The Influence of Changes in Fertility Related Norms on Contraceptive Use in Egypt, 1995-2005

"To what extent does a more progressive environment influence the adoption of contraception by a particular woman, above and beyond the other individual factors that have been known to influence family planning use? The interaction between communication messages and these normative changes also has not been fully explored..."

Published in Population Review (Volume 48, Number 1), this article describes research carried out to test the effect of changes in the collective or group norms related to the desire for a large family and the use of family planning in Egypt. Three questions drove the research: Does a change in fertility-related norms influence an individual's likelihood of contraceptive use? Do existing social norms measured at the aggregate level at the time of use influence an individual's decision to use modern contraceptives? Does exposure to family planning messages influence a woman's decision to use contraceptives adjusting for all individual and normative factors?

Introductory sections of the paper explore academic debates in the field of communication about the mechanism by which societal shifts in behaviour occur and are sustained, such as "[t]he debate around the relative influence of ideation versus development on fertility reduction." The paper also describes the Eyptian context and some efforts that have been carried out to develop and support strategic communication programmes on health and family planning. For example, a national media campaign named for Zeinab and Zaki, a fictional married couple who were the main characters of a television drama, explicitly promoted the use of contraceptives after the first birth to space subsequent pregnancies further apart. This national entertainment-education campaign became part of a larger Private Sector Provider (PSP) programme which was composed of five intensive national media campaigns over a three-year period, featuring television and radio messages, the development of a national network of "Ask-Consult" private pharmacies that sold hormonal contraceptives and other family health products over the counter, local and regional public relations events, national scientific meetings with hospital staff, and national and regional workshops with journalists.

Using multilevel analysis of consecutive 1995, 2000, and 2005 Egypt Demographic and Health Surveys (EDHS), the researchers tested the effect of changes in the norms related to the desire for a large family and the use of family planning at parity 0 or 1 on self-reported contraceptive use among 2,432 married women aged 15-49 years for the 1995-2000 period and 5,285 women for the 2000-2005 period.

In brief, the research revealed that contraceptive use was lower where attitudinal norms favouring large families were stronger and higher where behavioural norms favoring earlier initiation of family planning after the first child were stronger. Individual-level exposure to family planning messages was a consistently strong predictor of contraceptive use. More specifically: After controlling for individual and other community factors, including changes in literacy, the researchers found that women residing in communities where the desire for large families increased from 1995-2000 were more than 70% less likely to use a contraceptive method. While the trend was similar, no such effect of desired family size was observed from 2000-2005. Instead, residence in a community where use of family planning after the first child increased from 2000-2005 resulted in a more than three-fold increase in contraceptive use in 2005. "This shift in the normative influence between the earlier and the later periods appears to coincide with the change in the focus of the Egyptian population program that began around 1998. As the program messages shifted attention from limiting one’s family size and introduced the new norm of earlier initiation of family planning and spacing births, the latter norm appeared to take hold and become a strong factor in individual decisions to use family planning.

In conclusion, the results indicate that changes in norms measured at the collective level affect individual contraceptive use. Citing other researchers, the paper recommends using multiple channels, providing reinforcing messages, over time, producing interpersonal discussion and a slow change in values, and working at a level of social aggregation higher than the individual. The results "also seem to suggest that while women's behavior and attitudes may be shaped by the normative environment around them, in the short term, the influence of these norms could be enhanced by media messages. As such, even in bounded social networks, the behavior of nearby others may not affect a particular woman's behavior in the short term if this behavior is not perceived as normative or beneficial. The media, therefore, tend to play an important role in establishing and spreading behavioral and attitudinal norms. In addition to providing information, media messages on family planning may serve to validate women's choices, making them more comfortable to practice these behaviors. In summary, public health programs that are able to introduce and reinforce social norms by mobilizing the symbolic environment are more likely to succeed in reaching their behavioral objectives."