A Vignette-based Approach to Understanding Social Norms around Family Planning in Three Nigerian Cities

"Interventions that influence social norms around healthy behaviours may be part of a sustainable solution to improving health status..."

This article discusses the Nigerian Urban Reproductive Health Initiative (NURHI)'s effort to increase contraceptive uptake through advocacy, service delivery, and demand generation. Using data from focus group discussions (FGDs), the researchers 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. The goal is to understand how social norms influence contraceptive use in preventing unintended pregnancies in low-income countries.

While FP investments in Nigeria have been ongoing for decades, and knowledge of contraceptive methods is high (e.g., 93% of women of reproductive age have knowledge of at least one contraceptive method), demand for and use of contraceptives remains low. Thus, from 2009 to 2014, the Bill & Melinda Gates Foundation (BMGF) supported NURHI with the aim of increasing voluntary use of MC among women ages 15-49 years in six large cities: Abuja, Ibadan, Ilorin, Kaduna, Benin, and Zaira. NURHI received a second grant from BMGF to implement NURHI Phase 2 in three states: Lagos and Kaduna (2015-2020) and Oyo (2015-2018).

Demand generation elements included mass media campaigns through radio and television spots, entertainment-education, and social mobilisation through outreach activities. NURHI's advocacy strategy complemented demand generation efforts by working with policymakers, religious and traditional leaders, and the media to create an enabling environment supportive of FP. NURHI incorporated the theory of ideation, which purports that people's actions are influenced strongly by their beliefs, ideas, and feelings. NURHI hypothesised that demand generation elements of the programme would work together to influence ideation factors, including social norms.

This study focuses on social norms around FP, specifically MC use, among residents of the cities of Kaduna (who were exposed to NURHI 1 and 2), Ilorin (exposed to only NURHI 1), and Jos (not exposed to NURHI). In each city, six FGDs were conducted with married and unmarried women between ages 15 and 39 years; 175 women participated across 18 FGDs. FGD questions centred around the constructs of injunctive norms (beliefs about what their community would find acceptable), descriptive norms (beliefs about what women in their communities are doing) and personal attitudes (beliefs about what a character should do). Three vignettes were developed involving (1) a 16-year-old unmarried young woman who was sexually active with her 17-year-old boyfriend and was considering using MC; (2) a 21-year-old mother with a 6-month-old baby who wanted to space her next pregnancy, while her husband wanted another child immediately; and (3) a 28-year-old woman with 4 children who wanted to prevent future pregnancies.

The paper presents results as follows:

• Injunctive norms, personal attitudes, and descriptive norms around non-marital use of MC by adolescents to prevent the first pregnancy - In general, strong injunctive norms held that participants' communities would deem it unacceptable for the adolescent girl in the vignette to have sex and use MC. Despite the perceived lack of community acceptance and mixed personal attitudes towards premarital sex and adolescent's use of contraception, most participants believed the adolescent would use MC, and that unmarried girls in their communities were using MC.
• Injunctive norms, personal attitudes, and descriptive norms around the use of MC by married women to space or limit pregnancy - In both the spacing and limiting vignettes, the pattern identified in descriptive norms aligned with injunctive norms and personal attitudes, with participants reporting that FP and MC use were generally acceptable and common in their communities.
• Perceptions of changes in norms over time - Participants reported that norms around FP and MC use have become more accepting in their communities over time. They stated that men were recently more willing to allow their wives to use FP, and some men had even begun asking their wives to go to FP clinics. Participants' perceptions of religious leaders' support for FP use may have contributed to positively influencing social norms. In terms of raising awareness of FP/MC, posters, billboards, flyers, and door-to-door education were mentioned in Kaduna and Ilorin, but not in Jos. Radio and TV programmes were mentioned in every FGD in Ilorin and almost every FGD in Kaduna

The data reveal some normative differences between locations regarding community acceptance and use of contraception, and substantial differences across locations in personal attitudes. For example, given that NURHI was implemented in Kaduna and Ilorin, where participants reported being exposed to the programme messages through churches, posters, billboards, and flyers, these findings suggest that NURHI may have influenced norms and attitudes to be more positive towards adolescent girls' use of MC. However, given the qualitative design of the study, establishing a causal association is not possible.

As noted in the paper, the pervasive belief that adolescents and young women should not have sex outside of marriage is not a new finding in Nigeria (or in other settings). Leveraging the local tradition of female community members who act as advisors or counsellors to adolescents and young women could be an opportunity for future projects to advocate with this group for the health and social benefits of MC for unmarried sexually active women, including the ability to stay in school. Such advocacy would aim to shift injunctive norms, specifically in reference to the group of youth advisors, in support of contraceptive use.

In light of NURHI's focused work with religious leaders to increase male involvement and advocate for positive FP messages, sustained engagement with influential leaders could be a tool to increase the use of MC. While attribution is not possible, the positive and sustained impact of the programme may have transpired, particularly in Kaduna, through positive changes in injunctive norms, particularly when considering religious leaders as an important reference group.

This study suggests that differentiating between social norms for MC use to delay, space, and limit pregnancies can aid in designing targeted MC programmes that meet women's needs based on where they are in their reproductive lives.

In conclusion: "Shifting social norms through communication campaigns that include mass media, organised community dialogues, and influential and far-reaching change agents such as religious leaders, implicitly and explicitly encourages women to use FP to prevent, space and limit pregnancies throughout their life course and helps sustain contraceptive behaviours and fertility outcomes across communities and over time."