The power of women's and men's 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 TJ's 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 Pearson's 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: women's 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. Men's 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.

In many places with relatively low family planning use, insufficient program attention is paid to socio-normative barriers that influence need and method use. TJ catalyses women and men's social networks to spread new ideas and break communication and other social barriers that prevent women and men with unmet needs ­ people who wish to space their next birth but are not using effective family planning methods - from acting on their desires. A rigorous evaluation of the approach in rural Benin showed after only 14 months, TJ led to statistically significant improvements in intention to use contraception and met need. While showing substantial gains, women's use of contraception was not statistically significant.TJ increased women's and men's partner and network communication on fertility desires and family planning use and individual self-efficacy and confidence to act on intentions to address unmet need. The network influence on family planning use was equally significant. TJ led to new ideas within communities/social networks, including the perception that one's social networks approve of FP. Women and men who report that their network approves of FP were significantly more likely to discuss method use with their partners and seek services. TJ led to new perceptions that one's networks support FP.TJ represents an underused strategy for social and behaviour change. The social network approach encourages addressing the often-neglected social factors that stop women and men from acting on their desires to space births and use modern family planning methods.

Pathways to Modern Family Planning: A Longitudinal Study on Social Influence among Men and Women in Benin.

Despite improvements in family planning (FP) knowledge and services in West Africa, unmet need for FP continues to grow. Many programs apply a demographically and biologically driven definition of unmet need, overlooking the complex social environment in which fertility and FP decisions are made. This longitudinal, qualitative cohort study captures the changing nature of FP need, attitudes and behaviors, taking into account life context to inform understanding of the complex behavior change process. Purposively sampled, 25 women and 25 men participated in three rounds of in-depth interviews over 18 months. Analyses used a social network influence lens. Findings suggest alignment of six foundational building blocks operating at individual, couple, services, and social levels is essential to meet FP need. If one block is weak, a person may not achieve met need. Women and men commonly follow five pathways as they seek to fulfill their FP need. Some pathways achieve met need (determined users, quick converters), some do not (side effect avoiders), and some do not lead to consistent FP outcomes (male-priority decision makers, gender-egalitarian decision makers). Findings clarify the role of social determinants of FP and offer insight into program approaches informed by user typologies and return on program investments.

Transforming social norms to improve girl-child health and well-being: a realist evaluation of the Girls' Holistic Development program in rural Senegal.

BACKGROUND: Early adolescence is a critical period where social norms, attitudes, and behaviors around gender equality form. Social norms influence adolescent choices and behaviors and are reinforced by caregivers and community members, affecting girls' reproductive health and educational opportunities. Understanding how to shift these often-interconnected norms to delay child marriage, pregnancy and keep girls in school requires understanding of the structure and dynamics of family and community systems. The Senegalese and American non-governmental organization, the Grandmothers Project-Change through Culture, seeks to address these intertwined factors through innovative community change strategies that build on the specific structure and values of West African collectivist cultures. METHODS: The Girls' Holistic Development approach in rural Vélingara, Senegal posits that by increasing recognition, knowledge and empowerment of elder community women and reinforcing intergenerational communication and decision-making, community members including girls will support and advocate on behalf of girls' interests and desires. We assessed the Girls Holistic Development approach using Realist Evaluation with a mixed-method, quasi-experimental design with a comparison population. We examined differences in intergenerational communication, decision-making and descriptive and injunctive norms related to early marriage, pregnancy and schooling. RESULTS: After 18 months, intergenerational communication was more likely, grandmothers felt more valued in their communities, adolescent girls felt more supported with improved agency, and norms were shifting to support delayed marriage and pregnancy and keeping girls in school. Grandmothers in intervention villages were statistically significantly more likely to be perceived as influential decision-makers by both VYA girls and caregivers for marriage and schooling decisions compared to girls and caregivers in comparison villages. CONCLUSIONS: This realist evaluation demonstrated shift in social norms, particularly for VYA girls, in intervention villages favoring delaying girls' marriage, preventing early pregnancy and keeping girls in school along with increased support for and action by grandmothers to support girls and their well-being related to these same outcomes. These shifts represent greater community social cohesion on girl-child issues. This research helps explain the linkage between social norms and girls' reproductive health and education outcomes and demonstrates that normative shifts can lead to behavior change via collective community action mechanisms.

During adolescence in Senegal, as elsewhere, decisions on whether to keep girls in school and at what age to marry girls are made by their caregivers and influenced by family and community members. Early pregnancy occurs at these ages, either before or during marriage. These social influences, called social norms, set expectations for parents and girls.The Grandmothers Project­Change through Culture developed an intervention to shift social norms and change these three outcomes­early pregnancy, early marriage and keeping girls in school. The project, called Girls Holistic Development (GHD), builds on local relationships between girls, grandmothers, parents and community leaders and local values to facilitate discussion, reflection, collaboration and advocacy.This study used realist evaluation methods, including qualitative and quantitative interview and focus group discussions, to understand whether these shifts in norms and behaviors took place. Research took place with girls, grandmothers and male and female caregivers 18 months after GHD started. Quantitative survey included 7 intervention and 7 comparison villages.Results supported GHDs' expectations and strategy. In intervention villages, grandmothers and girls reported closer relationships; parents considered grandmothers important sources of advice. Girls, grandmothers and caregivers described social expectations as favoring girl's education, marriage at older ages and development of strategies to prevent girl's pregnancy in intervention villages.This evaluation provided strong support for GHDs' ability to shift social norms to improve girls' outcomes. By working with local relationships and values, GHD created more communication between community and family members and facilitated increased social bonds within the community.

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.

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.

Building evidence on what works (and what does not): practical guidance from the World Health Organization on post-project evaluation of adolescent sexual and reproductive health projects.

Over the past 25 years, there has been significant progress in increasing the recognition of, resources for, and action on adolescent health, and adolescent sexual and reproductive health (ASRH) in particular. As with numerous other health areas, however, many of the projects that aim to improve ASRH are implemented without well-thought-out plans for evaluation. As a result, the lessons that projects learn as they encounter and address policy and programmatic challenges are often not extracted and placed in the public arena. In such cases, post-project evaluation (PPE) offers the possibility to generate learnings about what works (and does not work), to complement prospective studies of new or follow-on projects. To fill the gap in the literature and guidance on PPE, the World Health Organization developed The project has ended, but we can still learn from it! Practical guidance for conducting post-project evaluations of adolescent sexual and reproductive health projects. This article provides an overview of the guidance by outlining key methodological and contextual challenges in conducting PPE, as well as illustrative solutions for responding to them.

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.

Scaling-up Normative Change Interventions for Adolescent and Youth Reproductive Health: An Examination of the Evidence.

Adolescent and youth reproductive health (AYRH) outcomes are influenced by factors beyond individual control. Increasingly, interventions are seeking to influence community-level normative change to support healthy AYRH behaviors. While evidence is growing of the effectiveness of AYRH interventions that include normative change components, understanding on how to achieve scale-up and wider impact of these programs remains limited. We analyzed peer-reviewed and gray literature from 2000 to 2017 describing 42 AYRH interventions with community-based normative change components that have scaled-up in low/middle-income countries. Only 13 of 42 interventions had significant scale-up documentation. We compared scale-up strategies, scale-up facilitators and barriers, and identified recommendations for future programs. All 13 interventions addressed individual, interpersonal, and community-level outcomes, such as community attitudes and behaviors related to AYRH. Scale-up strategies included expansion via new organizations, adapting original intervention designs, and institutionalization of activities into public-sector and/or nongovernmental organization structures. Four overarching factors facilitated or inhibited scale-up processes: availability of financial and human resources, transferability of intervention designs and materials, substantive community and government-sector partnerships, and monitoring capacity. Scaling-up multifaceted normative change interventions is possible but not well documented. The global AYRH community should prioritize documentation of scale-up processes and measurement to build evidence and inform future programming.

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.

A practical alternative to calculating unmet need for family planning.

The standard approach for measuring unmet need for family planning calculates actual, physiological unmet need and is useful for tracking changes at the population level. We propose to supplement it with an alternate approach that relies on individual perceptions and can improve program design and implementation. The proposed approach categorizes individuals by their perceived need for family planning: real met need (current users of a modern method), perceived met need (current users of a traditional method), real no need, perceived no need (those with a physiological need for family planning who perceive no need), and perceived unmet need (those who realize they have a need but do not use a method). We tested this approach using data from Mali (n=425) and Benin (n=1080). We found that traditional method use was significantly higher in Benin than in Mali, resulting in different perceptions of unmet need in the two countries. In Mali, perceived unmet need was much higher. In Benin, perceived unmet need was low because women believed (incorrectly) that they were protected from pregnancy. Perceived no need - women who believed that they could not become pregnant despite the fact that they were fecund and sexually active - was quite high in both countries. We posit that interventions that address perceptions of unmet need, in addition to physiological risk of pregnancy, will more likely be effective in changing behavior. The suggested approach for calculating unmet need supplements the standard calculations and is helpful for designing programs to better address women's and men's individual needs in diverse contexts.

Investing in very young adolescents' sexual and reproductive health.

Very young adolescents (VYAs) between the ages of 10 and 14 represent about half of the 1.2 billion adolescents aged 10-19 in the world today. In lower- and middle-income countries, where most unwanted pregnancies, unsafe abortions, maternal deaths and sexually transmitted infections occur, investment in positive youth development to promote sexual and reproductive health (SRH) is increasing. Most interventions, though, focus on older adolescents, overlooking VYAs. Since early adolescence marks a critical transition between childhood and older adolescence and adulthood, setting the stage for future SRH and gendered attitudes and behaviours, targeted investment in VYAs is imperative to lay foundations for healthy future relationships and positive SRH. This article advocates for such investments and identifies roles that policy-makers, donors, programme designers and researchers and evaluators can play to address the disparity.

Systems approach to monitoring and evaluation guides scale up of the Standard Days Method of family planning in Rwanda.

There is no guarantee that a successful pilot program introducing a reproductive health innovation can also be expanded successfully to the national or regional level, because the scaling-up process is complex and multilayered. This article describes how a successful pilot program to integrate the Standard Days Method (SDM) of family planning into existing Ministry of Health services was scaled up nationally in Rwanda. Much of the success of the scale-up effort was due to systematic use of monitoring and evaluation (M&E) data from several sources to make midcourse corrections. Four lessons learned illustrate this crucially important approach. First, ongoing M&E data showed that provider training protocols and client materials that worked in the pilot phase did not work at scale; therefore, we simplified these materials to support integration into the national program. Second, triangulation of ongoing monitoring data with national health facility and population-based surveys revealed serious problems in supply chain mechanisms that affected SDM (and the accompanying CycleBeads client tool) availability and use; new procedures for ordering supplies and monitoring stockouts were instituted at the facility level. Third, supervision reports and special studies revealed that providers were imposing unnecessary medical barriers to SDM use; refresher training and revised supervision protocols improved provider practices. Finally, informal environmental scans, stakeholder interviews, and key events timelines identified shifting political and health policy environments that influenced scale-up outcomes; ongoing advocacy efforts are addressing these issues. The SDM scale-up experience in Rwanda confirms the importance of monitoring and evaluating programmatic efforts continuously, using a variety of data sources, to improve program outcomes.

Improving the quality of child health services: participatory action by providers.

OBJECTIVE: To test a quality improvement approach called COPE (Client-Oriented, Provider-Efficient services), for use in strengthening health systems and supporting Integrated Management of Child Health (IMCI) efforts. DESIGN: Pre- and post-intervention observations of client/provider interactions, facility audits, staff and client surveys, and focus groups to evaluate differences between eight COPE intervention and eight matched non-intervention facilities after a 15-month intervention in 2001. SETTING: Primary care clinics in Guinea and Kenya. STUDY PARTICIPANTS: Health care providers and child caregivers. INTERVENTIONS: Over 15 months, the intervention supported four COPE exercises at each intervention site, supported supervisor training in quality management, and organized minimal training in topics selected by site staff as areas where training was needed. MAIN OUTCOME MEASURES: Differences in staff's and child caregiver's knowledge, attitudes, and practices; differences in the quality of services provided. RESULTS: On almost every quality indicator (over 65 indicators), whether reported by staff, observed by evaluators, or reported by clients, the intervention sites performed statistically significantly better than control sites. INTERVENTION: sites were cleaner and more pleasant, with more respect and information for clients, and more privacy. Staff had better personal communication skills, better diagnostic skills, and prescribing practices and gave better home care instructions to carers. Clients in intervention sites were more informed and more satisfied, and their children had better immunization coverage than those in control sites. CONCLUSION: COPE is a simple process, yet our study confirms that it can have a very dramatic effect on the quality of services. This study demonstrated how all areas of quality can be addressed by empowering health care providers to take action by using COPE. We suggest that COPE can complement Integrated Management of Childhood Illness (IMCI) training and can help to achieve better health for children.