H, Vazquez M, et al. “Violence. Enough already”: findings from a global participatory survey among women living with HIV. J Int AIDS Soc. 2015;18:20285. doi:10.7448/ IAS.18.6.20285. 35. Definition of psychosocial supports. Tokyo: United Nations Children’s Fund (https://www.unicef.org/tokyo/ jp/Definition_of_psychosocial_supports.pdf, accessed 19 March 2021). 36. Gruskin S, Ferguson L, O’Malley J. Ensuring sexual and reproductive health for people living with HIV: an overview of key human rights, policy and health systems issues. Reprod Health Matters. 2007;15(29 Suppl):4–26. doi:10.1016/S0968-8080(07)29028 37. Health literacy. In: World Health Organization, Health promotion [website]. Geneva: World Health Organization (https://www.who.int/healthpromotion/ health-literacy/en, accessed 19 March 2021). 38. Youth-centred digital health interventions: a framework for planning, developing and implementing solutions with and for young people. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/ item/9789240011717, accessed 25 May 2021). 39. Digital implementation investment guide (DIIG): integrating digital interventions into health programmes. Geneva: World Health Organization; 2020. (https://www.who.int/publications/i/ item/9789240010567, accessed 19 March 2021). https://apps.who.int/iris/bitstream/handle/10665/44344/9789241599528_eng.pdf https://apps.who.int/iris/bitstream/handle/10665/44344/9789241599528_eng.pdf https://unesdoc.unesco.org/ark:/48223/pf0000260770 https://unesdoc.unesco.org/ark:/48223/pf0000260770 http://apps.who.int/iris/bitstream/10665/42495/1/9241545615_eng.pdf http://apps.who.int/iris/bitstream/10665/42495/1/9241545615_eng.pdf http://apps.who.int/iris/bitstream/10665/246200/1/9789241511124-eng.pdf http://apps.who.int/iris/bitstream/10665/246200/1/9789241511124-eng.pdf https://www.unicef.org/tokyo/jp/Definition_of_psychosocial_supports.pdf https://www.unicef.org/tokyo/jp/Definition_of_psychosocial_supports.pdf https://www.who.int/healthpromotion/health-literacy/en https://www.who.int/healthpromotion/health-literacy/en https://www.who.int/publications/i/item/9789240011717 https://www.who.int/publications/i/item/9789240011717 https://www.who.int/publications/i/item/9789240010567 https://www.who.int/publications/i/item/9789240010567 Chapter 3 28 WHO Guideline on Self-Care Interventions for Health and Well-Being 3 Recommendations and key considerations 3. 28 Chapter 3 29 Chapter 3: Recommendations and key considerations This chapter presents new and existing evidence- based WHO recommendations on self-care interventions as well as new key considerations on priority areas and interventions that are promising, but require additional research. At a Glance3. Chapter 29 Return to Overview p. 46 p. 50 p. 30 p. 40 p. 55 p. 47 Eliminating unsafe abortion Promoting sexual health Improving antenatal, intrapartum and postnatal care Providing high-quality services for family planning, including infertility services Addressing noncommunicable diseases, including cardiovascular diseases and diabetes Combating sexually transmitted infections (including HIV), reproductive tract infections, cervical cancer and other gynecological morbidities Key considerations Existing recommendations New recommendations Recommendations and key considerations are identified throughout the chapter by these icons: Chapter 3 30 WHO Guideline on Self-Care Interventions for Health and Well-Being This chapter presents the World Health Organization (WHO) recommendations that have been newly developed and published for the first time in this guideline, alongside the existing recommendations previously published in other WHO guidelines. In addition to the recommendations, which were reached through the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, this chapter also presents new, adapted or existing good practice statements. For this guideline, the Guideline Development Group (GDG) formulated several key considerations to guide and inform future research and guidelines processes for those questions for which neither recommendations nor good practice statements had been developed. For these questions, the decision not to make a recommendation was largely driven by the limited or non-existent evidence of effectiveness for the self-care option of the intervention. Nonetheless, the GDG deemed that the scarcity of knowledge related to self-care for these critically important topics warranted foregrounding, and the key considerations are presented alongside the recommendations and good practice statements. The recommendations concern health interventions that reflect the priority areas of the 2004 WHO Global Reproductive Health Strategy. The recommendations are numbered in Table 1 of the executive summary, and given greater detail in the following sections 3.1–3.5. The new and existing recommendations are presented in boxes along with information about the strength of each recommendation and the certainty of the evidence on which it is based (assessed using the GRADE method, as described in section A2.5 of Annex 2), followed by any remarks, including any key considerations highlighted by the GDG. For existing recommendations, the remarks are limited to the title, year of publication and the weblink for the original source guideline. For each of the new recommendations, which address new topic areas or replace previous recommendations, additional information is presented in this order: • Background information about the intervention; • Summary of evidence and the considerations of the GDG, including results on the effectiveness of the intervention (the balance of benefits and risks) and explanations about the certainty of the evidence and the strength of the recommendation, plus information on resource use, feasibility and equity implications, and the acceptability of the intervention to end users and health workers (i.e. relative to end users’ and health workers’ values and preferences). A rationale underpinning the decisions leading to each recommendation is provided. For existing recommendations, additional information after the box presenting the recommendations is limited to background information about the intervention. The key considerations relate to four priority guideline questions for which the GDG judged there to be insufficient evidence to make a recommendation and for which best practice remained uncertain. For each new key consideration, additional information is presented in this order: • Background information; • Summary of the important issues noted by the GDG with respect to the question, and the identification of critical research gaps to support future decision- making. The recommendations presented are particularly suited to low- and middle-income countries (LMICs), where self-care interventions offer innovative strategies that go beyond a conventional health sector response. This is because a well-functioning health system – staffed with trained health workers, supported by a well-maintained infrastructure and a reliable supply of medicines and technologies, backed by adequate funding, strong health plans and evidence-based policies – is the reality in very few countries. 3.1 IMPROVING ANTENATAL, INTRAPARTUM AND POSTNATAL CARE Despite effective interventions for the prevention or treatment of virtually all the life-threatening maternal complications, and the important progress that has been made in the last two decades, about 295 000 women died during or following pregnancy and childbirth in 2017 (1). It has been established that implementing timely and appropriate evidence-based antenatal care practices can save lives. Crucially, antenatal care is also an opportunity to communicate with and support women, families and communities at a critical time in the course of a woman’s life. A positive pregnancy experience is defined as maintaining physical and sociocultural normality, maintaining a healthy pregnancy for mother and baby (including preventing or treating risks, illness and death), having an effective transition to positive labour and birth, and achieving positive motherhood (including maternal self- esteem, competence and autonomy) (2). Services include a package of interventions, including advice and support for individuals and their family members for developing healthy home behaviours, and a birth and emergency-preparedness plan, to increase awareness of maternal and newborn health needs and self-care during pregnancy and the postnatal period, including the need for social support during and after pregnancy (3). Chapter 3 31 Chapter 3: Recommendations and key considerations 3.1.1 EXISTING RECOMMENDATIONS ON SELF-CARE DURING ANTENATAL CARE AND DELIVERY Recommendation Recommendation 1 Health education for women is an essential component of antenatal care. The following educational interventions and support programmes are recommended to reduce caesarean births only with targeted monitoring and evaluation. (Context-specific recommendation; low certainty evidence) Recommendation 1a Childbirth training workshops (content includes sessions about childbirth fear and pain, pharmacological pain-relief techniques and their effects, non-pharmacological pain-relief methods, advantages and disadvantages of caesarean sections and vaginal delivery, indications and contraindications of caesarean sections, among others). (Low to moderate certainty evidence) Recommendation 1b Nurse-led applied relaxation training programme (content includes group discussion of anxiety and stress-related issues in pregnancy and purpose of applied relaxation, deep breathing techniques, among other relaxation techniques). (Low to moderate certainty evidence) Recommendation 1c Psychosocial couple-based prevention programme (content includes emotional self- management, conflict management, problem-solving, communication and mutual support strategies that foster positive joint parenting of an infant). “Couple” in this recommendation includes couples, people in a primary relationship or other close people. (Low to moderate certainty evidence) Recommendation 1d Psychoeducation (to address fear of pain; comprising information about fear and anxiety, fear of childbirth, normalization of individual reactions, stages of labour, hospital routines, birth process, and pain relief [led by a therapist and midwife], among other topics). (Low to moderate certainty evidence) Recommendation 2 When considering the educational interventions and support programmes, no specific format (e.g. pamphlet, videos, role play education) is recommended as more effective. Recommendation 3 Ginger, chamomile, vitamin B6 and/or acupuncture are recommended for the relief of nausea in early pregnancy, based on a woman’s preferences and available options. Recommendation 4 Advice on diet and lifestyle is recommended to prevent and relieve heartburn in pregnancy. Antacid preparations can be offered to women with troublesome symptoms that are not relieved by lifestyle modification. Recommendation 5 Magnesium, calcium or non-pharmacological treatment options can be used for the relief of leg cramps in pregnancy, based on a woman’s preferences and available options. Recommendation 6 Regular exercise throughout pregnancy is recommended to prevent low back and pelvic pain. There are a number of different treatment options that can be used, such as physiotherapy, support belts and acupuncture, based on a woman’s preferences and available options. Recommendation 7 Wheat bran or other fibre supplements can be used to relieve constipation in pregnancy if the condition fails to respond to dietary modification, based on a woman’s preferences and available options. Chapter 3 32 WHO Guideline on Self-Care Interventions for Health and Well-Being Recommendation Recommendation 8 Non-pharmacological options, such as compression stockings, leg elevation and water immersion, can be used for the management of varicose veins and oedema in pregnancy based on a woman’s preferences and available options. Recommendation 9 Pain relief for preventing delay and reducing the use of augmentation in labour is not recommended. (Conditional recommendation; very low certainty evidence) Recommendation 13 WHO recommends that each pregnant woman carries their own case notes during pregnancy to improve the continuity and quality of care and their pregnancy experience. 3.1.2 ADDITIONAL EXISTING GUIDANCE ON SELF-CARE INTERVENTIONS DURING ANTENATAL AND INTRAPARTUM CARE WHO also recommends the use of home-based records for the care of pregnant women, mothers, newborns and children to complement facility-based records and to improve care-seeking behaviours, male involvement and support in the household, maternal and child home-care practices, infant and child feeding, and communication between health providers and women/caregivers (4). Qualitative evidence suggests that women from a variety of settings are likely to favour carrying their case notes, because it offers more opportunity to acquire pregnancy and health-related information, and because of the sense of empowerment this brings. For paper-based systems, health-system planners also need to ensure that case notes are durable and transportable. Health systems that give women access to their case notes through electronic systems need to ensure that all pregnant women have access to the appropriate technology and that attention is paid to data security. Furthermore, policy-makers should involve stakeholders to discuss the important considerations with respect to the type, content and implementation of home-based records. In the context of developing SMART (standards-based, machine-readable, adaptive, requirements-based and testable) guidelines (5), WHO released guidance and tools for health workers’ digital tracking and decision support during antenatal care contacts, which include components of self-care interventions from the 2019 guideline (6). 3.1.3 NEW RECOMMENDATIONS ON IRON AND FOLIC ACID SUPPLEMENTS DURING ANTENATAL CARE AND DELIVERY Recommendation Recommendation 10a (new) WHO recommends making the self-management of folic acid supplements available as an additional option to health worker-led provision of folic acid supplements for individuals who are planning pregnancy within the next three months. (Strong recommendation; very low certainty evidence) Recommendation 10b (new) WHO recommends making the self-management of iron and folic acid supplements available as an additional option to health worker-led provision of folic acid supplements for individuals during pregnancy. (Strong recommendation; very low certainty evidence) Recommendation 10c (new) WHO recommends making the self-management of iron and folic acid supplements available as an additional option to health worker-led provision of iron and folic acid supplements for individuals during the postnatal period. (Strong recommendation; very low certainty evidence) Chapter 3 33 Chapter 3: Recommendations and key considerations Remarks: • Early linkage to antenatal and postnatal care is essential. • Information on how to monitor possible side-effects and harms (e.g. iron toxicity due to overdosing; child poisoning) is essential. • Folic acid is to be taken up to 12 weeks gestation. Background The use of iron and folic acid supplements during pregnancy is an effective and recommended intervention to reduce maternal anaemia, puerperal sepsis, low birthweight and preterm birth (3, 7). The use of folic acid supplements is recommended as early as possible during pregnancy, and ideally prior to pregnancy, to prevent neural tube defects (3, 8). Postpartum use of iron supplements (either alone or with folic acid) may also reduce the risk of anaemia in settings with a high prevalence of maternal anaemia (9). Despite the efficacy of these supplements, the use of iron and folic acid supplementation during pregnancy is not reaching its potential impact, because of a lack of consistent use; this is attributed to a range of issues, including supply and demand factors (10–14), side-effects, cost and access. Promoting over-the-counter or home-use folic acid or iron and folic acid supplementation when planning a pregnancy (before pregnancy), during pregnancy and/or postpartum (after delivery) may help to expand the delivery of micronutrient supplements beyond the clinical care setting and ultimately improve maternal, fetal and newborn health outcomes. Summary of evidence and considerations for the new recommendation The WHO Guideline Steering Group selected to compare the self-management of iron and folic acid, or folic acid supplements with provider-initiated provision in relation to pregnancy. The PICO (population, intervention, comparator, outcome) questions were: • Should individuals who are planning pregnancy self-manage the use of folic acid supplements or be offered only provider-led management of such supplements? • Should pregnant individuals self-manage the use of iron and folic acid supplementation as per international guidance (currently either a daily dose of 30–60 mg of elemental iron and 400 µg [0.4 mg] of folic acid, or an intermittent [e.g. weekly] dose of 120 mg of elemental iron and 2.8 mg of folic acid) or be offered only provider-led management of such supplements (3)? • Should postnatal individuals self-manage the use of iron (with or without folic acid) supplementation for at least three months after delivery as per international guidance (currently either a daily dose of 30–60 mg of elemental iron and 400 µg [0.4 mg] of folic acid, or an intermittent [e.g. weekly] dose of 120 mg of elemental iron and 2.8 mg of folic acid) or be offered only provider-led management of such supplements (10)? A systematic review was conducted of the extant literature in three areas relevant to these questions: the effectiveness of the intervention on maternal and/or fetal and newborn outcomes in the pre-pregnancy, pregnancy or postpartum periods; the values and preferences of end users; and the cost and/or cost-effectiveness of the intervention during pre-pregnancy, pregnancy and postpartum periods. The review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (15). The protocol was published at PROSPERO, the international prospective register of systematic reviews (registration number CRD42020205548). The systematic review has been published in a peer- reviewed journal (16). Results Of 2587 unique citations identified, no studies met the inclusion criteria. The articles were excluded generally because they lacked the outcomes of interest, lacked comparison groups or focused on supplement use in general and did not specifically look at folic acid or iron and folic acid supplementation. Lastly, no articles presented cost or cost-effectiveness data. Certainty of the evidence for the recommendation No direct evidence was identified and the overall certainty of the evidence was very low. Rationale for the strength and the direction of the recommendation The GDG noted that that this intervention was already widely used in many countries with no major concerns or controversy. Harms related to possible toxicity or poisoning were discussed and the GDG agreed that health literacy and education around this self-care intervention would be an important component to promote its correct use. The question of how best to build health literacy, however, was an important research gap that should be addressed. The GDG deemed that, overall, the balance of large benefits and trivial harms was in favour Chapter 3 34 WHO Guideline on Self-Care Interventions for Health and Well-Being of making self-management an additional choice for individuals. Given the likely impact on improving equity and accessibility if self-management is made available as an additional choice to individuals, the GDG made a strong recommendation. Resource use No direct cost evidence was identified in this review. Lower costs of supplements in general, however, have been shown to increase uptake. When private facilities factor in the costs of access to antenatal care, the costs of supplements may be lower here. In low-income countries, cost is largely dependent on packaging. The GDG discussed that costs for iron and folic acid supplements were generally low, but that there may be additional costs for the end user to reach the place of purchase. Feasibility All GDG members agreed that this recommendation was feasible given that iron and folic acid supplementation was already available in many places globally. Equity and human rights No major equity or human rights issues were foreseen if iron and folic acid supplementation were made available as an additional option to provision through the healthcare system. The GDG agreed that, despite insufficient information, there was a potential for this self-care intervention to improve equity if implemented in the context of an enabling environment. An enabling environment, however, may be lacking if literacy levels are low and there are barriers to education that may decrease access to the intervention. Acceptability of the intervention: values and preferences of end users and health workers No studies were included in the values and preferences review. Indirect evidence from studies suggests that the facilitators of supplement use in general (not specific to folic acid or iron and folic acid) include convenient supply, cost/affordability, health worker messaging and personal risk perception. Barriers to use include poor communication with health workers, scepticism about the effectiveness and necessity of supplements, and perceptions of the supplement itself. It is important to note, though, that these facilitators and barriers were only found for those end users who were currently pregnant. As described in Chapter 1, section 1.7, a Global Values and Preferences Survey (GVPS) was also conducted among health workers and potential end users on their values and preferences in relation to this and other interventions covered by the new recommendations in this guideline. The results show that more health workers than people in the general population are aware of iron and folic acid supplementation. Convenience and cost were the top reasons for use. Most health workers had provided iron and folic acid supplements, although slightly fewer were comfortable with it. Pharmacies were identified as the top choice of location for access. 3.1.4 NEW RECOMMENDATION ON SELF-MONITORING OF BLOOD PRESSURE DURING PREGNANCY Background Hypertensive disorders of pregnancy are among the leading causes of pregnancy-related mortality and morbidities for women and adolescent girls and their newborns, particularly in LMICs, affecting around 10% of all pregnant individuals globally (17–19). Hypertension in pregnancy can also lead to long-term disability such as chronic hypertension in women and adolescent girls, and pre-eclampsia, which can result in a range of morbidities in newborns, including low birth weight and respiratory distress syndrome (20–22). Early hypertensive treatment and timely delivery can prevent morbidity and, potentially, mortality (23). Improving the management of hypertension during pregnancy is thus an essential aspect of quality care for maternal and neonatal health. Recommendation Recommendation 11 (new) WHO suggests making the self-monitoring of blood pressure during pregnancy available as an additional option to clinic blood pressure monitoring by health workers during antenatal contacts only, for individuals with hypertensive disorders of pregnancy. (Conditional recommendation; very low certainty evidence) Chapter 3 35 Chapter 3: Recommendations and key considerations Routine antenatal care visits generally include blood pressure measurement, but blood pressure changes may be missed between visits. The self-monitoring of blood pressure (SMBP), a strategy in which patients take a more active role in their own healthcare by measuring their own blood pressure, may be particularly useful in settings where access to and resources for conventional antenatal care are limited. SMBP has been reviewed extensively for the general hypertensive population (i.e. not just in pregnancy). SMBP compared with clinic-based monitoring is associated with improved hypertension control (24–26), although its impact depended on the specific outcomes that were assessed or implemented (27). Two recent reviews reported mixed benefits of SMBP compared with clinic-based monitoring for multiple maternal and neonatal outcomes among pregnant and postpartum individuals (28, 29), suggesting that home-based monitoring may not be inferior to receiving provider-administered care. However, less is known about SMBP specifically for pregnant individuals and their newborns (30). A recent review found that SMBP had limited impact on improving blood pressure control unless accompanied by certain co-interventions (31). Summary of evidence and considerations for the new recommendation The WHO Guideline Steering Group decided to examine whether SMBP should be made available in addition to clinic check-ups among individuals with hypertensive disorders of pregnancy. The PICO question was: • Should SMBP among individuals with hypertensive disorders of pregnancy be made available in addition to clinic check-ups? A systematic review was conducted of peer-reviewed journal publications in any location or language. It included literature in three areas relevant to this question: the effectiveness of the intervention, the values and preferences of end users and health workers, and cost information. The included studies on pregnant individuals with hypertension (gestational hypertension, chronic hypertension and pre-eclampsia) compared individuals who were self-monitoring blood pressure (either by the pregnant individual or by another layperson, such as a family member) with those whose blood pressure was monitored in the clinic by health workers during antenatal care contacts only. The studies measured one or more of the following maternal outcomes: maternal mortality or near miss; eclampsia or pre-eclampsia (for those without pre-eclampsia prior to entering the study); long-term risk or complication (stroke, cardiovascular outcomes, chronic kidney disease, or chronic hypertension); autonomy (self-efficacy, self- determination, empowerment); HELLP syndrome (haemolysis, elevated liver enzymes and low platelet count); caesarean section; antenatal hospital admission; adverse pregnancy outcomes (spontaneous abortion, premature rupture of membranes, placental abruption); device-related issues (e.g. test failure; problems with manufacturing, packaging, labelling or instructions for use); follow-up care with appropriate management; mental health and well-being (e.g. anxiety, stress, self-harm); social harms (stigma, discrimination, intimate partner violence); and neonatal outcomes (stillbirth or perinatal death; birthweight/size for gestational age; Apgar [appearance, pulse, grimace, activity and respiration] score) (see Annex 6 for further details of the PICO questions). The review followed PRISMA guidelines (15), and the protocol was published at PROSPERO (registration number CRD42021233839), and the systematic review in a peer- reviewed journal (32). Results The systematic review included 1794 unique references, of which 91 were retained for the full-text review. Six studies were ultimately included in the effectiveness review, seven in the values and preferences review, and one in the cost review. Of the six studies in the effectiveness review, one randomized controlled trial (RCT) and five observational studies were included. All the studies were from high- income countries, and they compared daily SMBP using an automated blood pressure monitor, recorded on paper or submitted via app, with routine care at antenatal visits (one study) and routine care at prenatal visits (two studies). Two observational studies found that SMBP had no impact on maternal morbidity. The RCT found that SMBP was associated with higher caesarean section rates among pregnant individuals with chronic hypertension (risk ratio: 2.01, 95% confidence interval: 1.22–3.30), but was associated with no difference among those with gestational hypertension; found no difference in the pre-eclampsia rate among pregnant women with either chronic or gestational pre-eclampsia (risk ratio: hypertension; no impact on antenatal hospital admissions; no impact on stillbirth or perinatal death); and found that SMBP was associated with lower birthweight and a higher rate of infants being born small for their gestational age among pregnant individuals with chronic hypertension (although this was not a statistically significant difference), but had no impact among those with gestational hypertension. Chapter 3 36 WHO Guideline on Self-Care Interventions for Health and Well-Being No quantitative comparative data were identified from either the RCTs or the observational studies related to maternal mortality or near miss; long-term risk or complications (e.g. stroke, cardiovascular outcomes, chronic kidney disease or chronic hypertension); autonomy (measured by self-efficacy, self-determination, empowerment); HELLP syndrome; device-related issues; follow-up care with appropriate management; mental health and well-being (e.g. anxiety, stress, self-harm); social harms (e.g. stigma, discrimination, intimate partner violence); or Apgar score. Certainty of the evidence for the recommendation The available evidence was of moderate to very low certainty overall. Rationale for the strength and the direction of the recommendation The GDG made a conditional recommendation in favour of the intervention. In the wording of the recommendation, the GDG emphasized that the intervention should be made available as an additional approach, with early linkage to and continuation of antenatal care, and accompanied by comprehensive information and guidance on the interpretation of blood pressure readings and actions required for SMBP. Resource use There was evidence that, compared with usual care, SMBP during pregnancy decreased costs for the overall health system, in part due to fewer clinic visits. A study in the United Kingdom of Great Britain and Northern Ireland found that, among hypertensive pregnant women using an automated blood pressure machine linked to paper notes, the health system would see greater weekly savings per patient among those using SMBP, compared with those using a smartphone app or traditional monitoring. The GDG agreed that costs would vary by health system and the cost of the device. It also acknowledged that, if the individual was unable to read the blood pressure monitor and the blood pressure readings, inaccurate readings would also incur a cost. Feasibility All GDG members agreed that this recommendation was feasible but noted that considerations around literacy, counselling and reinforcement/mentorship were incorporated for implementation. Equity and human rights The GDG agreed that, despite insufficient information, there was potential for this self-care intervention to improve equity because it provided choice to the individual, fostered participation in their own care and can promoted the right to privacy. Acceptability of the intervention: values and preferences of end users and health workers Overall, seven studies from four countries were included in the values and preferences review. There were three qualitative studies, three quantitative studies and one mixed-methods study. The included studies were generally among pregnant individuals with, or at risk of, hypertensive disorders. One study examined the values and preferences of health workers. All seven studies took place in high- income countries (in Europe, North America and Oceania). The evidence suggested that most end users found SMBP highly satisfactory or acceptable. They cited various factors for liking self-monitoring, including the device’s ease of use, the convenience and the ability to help them to feel empowered and less anxious or stressed. Barriers included some variations in end users’ perceptions of ease of use, and some users perceived the SMBP device to be uncomfortable and noisy. The practice of SMBP created the impression that end users were taking a greater role in self-care on blood pressure, pregnancy and health through taking the initiative and using the device. The resulting sense of empowerment helped to alleviate anxiety. Despite SMBP reducing the number of care visits, many patients whose SMBP devices enabled them to communicate with their health worker (i.e. through apps for remote monitoring and telehealth) expressed being even more connected to their care team. Women generally agreed that they would continue to use SMBP and would recommend others to do the same. Health workers acknowledged the convenience and comfort of clients monitoring at home and were generally in favour of SMBP, but some expressed concerns that SMBP may induce anxiety or falsely reassure women about their health. As described in Chapter 1, section 1.7, a GVPS was also conducted among health workers and potential end users to survey their values and preferences in relation to this and other interventions covered by new recommendations in this guideline. Most participants in the GVPS were aware of SMBP and had used it. Convenience and cost were the main factors important to the decision. Chapter 3 37 Chapter 3: Recommendations and key considerations 3.1.5 KEY CONSIDERATIONS FOR SELF-TESTING FOR PROTEINURIA Background Pre-eclampsia is generally diagnosed in pregnant individuals who have an onset of hypertension and subsequent proteinuria (greater than normal amounts of protein in urine) during pregnancy (33). About a third of individuals with new-onset proteinuria after their 20th week of pregnancy may ultimately contract pre-eclampsia (34). Measuring proteinuria early in pregnancy can help to identify individuals who are at high risk of pre-eclampsia and related complications, including preterm delivery and fetal malformations (35). Screening for proteinuria is typically through dipstick urinalysis, which needs a small sample of clean urine and gives a result rapidly (36). Dipstick urinalysis is typically done at the point of care during routine prenatal visits; however, emerging research suggests that screening can also be done through self- testing (37). Given that pre-eclampsia is a significant cause of maternal and perinatal morbidity and mortality, affecting between 2% and 8% of pregnancies worldwide, self-testing for proteinuria may be useful to help to identify the risk of pre-eclampsia in pregnant women, increase end-user empowerment and reduce the burden on the health system. Summary of evidence and considerations The WHO Guideline Steering Group decided to examine whether self-testing for proteinuria during pregnancy should be available in addition to clinic check-ups. The PICO question was: • Should self-testing for proteinuria during pregnancy be available in addition to clinic check-ups? A systematic review assessed three areas relevant to this topic: (i) effectiveness of the intervention, (ii) values and preferences of end users and health workers, and (iii) cost information. The PRISMA guidelines (15) were followed, and the protocol was published at PROSPERO (registration number CRD42021233845) and the systematic review in a peer-reviewed journal (38). Results Of the 334 unique records, 20 were retained for full- text review, two studies were included in the values and preferences review and none in the cost review. The studies included pregnant women with non-proteinuric hypertension and the comparison was with the provision of proteinuria testing during inpatient care. Most studies were from high-income countries. Overall, there was no statistically significant difference between self-testing and clinic-based testing for proteinuria in any of the outcomes for which data were available. In general, both the women and their health worker approved of self-testing for reasons including that it gave the women a greater role in self-care and reduced their visits to clinics, although some health workers emphasized the need to train end users for proper testing and appropriate follow-up actions. The GDG agreed that the sense of self-empowerment, ownership of care and decreased frequency of clinic visits were important considerations for making self-testing available for proteinuria. However, the GDG questioned the clinical utility of urine dipstick testing, in part due to the lack of a gold standard for the diagnosis of proteinuria in pregnancy. Urine dipstick testing for this use has several limitations, including variability in urine concentration, which depends on fluid status, the time of day during which the test takes place, and whether the subject has urinated prior to testing. Furthermore, the GDG noted that clinical guidelines highlighted the need for information beyond the presence of proteinuria to diagnose and manage complications of pregnancy, as non-proteinuric hypertensive disease is a recognized entity that has outcomes quite similar to those of pre-eclampsia. Nonetheless, the GDG agreed that the evidence showed that self-testing for proteinuria was not harmful. Further studies would be needed to assess whether self-testing for proteinuria as part of routine prenatal care could improve pregnancy outcomes. Recommendation Key consideration 1 For pregnant individuals with non-proteinuric hypertension, there may be some benefit of home-based urine self-testing compared with inpatient care to detect proteinuria, but clinicians need to balance this with the additional burden placed on the individual. Chapter 3 38 WHO Guideline on Self-Care Interventions for Health and Well-Being Feasibility The GDG agreed that there was evidence for the feasibility and acceptability of self-testing for proteinuria and that it generally did not negatively impact the maternal and neonatal health outcomes. However, the GDG agreed that more research in resource-limited settings was needed. Equity and human rights Despite the recognized limitations, initial proteinuria testing based on dipstick urinalysis with follow-up tests as indicated may help to triage patients appropriately in resource-limited settings, although the value added by routine proteinuria testing via urine dipsticks may be limited in well-resourced settings. The testing method remains a standard tool for testing for proteinuria in the setting of LMICs, where the affordability of testing is a key issue. Acceptability of the intervention: values and preferences of end users and health workers Two quantitative feasibility studies for self-testing urine for proteinuria during pregnancy, one from the United Kingdom (37) and the other from the United States of America (USA) (39), found that most pregnant women were highly satisfied with self-testing for proteinuria or preferred it over in-clinic testing. Ease of use was the common reason across the two studies for liking self-testing. Most of the surveyed health workers saw self-testing for proteinuria as a way for women to detect pre-eclampsia early, to empower themselves and to save time and money (37). Close to 80% believed

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