Understanding how social norms affect modern contraceptive use

Fertility preservation and protection: young women's decision-making about contraceptive use in Zimbabwe

The study explored social and health system influences on young women's decision-making about family planning in a community setting with low uptake. Seventy-two semi-structured interviews were conducted between April 2020 and November 2021, with both young women accessing, and healthcare workers providing, a community-based integrated package of HIV and sexual and reproductive health services (CHIEDZA) in Zimbabwe. Data were thematically analysed. Although long-acting contraception was freely available as part of the CHIEDZA initiative, uptake was low. Young women's contraception choices were influenced by a desired reproductive sequence, which reflected prevailing social norms and was conveyed by peers and female relatives. Nulliparous young women preferred short-term contraception and avoided hormonal contraceptives prepartum to 'preserve' their fertility. Once fertility had been confirmed within marriage through the birth of a child, hormonal contraceptive use became socially permissible. Healthcare workers, cognisant of community discourse, sensitively proposed alternative approaches. Increasing the availability of correct and adequate information and commodities is critical to improving the uptake of contraceptives for young women, but it is insufficient alone. Recognising and responding to local contextual understandings which frame considerations of appropriateness is paramount. Successful implementation of family planning interventions requires engaging with social norms and the influential groups that perpetuate them.

What Underlies State Government Performance in Scaling Family Planning Programming? A Study of The Challenge Initiative State Partnerships in Nigeria

INTRODUCTION

Relatively few studies rigorously examine the factors associated with health systems strengthening and scaling of interventions at subnational government levels. We aim to examine how The Challenge Initiative (TCI) coaches subnational (state government) actors to scale proven family planning and adolescent and youth sexual and reproductive health approaches rapidly and sustainably through public health systems to respond to unmet need among the urban poor.

METHODS

This mixed-methods comparative case study draws on 32 semistructured interviews with subnational government leaders and managers, nongovernmental organization leaders, and TCI Nigeria staff, triangulated with project records and government health management information system (HMIS) data. Adapting the Consolidated Framework for Implementation Research (CFIR), we contrast experience across 2 higher-performing states and 1 lower-performing state (identified through HMIS data and selected health systems strengthening criteria from 13 states) to identify modifiable factors linked with successful adoption and implementation of interventions and note lessons for supporting scale-up.

RESULTS

Informants reported that several TCI strategies overlapping with CFIR were critical to states' successful adoption and sustainment of interventions, most prominently external champions' contributions and strengthened state planning and coordination, especially in higher-performing states. Government stakeholders institutionalized new interventions through their annual operational plans. Higher-performing states incorporated mutually reinforcing interventions (including service delivery, demand generation, and advocacy). Although informants generally expressed confidence that newly introduced service delivery interventions would be sustained beyond donor support, they had concerns about government financing of demand-side social and behavior change work.

CONCLUSION

As political and managerial factors, even more than technical factors, were most linked with successful adoption and scale-up, these processes and systems should be assessed and prioritized from the start. Government leaders, TCI coaches, and other stakeholders can use these findings to shape similar initiatives to sustainably scale social service interventions.

Behavioral Insights from Vaccine Adoption in Nigeria: Cross-Sectional Survey Findings

BACKGROUND

To generate behavioral insights for the development of effective vaccination interventions, we need approaches that combine rapid and inexpensive survey data collection with instruments based on easy-to-use behavior models. This study demonstrates how an inexpensive digital survey helped identify the drivers of COVID-19 vaccination in Nigeria.

OBJECTIVE

This study aims to illustrate how behavioral insights can be generated through inexpensive digital surveys.

METHODS

We designed and conducted a cross-sectional survey with multistage sampling. Data were collected from Nigerians (aged ≥18 years) from 120 strata based on age, sex, state, and urban or rural location. Respondents were recruited via advertisements on Meta platforms (Facebook and Instagram) using the Virtual Lab open-source tool. We used a Meta Messenger chatbot for data collection; participants were compensated with 400 naira (US $0.87 cents). Data collection took 2 weeks. In total, 957 respondents completed the survey, at an advertising cost of US $1.55 per respondent. An 18-item instrument measuring core motivators, ability barriers, sociodemographic characteristics, and respondents' vaccination status was pretested before data collection. We ran separate logistic regression models to examine the relationships between vaccine uptake and core motivators, ability barriers, and sociodemographic variables. A final model that predicted vaccine uptake included all 3 sets of variables.

RESULTS

About 56% (n=540) of respondents reported that they had received at least 1 COVID-19 vaccination. Three core motivators were positively associated with vaccine uptake: the belief that the COVID-19 vaccine promised a better life (adjusted odds ratio [aOR] 3.51, 95% CI 2.23-5.52), the belief that the vaccine would allow respondents to do more things they enjoyed (aOR 1.97, 95% CI 1.33-2.93), and respondents' perception that their friends and family members accepted their decision to get vaccinated (aOR 1.62, 95% CI 1.06-2.48). Two ability barriers were negatively associated with vaccine uptake: cost- or income-related concerns lowered the odds of being vaccinated (aOR 0.35, 95% CI 0.24-0.50) and the lack of availability of vaccines at places respondents routinely visited also lowered their odds of being vaccinated (aOR 0.29, 95% CI 0.21-0.40). After adjusting for other variables, the perceived fear of getting COVID-19 and the hardship associated with the disease were no longer associated with vaccine uptake.

CONCLUSIONS

These findings suggest that hope is more important for Nigerians than fear when it comes to vaccine adoption, enjoying life is more important than worrying about getting the disease, and approval from friends and family is more powerful than their disapproval. These findings suggest that emphasizing the benefits of leading a fuller life after being vaccinated is more likely to succeed than increasing Nigerians' fear of COVID-19. This study identifies a very different set of factors associated with COVID-19 vaccine adoption than previous Nigerian studies.

Barriers to family planning through structural health vulnerabilities: findings from case studies from rural Uganda

The burden of maternal mortality in sub-Saharan Africa is the highest in the world. As high fertility rates present an increased risk to women's health, programmes and services have been put in place to increase access to family planning. Several studies have identified sociocultural factors as limiting access to family planning, including male resistance and women's low decision-making power. However, these studies have often used a behavioural approach that anchors barriers to access in women's attitudes or motivations. In 2019, a qualitative evaluation of a family planning programme using a behavioural approach was conducted in rural Uganda, focusing on women's attitudes and unmet needs. With hindsight, we realised that our evaluation was insufficient to adequately capture barriers that extend beyond women's motivations. This paper shares three case studies that we analysed using a structural health vulnerabilities approach. Our analysis highlights political, economic, social and cultural structures that can impede access to family planning. Using a structural health vulnerabilities approach, we identify structural barriers which have their roots in the local realities women face and propose context-specific structural recommendations. Finally, we contrast our initial results with findings the case studies presented to highlight the relevance of taking structural vulnerabilities into account in future family planning programme evaluation and women's sexual and reproductive health studies.

Mediating effects of inequitable gender norms on intimate partner violence and contraceptive use in a cluster randomized control trial in Niger: A causal inference mediation analysis

Background

Gender inequity, a deeply-rooted driver of poor health globally, is expressed in society through gender norms, the unspoken rules that govern gender-related roles and behavior. The development of public health interventions focused on promoting equitable gender norms are gaining momentum internationally, but there remain critical gaps in the evidence about how these interventions are working to change behavioral outcomes.

Methods

A four-arm cluster randomized control trial (cRCT) was conducted to evaluate the effects of the Reaching Married Adolescents in Niger (RMA) intervention on modern contraceptive use and intimate partner violence (IPV) among married adolescent girls and their husbands in Dosso, Niger (T1: 1042 dyads; 24 mos. follow-up: 737 dyads, 2016-2019). This study seeks to understand if changes in perceived inequitable gender norms among husbands are the mechanism behind effects on modern contraceptive use and IPV. We estimated natural direct and indirect effects via these gender norms using inverse odds ratio weighting. An intention-to-treat approach and a difference-in-differences estimator in a hierarchical linear probability model was used to estimate prevalence differences, along with bootstrapping to estimate confidence intervals.

Results

The total effects of the RMA small group intervention (Arm 2) is estimated to be an 8% reduction in prevalence of IPV [95% CI: -0.18, 0.01]. For this arm, the natural indirect effect through gender inequitable social norms is associated with a 2% decrease (95% CI: -0.07, 0.12), accounting for 22.3% of this total effect, and the natural direct effect with a 6% decrease (95% CI: -0.20, -0.02) in IPV. Of the total effect of the RMA household visit intervention (Arm 1) on contraceptive use (20% increase), indirect effects via inequitable gender norms were associated with an 11% decrease (95% CI: -0.18, -0.01) and direct effects with a 32% increase (95% CI: 0.13, 0.44) in contraceptive use. For the combination arm, of the total effects on contraceptive use (19% increase), indirect effects were associated with a 9% decrease (95% CI: -0.20, 0.02) and direct effects with a 28% increase (95% CI: 0.12, 0.46).

Conclusion

The present study contributes experimental evidence that the small group RMA intervention reduced IPV partially via reductions in perceived inequitable gender norms among husbands. Evidence also suggests that increases in perceived inequitable gender norms resulted in decreased contraceptive use among those receiving the household visit intervention component. Not only do these results open the "black box" around how the RMA small group intervention may create behavior change to help inform its future use, they provide evidence supporting behavior change theories and frameworks that postulate the importance of changing underlying social norms in order to reduce IPV and increase modern contraceptive use.

Use of a Practitioner-Friendly Behavior Model to Identify Factors Associated with COVID-19 Vaccination and Other Behaviors

The lack of capacity for the design and implementation of behavioral interventions in low-and-middle income countries (LMICs) has been recognized by the World Health Organization (WHO) and other global health institutions. There is a need to task-shift, to translate social and behavioral science concepts into "practitioner-friendly" models-models which can be used by intervention designers, implementers, and evaluators with limited technical and financial resources. We illustrate the use of the Fogg Behavior Model (FBM), a model identified as being easy for practitioners to adopt in low-resource settings. The study uses data across four different behaviors in Nigeria, Pakistan, and India. The behaviors examined are COVID-19 vaccine uptake, condom use, iron folate use, and modern contraceptive use. The data are from surveys of healthcare workers (HCWs), married men, women of reproductive age, and adolescents, respectively. The FBM states that behavior happens when both motivation and ability are present, and a prompt occurs. In other words, persons with high motivation and high ability are the first to adopt a behavior. We created a categorical variable for motivation and ability and tested whether high motivation and high ability are associated with a greater likelihood of adopting a behavior. In Nigeria, HCWs with high motivation and high ability had 27 times higher odds of being vaccinated. In Pakistan, married men with high motivation and high ability had 35 times higher odds of condom use with their wives. In India, women with high motivation and high ability had 9 times higher odds of iron folate use. In Nigeria, adolescents and young women with high motivation and high ability had 8 times higher odds of contraceptive use. The study findings suggest that the FBM has the potential to be applied in low resource settings for the design, implementation, and evaluation of behavioral interventions. Rigorous testing of the FBM using data from experimental or quasi-experimental studies is recommended.

Implementation practice models for development in low- and middle-income countries: systematic review of peer-reviewed literature

Introduction

This study operationally defines a relatively small, but growing field of study on implementation practice models for health behavior change in the context of international development. We define ‘implementation practice models’ as theoretical models that take a practical and practitioner-focused approach to behavior change, and we illustrate how these models have been developed and applied. The paper examines the continuum of behavioral theories and their application in the context of development programs and research in low- and middle-income countries (LMICs). We describe implementation practice models, examine how they have been used to design and evaluate theory-based interventions in LMIC, and describe the state of evidence in this field of study.

Methods

The authors conducted a systematic search of the published, peer-reviewed literature following the widely accepted PRISMA methods for systematic reviews. We aimed to identify all relevant manuscripts published in the English language in health, social science, and business literature that apply implementation practice models, located in an LMIC, with a behavior change objective. We located 1,078 articles through database searching and 106 through other means. Ultimately, we identified 25 relevant articles for inclusion.

Results

We found that the peer-reviewed literature on implementation practice models for development has been growing in recent years, with 80% of reviewed papers published since 2015. There was a wide range of different models revealed by this review but none demonstrated clear-cut evidence of being most effective. However, the models found in this review share common characteristics of focusing on the three central tenets of Opportunity, Ability, and Motivation (OAM).

Conclusions

This review found that implementation practice models for development are a promising and growing approach to behavior change in LMICs. Intervention practice models research should be expanded and applied in new domains, such as vaccination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13530-0.

A Qualitative Exploration of Factors Explaining Non-Uptake of Hormonal Contraceptives Among Adolescent Girls in Rural Ghana: The Adolescent Girls' Perspective

BACKGROUND

Adolescent pregnancy remains a public health concern globally. The use of hormonal contraceptive methods are proven ways of preventing pregnancies and in turn unsafe abortions. However, research shows that use of hormonal contraceptive methods is rather low among African adolescent girls, of which Ghana is no exception.

OBJECTIVE

This manuscript uses the socio-ecological model to guide our understanding of the factors associated with non-use of hormonal contraceptives among adolescent girls in Ghana.

METHODS

An explorative study was done using qualitative data collection methods. Two focus group discussions and sixteen in-depth interviews were conducted among adolescent girls aged 15-19 years (N = 38) in the Kintampo area of Ghana to determine factors affecting uptake of hormonal contraceptives.

RESULTS

Adolescents showed a lack of in-depth knowledge related to the different hormonal contraceptive types. Negative attitudes towards adolescent hormonal contraceptive use, fear of real and perceived side effects of hormonal contraceptives, lack of self-efficacy to use contraceptives, fear of disclosure of use and fear of societal stigma related to sexual intercourse and its related issues among adolescents may explain why adolescent girls in this context do not use hormonal contraceptive methods.

CONCLUSION

To promote hormonal contraceptives among adolescent girls, a combination of multifaceted social-psychological, personal and community level interventions are needed.

Drivers of COVID-19 Vaccine Uptake amongst Healthcare Workers (HCWs) in Nigeria

This study applied a behavioral lens to understand drivers of COVID-19 vaccination uptake among healthcare workers (HCWs) in Nigeria. The study used data from an online survey of Nigerian HCWs ages 18 and older conducted in July 2021. Multivariate logistic regression analyses were conducted to examine predictors of getting two doses of a COVID-19 vaccine. One-third of HCWs in our sample reported that they had gotten two doses of a COVID-19 vaccine. Motivation and ability were powerful predictors of being fully vaccinated: HCWs with high motivation and high ability had a 15-times higher odds ratio of being fully vaccinated. However, only 27% of HCWs had high motivation and high ability. This was primarily because the ability to get vaccinated was quite low among HCWs: Only 32% of HCWs reported that it was very easy to get a COVID-19 vaccination. By comparison, motivation was relatively high: 69% of HCWs reported that a COVID-19 vaccine was very important for their health. Much of the recent literature coming out of Nigeria and other LMICs focuses on increasing motivation to get a COVID-19 vaccination. Our findings highlight the urgency of making it easier for HCWs to get COVID-19 vaccinations.