# Good practice statements
Recommendations and key considerations are identified throughout the Guideline by these icons: EXECUTIVE SUMMARY   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.

# Improving health and well-being

# Pandemics and humanitarian settings
In settings affected by conflict and humanitarian crises,
U N I V E R S A L H EALTH C O V E R A G E H E A L T H E M ERGE N C I E S H E A L T H AND W E L L - B E I N G
One billion more people benefiting from One billion more people enjoying better
One billion more people better protected from 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. 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 rightsbased 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. Implementation, applicability, and monitoring and evaluation of the guideline

# Developing the research agenda
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.   Where the recommendations, good practice statements or key considerations are new, this is noted.

# Summary of the recommendations, good practice statements and key considerations
Recommendations and key considerations a 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)

# Recommendation 1c
Psychosocial couple-based prevention programme (content includes emotional selfmanagement, 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)
Recommendations and key considerations a
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 homebased 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)
Recommendations and key considerations a
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.
Recommendations and key considerations a

# 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)

# 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)
Recommendations and key considerations a
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. 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)
Recommendations and key considerations a
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 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. 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 competencybased 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 selfmanage 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.
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)