Getting to intent: Are social norms influencing intentions to use modern contraception in the DRC?

Assessment of intention to use modern contraceptives among women of reproductive age in Benin: evidence from a national population-based survey

BACKGROUND

Women's intentions to use any contraceptive method are critical for better understanding their future needs and making them more likely to act on that intention. This study assessed the factors associated with the intention to use modern contraceptives among women of reproductive age in Benin.

METHODS

This was a cross-sectional study that used the 2017-2018 Benin Demographic and Health Survey (BDHS). The study analyzed a weighted sample of 13, 582 women of reproductive age who were non-users of contraceptives. The intention to use contraceptives was the outcome variable. Multivariate logistic regression analysis was conducted to determine the factors associated with the intention to use contraceptives among women of reproductive age. The results were estimated using an adjusted odds ratios (aOR) with a 95% confidence interval (CI) and statistical significance set at p < 0.05.  RESULTS: Approximately 35.0% of the women had the intention to use modern contraception. We found that women aged between 30 and 34 (aOR = 0.70, 95%CI: 0.57, 0.86), 35-39 (aOR = 0.52, 95%CI: 0.42, 0.66), 40-44(aOR = 0.30, 95%CI: 0.22, 0.39) and 45-49 (aOR = 0.10, 95%CI: 0.07, 0.14), Muslim women (aOR = 0.68, 95%CI: 0.53, 0.85) and those who perceived the distance to a health facility not to be a big problem (aOR = 0.75, 95%CI: 0.67, 0.84) were less likely to have the intention to use modern contraceptives compared with their counterparts. On the other hand, women who attained primary (aOR = 1.21, 95%CI: 1.07, 1.36), secondary (aOR = 1.39, 95%CI: 1.21, 1.59), and higher education (aOR = 1.60, 95%CI: 1.13, 2.26), women who were employed (aOR = 1.39, 95%CI: 1.23, 1.57), women with no religion (aOR = 1.32, 95%CI: 1.04, 1.69), women whose partners were working (aOR = 1.69, 95%CI: 1.16, 2.44), women who heard about family planning in the media (aOR = 1.51, 95%CI: 1.16, 2.44), and women in the poorer (aOR = 1.31, 95%CI: 1.10, 1.54), middle (aOR = 1.42, 95%CI: 1.20, 1.67]), richer (aOR = 1.23, 95%CI: 1.03, 1.47), and richest households (aOR = 1.42, 95%CI: 1.15, 1.75) were more likely to have the intention to use contraceptives than their counterparts.

CONCLUSION

The study provides valuable insights into the intention to use contraceptives among women of reproductive age in Benin. The findings indicate that the proportion of women who have intention to use contraceptives remains low. The findings of this study could inform the development of targeted interventions and policies to increase access to and uptake of contraceptives in Benin, with the ultimate aim of improving the reproductive health and well-being of women and their families.

Geographic and socioeconomic inequalities in the coverage of contraception in Uttar Pradesh, India

BACKGROUND

Uttar Pradesh (UP) is the most populous state in India, with a historically lower level of family planning coverage than the national average. In recent decades, family planning coverage in UP has significantly increased, yet there are considerable geographic and socio-economic inequalities.

METHODS

The data used for the study is derived from a cross-sectional quantitative survey of 12,200 currently married women conducted during December 2020-February 2021 in UP by the Technical Support Unit. Univariate and bivariate analyses were performed and equiplots were used to make visualizing inequalities easy.

RESULTS

The findings of the study reveal significant variation in family planning coverage indicators amongst currently married women in reproductive ages by administrative divisions in UP. For instance, in the Jhansi division, it was 72.4%, while in Faizabad, it was 39.3%. Jhansi division experienced the highest modern contraceptive coverage with the lowest inequity compared to other divisions. However, the range of coverage within the division by Accredited Social Health Activist (ASHA) areas is 25% to 75%. In fact, for some ASHA areas in the Jhansi division, the family planning demand satisfied for modern contraception ranged from more than 85% to less than 22%. On the other hand, the Gonda division with the lowest coverage and lowest inequity for demand satisfied for modern contraception has some ASHA areas with less than 5% and some with more than 36%. The study also revealed intersectionality of education, wealth, place of residence and geographic divisions in identifying inequity patterns. For instance, in case of Mirzapur and Varanasi, the demand satisfied among the illiterates was 69% and the corresponding percentage for literates was 49%. With respect to place of residence, Basti division, where the coverage for modern contraception is extremely low, demand satisfied for modern contraceptive methods is 16.3% among rural residents compared to 57.9% in the case of urban residents.

CONCLUSIONS

The findings showed inequality in the modern family planning methods coverage in UP in both best and worst performing divisions. The inequalities exist even in extremely small geographies such as ASHA areas. Within the geographies as well, the socio-economic inequalities persisted. These inequalities at multiple levels are important to consider for effective resource allocation and utilization.

Transforming masculine norms to improve men's contraceptive acceptance: results from a pilot intervention with men in western Kenya

Men's adherence to constraining male gender norms can lead them to resist contraceptive use. Very few interventions have attempted to transform masculine norms to encourage greater contraceptive acceptance and gender equality. We designed and evaluated a small-scale community-based intervention targeting the masculine norms tied to contraceptive resistance among partnered men (N = 150) in two western Kenya communities (intervention vs. control). Pre-post survey data fit to linear and logistic regression models evaluated differences in post-intervention outcomes, accounting for pre-intervention differences. Intervention participation was associated with increases in contraceptive acceptance scores (adjusted coefficient (aβ) 1.04; 95% confidence interval (CI) 0.16, 1.91; p = 0.02) and contraceptive knowledge scores (aβ 0.22; 95% CI 0.13, 0.31; p < 0.001) and with contraceptive discussions with one's partner (adjusted Odds Ratio (aOR) 3.96; 95% CI 1.21, 12.94; p = 0.02) and with others (aOR 6.13; 95% CI 2.39, 15.73; p < 0.001). The intervention was not associated with contraceptive behavioural intention or use. Our findings demonstrate the promise of a masculinity-driven intervention on increasing men's contraceptive acceptance and positive contraceptive involvement. A larger randomised trial is needed to test the effectiveness of the intervention among men as well as among couples.

Prevalence and factors associated with the intention to use contraception among women of reproductive age who are not already using a contraceptive method in Liberia: findings from a secondary analysis of the 2019-2020 Liberia Demographic Health Survey

OBJECTIVE

Contraception constitutes a vital aspect of sexual and reproductive healthcare. However, the high prevalence of non-use has become a great public health concern globally. This study examined the intention to use contraceptives and its associated factors among women of reproductive age who were not using any method in Liberia.

DESIGN AND SETTING

A cross-sectional population-based study was conducted. We used data from the 2019-2020 Liberia Demographic and Health Survey. The research framework used the theory of planned behaviour to identify the factors that influence women's intention to use contraception.

PARTICIPANTS

The study analysed a weighted sample of 4504 women aged 15-49 who were not currently using any form of contraception.

DATA ANALYSIS

The outcome variable was the intention to use a contraceptive method. A binary logistic regression was used to identify factors associated with the intention to use contraceptives in Stata V.13.0.

RESULTS

Of the 4504 women, 39.42% intended to use contraception. Contraception intention was significantly lower in married women than in never married women (adjusted OR (aOR) 0.78; 95% CI 0.62 to 0.98). Additionally, women aged 25-34 (aOR 0.434; 95% CI 0.339 to 0.556) and 35-49 (aOR 0.120; 95% CI 0.088 to 0.163) had a reduced intent to use contraceptives than those aged 15-24. However, women with at least one child, those with prior contraception experience and those who had their first sexual encounter at the age of 13 or older were more likely to intend to use contraception. Notably, Muslim and wealthy women displayed a lower likelihood of intending to use contraception.

CONCLUSION

These findings highlight that attitudes, subjective norms and perceived behavioural control significantly influence women's intentions to use contraception. Understanding and addressing these factors are crucial for promoting effective contraceptive use among women, facilitating informed reproductive choices.

Shifting Norms in Faith Communities to Reduce Intimate Partner Violence: Results from a Cluster Randomized Controlled Trial in Nigeria

Programs aiming to reduce intimate partner violence (IPV) increasingly seek to shift social norms. Few interventions have been rigorously evaluated for their impact on norms and incidence of IPV, particularly in sub-Saharan Africa. Shifting norms at the community level and subsequent pathways to behavior change remain poorly understood. We assessed shifts in individual- and couple-level factors, social norms, and IPV from an 18-month community-based trial of the Masculinity, Faith, and Peace (MFP) program-a faith-based, norms-shifting approach-in Plateau state, Nigeria. This study was part of a community-based, mixed-methods, two-arm cluster randomized control trial (cRCT) to evaluate the MFP program. Quantitative surveys were conducted with women 18 to 35 years old (n = 350) and their male partners (n = 281). Respondents came from 10 Muslim and 10 Christian congregations. Social norms were measured based on results from factor analysis. Intent-to-treat analyses assessed intervention effects. Qualitative research in MFP congregations explored pathways of change. All forms of IPV reduced over time among MFP participants. Regression analyses showed a significant 61% reduction in odds of reporting experiencing any IPV among women, a 64% reduction among Christians, and a 44% reduction in MFP congregations compared to their respective controls. In addition to improvement in norms, we found significant intervention effects on individual attitudes toward IPV and gender roles, relationship quality, and community cohesion. Qualitative findings reinforce these pathways, suggesting that critical reflection and dialogue on existing norms and the focus on faith and religious texts were valued by participants and supported IPV reductions. This study demonstrates that a faith-based, norms-shifting intervention can significantly reduce IPV in a short time. There are several pathways through which MFP reduced IPV, including shifts in norms, attitudes, relationship quality, and community cohesion.

Evaluation of the effect of the Momentum project on family planning outcomes among first-time mothers aged 15-24 years in Kinshasa, DRC

OBJECTIVES

This article presents the effect of Momentum, a nursing student-led community-based service delivery project, on postpartum family planning (FP) outcomes among first-time mothers in Kinshasa, Democratic Republic of the Congo.

STUDY DESIGN

We employed a quasi-experimental design, with three intervention and three comparison health zones (HZ). Data were collected through interviewer-administered questionnaires in 2018 and 2020. The sample consisted of 1927 nulliparous women aged 15-24 years who were 6 months pregnant at baseline. Random effects and treatment effects models were used to assess the effect of Momentum on 14 postpartum FP outcomes.

RESULTS

The intervention group was associated with a unit increase of 0.6 (95% confidence interval [CI]: 0.4, 0.8)) in contraceptive knowledge and personal agency (95% CI: 0.3, 0.9), a unit decrease of 0.9 (95% CI: -1.2, -0.5) in the number of FP myths/misconceptions endorsed, and percentage point increases of 23.4 (95% CI: 0.2, 0.3) in FP discussion with a health worker, 13.0 (95% CI: 0.1, 0.2) in obtaining a contraceptive method within 6 weeks of delivery, and 13.3 (95% CI: 0.1, 0.2) in modern contraceptive use within 12 months of delivery. Intervention effects included percentage point increases of 5.4 (95% CI: 0.0, 0.1) in partner discussion and 15.4 (95% CI: 0.1, 0.2) in perceived community support for postpartum FP use. The level of exposure to Momentum was significantly associated with all behavioral outcomes.

CONCLUSIONS

The study demonstrated the effect of Momentum on increased postpartum FP-related knowledge, perceived norms, personal agency, partner discussion, and modern contraceptive use.

IMPLICATIONS

Community-based service delivery by nursing students can potentially lead to improved postpartum FP outcomes among urban adolescent and young first-time mothers in other provinces of the Democratic Republic of the Congo and other African countries.

Collective norms and modern contraceptive use in men and women: A multilevel analysis of DHS Program data in Nigeria and Zambia

Background: Social norms have long been understood as essential for demographic preferences, intentions and behavior, despite a lack of consistent definitions and measures in the field. Recent work has more clearly defined these norms, both at the individual and community/collective levels. However, past research on the effect of social norms on contraceptive use has focused mainly on the influence of individual-level norms, largely among women only, contributing to mixed findings. Methods: This study addresses this gap through the use of multilevel models to identify associations between collective gender, fertility, and family planning norms and individual use of modern contraceptives for both men and women, using recent Demographic and Health Survey (DHS) data from Nigeria and Zambia. Multiple measures of variation, including community-level random effects and the intraclass correlation, are calculated, providing evidence of the general effect of community factors on behavior. Results: Our findings support the importance of social, demographic and economic context on how collective gender, fertility, and family planning norms relate to modern contraceptive use. Different social norms are associated with use in the two countries, and, even within the same country, men and women’s use are influenced by different norms. Among the examined norms, only collective fertility norms were associated with use for all the groups examined, consistently associated with lower use of modern contraception. Overall, clustering at the community level explained a larger proportion of variance in individual use in men compared to women, suggesting that men’s behavior was more consistently associated with the measured social norms than women’s. Conclusions: These findings suggest that careful attention should be paid to understanding and measuring social norms when considering programs or policy around the provision of modern contraception and that these should not assume that social norms influence men and women’s behaviors in the same way.

The role of partners, parents and friends in shaping young women's reproductive choices in Peri-urban Nairobi: a qualitative study

BACKGROUND

Contraceptive use among young women in Nairobi remains low despite high general knowledge of family planning (FP) methods. This paper draws on social norms theory to explore the role of key influencers (partners, parents and friends) in women's FP use and how women anticipate normative reactions or sanctions.

METHODS

A qualitative study with 16 women, 10 men and 14 key influencers across 7 peri-urban wards in Nairobi, Kenya. Interviews were conducted during the COVID-19 pandemic in 2020 by phone. A thematic analysis was conducted.

RESULTS

Women identified parents, specifically mothers, aunts, partners, friends and healthcare workers as key influencers on FP. Their interactions with these key influencers varied based on trust, the information they needed about FP, and whether they perceived a key influencer to perpetuate or challenge existing social norms on FP. Mothers were perceived to understand the social risks of using FP and thus could advise on discreet FP use, and aunts were trusted and approachable sources to impartially describe the benefits and drawbacks of FP. Although women identified partners as key FP decision makers, they were cognisant of possible power imbalances affecting a final FP choice.

CONCLUSIONS

FP interventions should consider the normative influence key actors have on women's FP choices. Opportunities to design and deliver network-level interventions which seek to engage with social norms surrounding FP in order to challenge misconceptions and misinformation among key influencers should be explored. Intervention design should consider dynamics of secrecy, trust and emotional closeness that mediate discussions of FP to address changing norms. Further training to change norms held by healthcare providers about why women, in particular unmarried young women, access FP should be provided to reduce barriers for FP access.

Validation of the Fertility Norms Scale and Association with Fertility Intention and Contraceptive Use in India

Social norms related to fertility may be driving pregnancy desire, timing and contraceptive use, but measurement has lagged. We validated a 10-item injunctive Fertility Norms Scale (FNS) and examined its associations with family planning outcomes among 1021 women and 1020 men in India. FNS captured expectations around pronatalism, childbearing early in marriage and community pressure. We assessed reliability and construct validity through Cronbach's alpha and exploratory factor analysis (EFA) respectively, examining associations with childbearing intention and contraceptive use. FNS demonstrated good reliability (α = 0.65-0.71) and differing sub-constructs by gender. High fertility norm among women was associated with greater likelihood of pregnancy intention [RRR = 2.35 (95% CI: 1.25,4.39); ARRR = 1.53 (95% CI: 0.70,3.30)], lower likelihood of delaying pregnancy [RRR = 0.69 (95% CI: 0.50,0.96); ARRR = 0.72 (95% CI: 0.51,1.02)] and greater ambivalence on delaying pregnancy [RRR = 1.92 (95% CI: 1.18,3.14); ARRR = 1.99 (95% CI: 1.21,3.28)]. Women's higher FNS scores were also associated with higher sterilization [RRR = 2.17 (95% CI: 1.28,3.66); ARRR = 2.24 (95% CI: 1.32,3.83)], but the reverse was noted for men [RRR = 0.61 (95% CI: 0.36,1.04); ARRR = 0.54 (95% CI: 0.32,0.94)]. FNS indicated better predictive value among women compared to men for key reproductive outcomes. This measure may be useful for social norms-focused evaluations in family planning and warrants cross-contextual study.

Understanding the rise in traditional contraceptive methods use in Uttar Pradesh, India

BACKGROUND

The sustainable development goals (SDG) aim at satisfying three-fourths of family planning needs through modern contraceptive methods by 2030. However, the traditional methods (TM) of family planning use are on the rise, along with modern contraception in Uttar Pradesh (UP), the most populous Indian state. This study attempts to explore the dynamics of rising TM use in the state.

METHODS

We used a state representative cross-sectional survey conducted among 12,200 Currently Married Women (CMW) aged 15-49 years during December 2020-February 2021 in UP. Using a multistage sampling technique, 508 primary sampling units (PSU) were selected. These PSU were ASHA areas in rural settings and Census Enumeration Blocks in urban settings. About 27 households from each PSU were randomly selected. All the eligible women within the selected households were interviewed. The survey also included the nearest public health facilities to understand the availability of family planning methods. Univariate and bivariate analyses were conducted. Appropriate sampling weights were applied.

RESULTS

Overall, 33.9% of CMW were using any modern methods and 23.7% any TM (Rhythm and withdrawal) at the time of survey. The results show that while the modern method use has increased by 2.2 percentage points, the TM use increased by 9.9 percentage points compared to NFHS-4 (2015-16). The use of TM was almost same across women of different socio-demographic characteristics. Of 2921 current TM users, 80.7% started with TM and 78.3% expressed to continue with the same in future. No side effects (56.9%), easy to use (41.7%) and no cost incurred (38.0%) were the main reasons for the continuation of TM. TM use increased despite a significant increase (66.1 to 81.3%) in the availability of modern reversible methods and consistent availability of limiting methods (84.0%) in the nearest public health facilities.

CONCLUSION

Initial contraceptive method was found to have significant implications for current contraceptive method choice and future preferences. Program should reach young and zero-parity women with modern method choices by leveraging front-line workers in rural UP. Community and facility platforms can also be engaged in providing modern method choices to women of other parities to increase modern contraceptive use further to achieve the SDG goals.

Using structural equation modeling to examine the influence of family planning social norms on modern contraceptive use in Nigeria

Despite high knowledge of family planning (FP) among Nigerian women, use of modern contraceptives remains low. While FP investments in Nigeria have been ongoing for decades, relatively little emphasis on contextual and structural factors may have contributed to low demand for and use of contraception. From 2009 to 2014, the Bill & Melinda Gates Foundation (BMGF) supported the Nigerian Urban Reproductive Health Initiative (NURHI) with the aim of increasing voluntary use of contraceptives among women ages 15-49 years in six Nigerian cities. A subsequent phase of NURHI was implemented in three states for the next 3 to 5 years. Using cross-sectional survey data from three cities (two exposed to NURHI, one not exposed), this study examines whether social norms around FP were related to women's use of modern contraception, and whether the relationship differed by varying levels of exposure to the program (i.e., by city). We identified three distinct FP social norms through factor analysis: norms around delaying first pregnancy; spacing or limiting pregnancies; and using contraception when the husband disagrees. Using structural equation modeling, we found that FP social norms are related to use of modern contraceptive methods, and the relationship varies by city and norm type. The observed differences suggest that this relationship depends on numerous factors at the individual, interpersonal and societal level, and this may include malleable factors influenced by the NURHI program.

Perinatal intimate partner violence and postpartum contraception timing among currently married women in Southern Ethiopia: A multilevel Weibull regression modeling

Background

Adopting contraception on time is a critical intervention for postpartum women, but violence exposure around pregnancy may interfere with postpartum contraceptive use behaviors. Hence, this study aimed to investigate the time duration of the first modern contraceptive adoption and its individual-and community-level predictors among postpartum women in the Wolaita zone, South Ethiopia.

Methods

A community-based prospective follow-up study was conducted among 1,292 postpartum women nested in 38 "Kebles" (clusters) using multistage-clustered sampling techniques. A multilevel Weibull regression model was employed to investigate predictors of time-to-method initiation after childbirth using STATA Version 14. Kaplan-Meier curve and Wilcoxon log-rank test were used to estimate time-to-modern contraceptive use across different variables. All variables with p-values <0.05 were considered for multivariate analysis. Adjusted time ratios (ATR) with 95 % CI were computed using Weibull accelerated failure time models.

Results

Of the respondents, 62% (95% CI: 59.1-64.5) had started the first modern contraception within a year after childbirth. The restricted mean survival time-to-postpartum modern contraceptive use was 6.28 months. Being a rural dweller (aTR: 1.44; 95% CI: 1.06-1.99) and living in the middle household wealth quintiles (aTR: 1.10; 95% CI: 1.02-1.19) predicted longer time duration to adopt first modern contraception by 44 and 10%, respectively. The women from the community with a high early marriage (aTR: 1.14; 95% CI: 1.01-1.28) took longer time to initiate modern postpartum methods. Furthermore, women who had no history of perinatal abuse took less time than those who had a history of abuse to start postpartum contraception (aTR: 0.71; 95% CI: 0.66-0.78).

Conclusion

Rural residence, poor household wealth status, history of perinatal abuse, and a high rate of early marriage in the community are predicted to lengthen the time duration to start modern postpartum contraception. Thus, community-level women's empowerment, particularly among rural women and integration of intimate partner violence screening into family planning counseling throughout the continuum of care will likely to improve postpartum contraception timing.

Association of Male Partners' Gender-Equitable Attitudes and Behaviors with Young Mothers' Postpartum Family Planning and Maternal Health Outcomes in Kinshasa, DRC

Inequitable gender norms can contribute to rapid repeat pregnancies and adverse maternal health outcomes among adolescent girls and young women. This study examined associations between male partners' gender-equitable attitudes and behaviors and postpartum family planning (FP) and maternal and newborn health (MNH) outcomes among first-time mothers aged 15-24 in Kinshasa, Democratic Republic of the Congo. Participants were 1335 couples who were successfully interviewed in the Momentum project's 2018 baseline and 2020 endline surveys. Multivariable regression models were used to analyze predictors of postpartum FP discussion and use, shared MNH decision making, completion of the maternal health continuum of care, and exclusive breastfeeding. Male involvement in maternal health was significantly associated with FP discussion and shared decision making. Male partners' willingness to be involved in routine childcare and shared decision making were significant positive predictors of exclusive breastfeeding. Postpartum FP outcomes were shaped by the intersection of marital status and male partners' gender-equitable attitudes, intimate partner violence perpetration, and willingness to engage in routine childcare activities to constitute advantage for some outcomes and disadvantage for others. Interventions must use multiple measures to better understand how young mothers' health outcomes are shaped by their male partners' gender-related attitudes and behaviors.

Use of digital media for family planning information by women and their social networks in Kenya: A qualitative study in peri-urban Nairobi

Access to information about family planning (FP) continues to have financial, physical and social barriers among young women living in Kenya. This paper draws on social norms theory to explore how young women and their social networks access FP information on digital media (e.g., WhatsApp, websites). Qualitative phone interviews were conducted with 40 participants - young women, their partners and key influencers - in seven peri-urban wards in Nairobi, Kenya. Data were analyzed using thematic analysis. Findings suggested that young women, their partners and key influencers predominately accessed FP information online through their informal networks, but identified healthcare workers as the most trusted sources of FP information. In digital spaces, participants described being more comfortable sharing FP information as digital spaces allowed for greater privacy and reduced stigma to talk about FP openly. Our findings highlight the importance of digital media in disseminating FP information among young women and their networks, the differences in norms governing the acceptability to talk about FP online vs. in-person and the significance of targeting misinformation about FP in digital media spaces.

Men's Involvement in Sexual and Reproductive Health Care and Decision Making in the Philippines: A Systematic Review of the Literature

Sexual and reproductive health care (SRH) and family planning (FP) services have been primarily female centered. In recent decades, international groups have advocated for men’s involvement in SRH and FP, yet related research remains limited and implementation not fully realized in many countries. This systematic review of literature seeks to summarize the barriers and facilitators to men’s involvement in SRH/FP services in the Philippines. It is limited to publications in English from 1994 to 2021 regarding studies conducted in the Philippines whose research questions focused on men’s involvement in SRH/FP. Eligible studies were assessed for methodological quality using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Evidence Rating Scale. The Ecological Model for Health Promotion was used as the guiding theoretical framework for analysis and to report findings. Barriers and facilitators were identified at every ecological level except that of policy. The most common barrier identified was men’s deficit in knowledge about SRH/FP; the most common facilitator was the positive influence of their social network on men’s attitudes, beliefs, and practices pertaining to SRH/FP. A range of factors from the individual to the community level influenced men’s involvement, including religious beliefs, economic means, and cultural gender roles. More studies are needed to provide a fuller understanding of the multilevel ecological factors influencing men’s involvement in SRH/FP and inform interventions with men that can positively affect their behavior related to SRH/FP decision making.

A vignette-based approach to understanding social norms around family planning in three Nigerian cities

Understanding the mechanisms through which social norms shape contraceptive use can help prevent unintended pregnancies in low-income countries. The Nigerian Urban Reproductive Health Initiative (NURHI) aimed to increase contraceptive uptake through advocacy, service delivery, and demand generation. Using data from focus group discussions, we examined whether social norms around family planning (FP), and specifically use of modern contraception (MC), varied among women and girls of reproductive age exposed to varying levels of the programme in three Nigerian cities. Injunctive social norms were generally unfavourable of unmarried adolescent girls' use of MC, though participants often shared exceptions for certain types of adolescents whose use of MC would be acceptable. There was greater acceptability for MC use by women who wanted to space or limit pregnancies. Participants reported that norms around FP and MC use have become more accepting in their communities over time. Normative differences between cities were identified. Participants' perceptions of religious leaders' support for FP use may have contributed to positively influencing social norms.

If fear of infertility restricts contraception use, what do we know about this fear? An examination in rural Ethiopia

BACKGROUND

Ethiopia has made great progress toward reducing unmet need for family planning and increasing contraception use over the last decade. However, almost one-quarter of women still have an unmet need. The primary reason for non-use is "method-related health concerns" and, within this broad category, the belief that using contraception will cause infertility is common. This belief extends beyond Ethiopia to low-, middle-, and high-income countries across the world. The objective of this paper is to examine associations with the belief that contraception use causes infertility and to subsequently suggest potential strategies to address this misperception.

METHODS

We collected data from women of reproductive age (between 15 and 49 years old) in 115 rural districts of Ethiopia (n = 706). Our main outcome variable was the belief that contraception causes infertility. We analyzed data, both individual-level factors and interpersonal factors, using nested logistic regression models.

RESULTS

Almost half of women in our sample (48.2%) believed that contraceptive use causes infertility. In the final model that included factors from both levels, self-efficacy to use contraception (AOR = 0.81, p < 0.05), visiting a health center and speaking to a provider about family planning in the last 12 months (AOR = 0.78, p < 0.05), and husband support of contraception (AOR = 0.77, p < 0.01) were associated with a reduction in the odds of believing that contraception causes infertility. The belief that infertility will result in abandonment from one's husband (AOR = 3.06, p < 0.001) was associated with an increase in the odds of holding the belief that contraception causes infertility. A home visit in the last 12 months from a health worker who discussed family planning was not associated with the belief that contraceptive use causes infertility.

CONCLUSIONS

Given that this belief is both salient and positively associated with other fears such as abandonment from one's husband, it is critical for family planning programs to address it. Communication campaigns or interventions that address this misperception among couples may diminish this belief, thereby increasing contraception use and reducing unmet need in rural Ethiopia.

Health inequalities in post-conflict settings: A systematic review

Conflict can be a primary driver of health inequalities, but its impact on the distribution of social determinants of health is not very well documented. Also, there is limited evidence on the most suitable approaches aiming at addressing health inequalities in post-conflict settings. Thus, we undertook a systematic review of the literature concerning the current knowledge and knowledge gaps about structural determinants of health inequalities and assessed the effects of approaches aimed at addressing health inequalities in post-conflict settings. We performed a systematic search in bibliographic databases such as Web of Science, PubMed, and PsycINFO for relevant publications, as well as institutional websites that are relevant to this topic. The search was initiated in March 2018 and ultimately updated in December 2020. No time or geographical restrictions were applied. The quality of each study included in this review was independently assessed using criteria developed by CASP to assess all study types. Sixty-two articles were deemed eligible for analysis. The key findings were captured by the most vulnerable population groups, including the civilian population, women, children, internally displaced persons (IDPs), and people with symptoms of mental illness. A considerable range of approaches has been used to address health inequalities in post-conflict settings. These approaches include those used to address structural determinants of health inequalities which are accountable for the association between poverty, education, and health inequalities, the association between human rights and health inequalities, and the association between health inequalities and healthcare utilization patterns. However, these approaches may not be the most applicable in this environment. Given the multifactorial characteristics of health inequalities, it is important to work with the beneficiaries in developing a multi-sector approach and a strategy targeting long-term impacts by decision-makers at various levels. When addressing health inequalities in post-conflict settings, it may be best to combine approaches at different stages of the recovery process.

Validation and Assessment of a Tool to Measure Psychosocial Readiness to Use Modern Contraceptives among Women in Tigray, Ethiopia

Social norms, beliefs, and attitudes around modern contraception (MC) use can influence the decision to take up a method, but susceptibility to these factors varies between individuals. The effect of psychosocial readiness to use MC at the individual level is not established for women in Ethiopia. Data from 349 women were used for validity and reliability testing of a 12-item MC psychosocial readiness scale. A rating-scale Rasch model tested for unidimensionality, rating scale functioning, and construct and content validity. Multiple linear regression assessed the effect of respondent characteristics on MC psychosocial readiness scores. The psychometric properties of the univariate MC psychosocial readiness scale were satisfactory after the stepwise removal of two items. Prior MC use, socioeconomic status, geographic zone, and education were significantly associated with increased endorsement of MC psychosocial readiness. The 10-item scale measures the extent of endorsement of MC psychosocial readiness for childbearing women in Tigray, Ethiopia. Further research should qualitatively explore the identified influence of education on MC psychosocial readiness.

Getting Intentional about Intention to Use: A Scoping Review of Person-Centered Measures of Demand

In recent years, there has been much reflection on the measures used to assess and monitor contraceptive programming outcomes. The meaning and measurement of intention‐to‐use (ITU) contraception, however, has had less attention and research despite its widespread inclusion in many major surveys. This paper takes a deeper look at the meaning and measurement of ITU around contraception. We conducted a scoping review guided by the following questions: What is the existing evidence regarding the measurement of ITU contraception? What definitions and measures are used? What do we know about the validity of these measures? We searched databases and found 112 papers to include in our review and combined this with a review of the survey instruments and behavioral theory. Our review found growing evidence around the construct of ITU in family planning programming and research. However there are inconsistencies in how ITU is defined and measured, and this tends not to be informed by advances in behavioral theory and research. Further work is needed to develop and test measures that capture the complexity of intention, examine how intention differently relates to longer‐range goals compared to more immediate implementation, and demonstrate a positive relationship between ITU and contraceptive use.

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.

Perceived norms, personal agency, and postpartum family planning intentions among first-time mothers age 15-24 years in Kinshasa: A cross-sectional analysis

Unintended pregnancy is an important global health problem and frequently occurs during the immediate postpartum period. However, few studies have examined postpartum family planning (PPFP) intentions among adolescent girls and young women. This study assessed whether perceived norms and personal agency predicted PPFP intentions among first-time mothers age 15–24 in Kinshasa, the Democratic Republic of Congo. Data were derived from the 2018 Momentum Project baseline survey. Analysis was based on 2,418 nulliparous pregnant women age 15–24 who were approximately six months pregnant with their first child in six health zones of Kinshasa. Overall PPFP intentions were low and ten to thirteen percent of women stated they were very likely to discuss PPFP next month with (a) their husband/male partner and (b) a health worker, and to (c) obtain and (d) use a contraceptive method during the first six weeks following childbirth. The results of multivariable linear regression models indicated that the PPFP intention index was predicted by description norms, perceptions of the larger community’s approval of PPFP, normative expectations, perceived behavioral control, self-efficacy, and autonomy. Rejection of family planning myths and misconceptions was also a significant predictor. Interaction terms suggested that the association of normative expectations with PPFP intentions varied across ethnic groups and that the positive association of injunctive norms with PPFP intentions was significantly increased when the larger community was perceived to disapprove of PPFP use. Normative expectations and PPFP-related self-efficacy accounted for two-thirds of the variance in PPFP intentions. The results suggested that understanding different normative influences may be important to motivate women to use contraception in the immediate postpartum period. In addition to addressing institutional, individual, and social determinants of PPFP, programs should consider integrating norm-based and empowerment strategies.

Understanding how social norms affect modern contraceptive use

BACKGROUND

An aim of this study is to introduce a practitioner-friendly behavior model. Few theories of health behavior explicitly take the effect of social norms on behavior into account. Generally, theories that do take social norms into account assume that the effect of social norms on behavior operates through motivation. We use the Fogg Behavior Model (FBM), a behavior model that is new to public health, to explore whether social norms are associated with modern contraceptive use among Nigerian women, and whether they affect behavior through motivation or through ability. In other words, do social norms that discourage contraception lower women's motivation to use contraception or do they lower women's ability to use contraception.

METHODS

This study uses data from a cross-sectional household survey of Nigerian women, ages 14-24. The survey collected data on socio-economic and demographic characteristics of women, whether they were sexually experienced, and whether they used contraception. Modern contraceptive use was the outcome of interest for the study. The survey also collected data on social norms around premarital sex and contraceptive use. Multivariate logistic regression was used for the analysis.

RESULTS

After adjusting for a range of socio-economic and demographic variables, we found that social norms that discourage contraception had a statistically significant negative association with contraceptive use (aOR = 0.90, p < 0.001). The analysis found that the negative association between social norms and contraceptive use remained statistically significant after controlling for motivation but did not remain statistically significant after controlling for ability.

CONCLUSION

These findings suggest that social norms may affect contraceptive use in Nigeria through ability rather than motivation. In terms of programmatic implications, these finding suggest that public health interventions may be able to counter the negative effects of social norms that discourage contraceptive use by increasing women's ability to practice contraception.

Reproductive health decision making among nomadic pastoralists in North Eastern Kenya: a qualitative social network analysis

BACKGROUND

To our knowledge, no studies exist on the influence of nomadic pastoralist women's networks on their reproductive and sexual health (RSH), including uptake of modern family planning (FP).

METHODS

Using name generator questions, we carried out qualitative egocentric social network analysis (SNA) to explore the networks of four women. Networks were analyzed in R, visuals created in Visone and a framework approach used for the qualitative data.

RESULTS

Women named 10-12 individuals. Husbands were key in RSH decisions and never supported modern FP use. Women were unsure who supported their use of modern FP and we found evidence for a norm against it within their networks.

CONCLUSIONS

Egocentric SNA proves valuable to exploring RSH reference groups, particularly where there exists little prior research. Pastoralist women's networks likely change as a result of migration and conflict; however, husbands make RSH decisions and mothers and female neighbors provide key support in broader RSH issues. Interventions to increase awareness of modern FP should engage with women's wider networks.

Factors Influencing Malaysian Men's Perceptions of Gender Equity in Family Planning

INTRODUCTION

Various factors influence men's perceptions regarding gender equity in family planning (FP). Identifying these factors can contribute to a deeper understanding of the roles that men play in family planning and ultimately leads to women's reproductive health outcomes.

OBJECTIVES

This paper aims to investigate factors influencing Malaysian men's perceptions of gender equity in family planning. To achieve this, the effects of sociodemographic characteristics (age, education, and marital status), masculine traits, and attitudes towards domestic violence are investigated.

METHODOLOGY

This is a cross-sectional study undertaken by administrating questionnaires to a sample of 168 men in Malaysia. The data are analyzed by applying partial least squares-structural equation modeling (PLS-SEM) and by using WarpPLS 6.0.

RESULTS

The results confirmed the significant effects of masculine traits and attitudes supporting domestic violence on perceived gender equity in family planning. In other words, the results showed that men's masculine traits and attitudes supporting domestic violence negatively influenced gender equity in family planning. The hypothesized effects of sociodemographic characteristics on perceived gender equity in family planning could not be verified.

CONCLUSIONS

This study suggests some practical implications for local authorities to implement interventions that take a gender transformative approach to reduce men's masculine traits and improve their attitudes towards domestic violence to enhance gender equity in family planning.

Socio-demographic and economic inequalities in modern contraception in 11 low- and middle-income countries: an analysis of the PMA2020 surveys

Background

Contraception is a key component of sustainable development, empowering women, reducing the risk of maternal and child mortality and promoting economic growth. It is part of the Sustainable Development Goals agenda, where the aim is to achieve universal access to sexual and reproductive health. Our objective was to evaluate trends and inequalities in modern contraceptive prevalence, and according to the type of modern contraceptive, in 11 low- and middle-income countries that are partners of the Family Planning 2020 initiative.

Methods

Analyses were performed using 62 Performance Monitoring and Accountability 2020 (PMA2020) surveys from 11 countries. Forty surveys were nationally representative, while 22 had regional coverage. Regional surveys were analyzed separately, totalizing 15 geographies from 11 countries. We described trends on modern contraceptive prevalence, and its subtypes (short- and long-acting reversible contraceptives, and permanent methods), by calculating absolute average annual changes. Absolute inequalities on the prevalence of modern contraceptives were assessed for the most recent survey of each geography using the slope index of inequality, and according to wealth, education and age.

Results

The overall prevalence of modern contraception increased in most geographies analyzed, reaching a 7.2 percentage points increase per year in Lagos, Nigeria. This increase was mostly influenced by the long-acting reversible contraceptives, which increased in 73% of the geographies. Although the largest share of modern contraception is represented by short-acting reversible contraceptives, these are reducing and giving space for the long-acting methods. The exception was Rajasthan, India, where the permanent methods accounted for 70% of the modern contraception share, and their prevalence was almost 40%. Inequalities were identified in favor of richer, older and better educated women.

Conclusions

Out of the 15 geographies analyzed, 11 demonstrated an increase in overall modern contraceptive use – mainly driven by the uptake of long-acting reversible contraception. However, even in the groups with the highest prevalence, modern contraceptive use was at most 60% in most geographies. So, we are far from reaching the desired universal coverage proposed by the Sustainable Development Goals.