Testing the effectiveness of integrating community-based approaches for encouraging abandonment of female genital cutting into CARE\u27s reproductive health programs in Ethiopia and Kenya

CARE International, with technical support from the Frontiers in Reproductive Health Program completed a study in Ethiopia and Kenya designed to test the effectiveness of education activities using behavior change communication (BCC) approaches and advocacy activities by religious and other key leaders to abandon female genital cutting (FGC). In Ethiopia, the increased knowledge of harmful FGC effects and human rights issues translated to a positive attitude in support of FGC abandonment and an intention not to cut their daughters in the future. In Kenya, the analysis indicated mixed results in attitude and intended behavior change

The power of womens and mens Social Networks to catalyse normative and behavioural change: evaluation of an intervention addressing Unmet need for Family Planning in Benin.

BACKGROUND: In Benin, despite good knowledge and availability, modern contraceptive prevalence remains relatively low, and the unmet need for family planning is relatively high. This is partly due to insufficient attention to socio-normative barriers that influence need and method use. Applying social network theory, Tékponon Jikuagou (TJ) aims to reduce socio-normative barriers preventing modern contraceptive use in rural Benin. After community identification, TJ trains influential network actors who encourage critical dialogue about unmet need, family planning, gender, and other social norms within their networks, complemented by radio and services linkages. This paper evaluates TJs effectiveness and how intervention components affect intermediate and primary FP outcomes. METHODS: We report findings from pre/post-intervention cross-sectional research with a comparison group conducted at baseline with 1,043 women and 1,030 men, and 14 months later at endline with 1,046 women and 1,045 men. Using sex-stratified models, we assessed balance across intervention and comparison groups on background characteristics using Pearsons chi-square tests of independence; performed bivariate tests of independence to assess differences between baseline to endline on intermediate outcomes and primary FP outcomes; used logistic regression to examine the effect of intervention components on intermediate and primary FP outcomes. RESULTS: Statistically significant improvements in primary outcomes: womens intentions to use modern contraception, achieve met need, and reduce perceived met need. The fourth primary outcome, actual use, showed substantial gains, although not statistically significant. Mens achievement of met FP need and reduced perceived met need were also statistically significant. Assessing intermediate outcomes at individual, couple, normative-network levels, TJ led to statistically significant increases in couple and network communication on fertility desires and family planning use and self-efficacy and confidence to access services. Both women and men showed significant shifts in the acceptability of discussing FP in public. Results for other indicators of norms change were inconsistent. CONCLUSIONS: An easy-to-implement, short-duration, gender-equitable social network intervention with a limited set of network actors, TJ effectively decreases social and normative barriers preventing women and men from seeking and using FP services. Results support the broader use of innovative social and behaviour change strategies that diffuse family planning ideas through social networks, diminish normative and communication barriers, and catalyse modern family planning use

Bringing ethical thinking to social change initiatives: Why it matters.

Norms-shifting interventions (NSI) seek to improve people's well-being by facilitating the transformation of harmful social norms, the shared rules of acceptable actions in a group that prop up harmful health behaviours. Community-based NSI aim for incremental normative change and complement other social and behaviour change strategies, addressing gender, other inequalities, and the power structures that hold inequalities in place. Consequently, they demand that designers and implementers-many who are outsiders-grapple with power, history, and community agency operating in complicated social contexts. Ethical questions include whose voices and values, at which levels, should inform intervention design; who should be accountable for managing resistance that arises during implementation? As interest and funding for NSI increases in lower and middle-income countries, their potential to yield sustained change is balanced by unintentionally reinforcing inequities that violate human rights and social justice pillars guiding health promotion efforts. A review of 125 articles on ethical considerations in public health, social justice, and human rights-where NSI actions intersect-indicated little guidance on practice. To begin to address this gap, we propose ten ethical values and practical ways to engage ethically with the social complexities of NSI and the social change they seek, and a way forward

Moving from theory to practice: A participatory social network mapping approach to address unmet need for family planning in Benin

In West Africa, social factors influence whether couples with unmet need for family planning act on birth-spacing desires. Tékponon Jikuagou is testing a social network-based intervention to reduce social barriers by diffusing new ideas. Individuals and groups judged socially influential by their communities provide entrée to networks. A participatory social network mapping methodology was designed to identify these diffusion actors. Analysis of monitoring data, in-depth interviews, and evaluation reports assessed the methodology's acceptability to communities and staff and whether it produced valid, reliable data to identify influential individuals and groups who diffuse new ideas through their networks. Results indicated the methodology's acceptability. Communities were actively and equitably engaged. Staff appreciated its ability to yield timely, actionable information. The mapping methodology also provided valid and reliable information by enabling communities to identify highly connected and influential network actors. Consistent with social network theory, this methodology resulted in the selection of informal groups and individuals in both informal and formal positions. In-depth interview data suggest these actors were diffusing new ideas, further confirming their influence/connectivity. The participatory methodology generated insider knowledge of who has social influence, challenging commonly held assumptions. Collecting and displaying information fostered staff and community learning, laying groundwork for social change

Men’s social networks, social norms, & family planning in Benin

To address low family planning (FP) use and high unmet need in West Africa, attention has been paid to addressing FP-related social networks and norms. Most work focuses on women. This analysis assesses men’s FP-related social networks and norms and their relation to FP use in Benin using data from baseline surveys from the Tékponon Jikuagou intervention. We descriptively analysed men’s egocentric FP-related social networks and norms at the village level. Multivariable logistic regression analyses (N = 885) examined the relationship between FP-related social networks, norms, and men’s current and future FP use. Twenty-three percent of men reported current modern contraception use and 47% reported intended future use. Most had few network members. While most believed it was acceptable to discuss FP, few talked with peers about FP and most did not discuss FP with their partner(s). In multivariable analyses, neither networks nor norms were significantly related to men’s FP use. Men’s networks being small and men rarely discussing FP indicate an opportunity for village-based approaches to engage men in FP discussions and spark FP dialogue within couples, between men, and within villages. Future work should further explore the relationship between men’s social networks, norms, and FP use

Reaching the youngest moms and dads: a socio-ecological view of actors and factors influencing first-time young parents’ use of sexual and reproductive health services in Madagascar

Globally, few programs consider the needs of first-time young parents (FTYPs), who face disproportionate negative health consequences during pregnancy and childbirth. Scant evidence exists on FTYPs‘ broader health needs. Formative research in two regions of Madagascar used a socio-ecological lens to explore, via 44 interviews and 32 focus group discussions, the influences on FTYPs at the individual, couple, family, community, and system levels. We spoke with FTYPs who had, and who had not, used sexual and reproductive health (SRH) services, their parents/kin and influential adults,  and community health workers and facility health providers. Data analysis, guided by a codebook, used Atlas.ti. Age, social position, and implicit power dynamics operating within and across socio-ecological levels affected FTYPs‘ service-seeking behaviors. The nature and extent of influence varied by health service type. Cross-cutting social factors affecting service use/non-use included gender dynamics, pressures from mothers, in-laws, and family tradition, and adolescent stigmatization for too-early pregnancy. Structural and economic factors included limited awareness of and lack of trust in available services, unfriendliness of services, and FTYPs‘ limited financial resources. A socio-ecological program perspective can inform tailoring of activities to address broader SRH issues, including how relationships, gender, power, and intergenerational dynamics influence service use. À l'échelle mondiale, peu de programmes prennent en compte les besoins des jeunes gens devenus parents pour la première fois (JPPPF), qui font face à des conséquences négatives sur la santé disproportionnées pendant la grossesse et l'accouchement. Il existe peu de preuves sur les besoins de santé plus généraux des JPPPF. La recherche formative menée dans deux régions de Madagascar a utilisé une lentille socio-écologique pour explorer, par l‘intermédiaire de 44 entretiens et 32 discussions de groupe, les influences sur les JPPPF aux niveaux de l'individu, du couple, de la famille, de la communauté et du système. Nous avons parlé avec les JPPPF qui avaient utilisé, et ceux qui n‘avaient pas utilisé les services de santé sexuelle et de la reproduction, leurs parents/relations et des adultes influents, ainsi que des agents de santé communautaires et des prestataires de soins en établissement. L‘analyse des données, guidée par un livre de codes, a été réalisée par Atlas.ti. L‘âge, la position sociale et les dynamiques de pouvoir implicites opérant à l‘intérieur et entre les niveaux socio-écologiques ont affecté les comportements de recherche de services des JPPPF. La nature et l'étendue de l'influence variaient selon le type de service de santé. Les facteurs sociaux transversaux ayant une incidence sur l'utilisation/la non-utilisation des services comprenaient la dynamique de genre, les pressions exercées par les mères, la belle-famille et les traditions familiales et la stigmatisation des adolescentes pour une grossesse trop précoce. Les facteurs structurels et économiques comprenaient une connaissance limitée et un manque de confiance dans les services disponibles, un manque de convivialité des services et des ressources financières limitées des JPPPF. Une perspective de programme socio-écologique peut aider à adapter les activités aux problèmes plus généraux de la SSR, notamment en ce qui concerne l'influence des relations, du genre, du pouvoir et de la dynamique intergénérationnelle sur l'utilisation des services. Afr J Reprod Health 2019; 23[3]: 19-29)