A series of studies from the Innovations for Choice and Autonomy (ICAN) project, led by a research consortium that includes UCSF, highlights how peer support and human-centered design can improve contraceptive agency—the ability to make and act on pregnancy prevention decisions—in rural Malawi and Uganda.
UCSF researchers Kelsey Holt, MA, ScD and Jenny Liu, PhD, MPP are co–principal investigators for UCSF’s role in ICAN, which has shown that community-driven approaches can address persistent barriers to contraceptive decision-making and access.
Addressing Complex Barriers
Across rural communities in Malawi and Uganda, women face multiple, overlapping challenges to their agency related to contraception. These include restrictive social norms, provider biases, long distances to health facilities, limited resources for community outreach, and inconsistent service delivery.
“Many of these barriers are deeply embedded in daily life,” said Holt, Associate Professor, Family Community Medicine. “We wanted to understand how to design solutions that actually fit within the realities women and health workers navigate every day.”
Co-Designing Solutions with Communities
Rather than relying on top-down interventions, ICAN researchers used a human-centered design approach—partnering with women, community members, and health workers to co-create solutions.
In Malawi, the Ndingathe (“I Can”) intervention focused on improving health worker outreach through tools and strategies shaped directly by community input.
In Uganda, researchers co-developed a peer-support model with community members to help women build confidence in contraceptive decision-making, including the option of self-injectable contraception.
Key components across the studies included:
Peer mentors providing non-directive emotional and practical support for women to make and act on contraceptive decisions
Community-informed tools and messaging, such as simple memory aids (e.g.., in Malawi, the “Sakufima” mnemonic for self-injection translates to “Shake, Close, Insert, Squeeze”)
Support for health workers, including transportation and small incentives to improve outreach consistency
Peer Support as a “Game Changer”
Findings across the three studies point to the powerful role of peer support.
In Uganda, peer mentors helped women navigate conversations with partners, build confidence in their choices, and reduce fear around self-injection. A longitudinal qualitative evaluation found that these social support networks significantly strengthened women’s contraceptive agency.
“Peer support created a space where women could learn from each other and feel supported in their choices,” said Liu, Director of UCSF School of Nursing’s Institute for Health & Aging. “It’s not just about information—it’s about trust, confidence, and shared experience.”
Measurable Impact
Across the studies, the ICAN evaluations found these interventions:
Increased confidence and agency in contraceptive decision-making
Reduced fear of self-injection
Improved reach and consistency of community-based services
The findings suggest that strengthening existing community support systems—rather than replacing them—can lead to more effective and sustainable health interventions.
A Shift in How Programs Are Designed
The ICAN research underscores a broader lesson for global health programs: successful interventions go beyond training or service delivery alone.
“Programs are more effective when they are designed with communities, not just for them,” Holt said. “Human-centered design helped ensure that solutions were practical, acceptable, and grounded in lived experience.”
Looking Ahead
Building on these findings, ICAN researchers are advancing new NIH-funded work to better understand how self-injectable contraception and peer support models can be expanded across diverse settings.
“Women already have knowledge, resilience, and support systems,” said Liu. “Our role is to work alongside communities to amplify those strengths and remove barriers to choice.”
For more information, visit ican.ucsf.edu.
About the Research
The findings are detailed in three publications:
This research was funded by The Gates Foundation (grant number OPP1216593).