Effect of a gender-synchronized family planning intervention on inequitable gender norms in a cluster randomized control trial among husbands of married adolescent girls in Dosso, Niger.

Gender inequity is pervasive globally and has severe consequences for health and well-being, particularly for women and girls in Niger. The Reaching Married Adolescents in Niger (RMA) intervention aimed to promote equitable gender norms in order to increase modern contraceptive use and reduce intimate partner violence among married adolescent girls and their husbands in Niger. Using data from a 4-arm factorial cluster randomized control trial of the RMA intervention (2016-2019), the current study assesses effects of the RMA intervention on gender norms among husbands. We used an adjusted hierarchical difference-in-differences linear regression model to assess these effects. The mean score for perceived gender inequitable norms at baseline was 4.1 (n=1,055; range: 0-5). Assignment to the RMA small groups intervention was associated with a 0.62 lower score (95% CI: -1.05, -0.18) relative to controls at follow-up, after adjusting for baseline differences. No significant effects were detected for other intervention arms. As a low-cost, simple, scalable, and transferrable intervention with rigorous evidence of being able to change such gender norms, this community health worker-based small group intervention could be valuable to the field of public health for reducing the negative impact of inequitable gender norms on health and wellbeing in similar settings.

Effects of the reaching married adolescents program on modern contraceptive use and intimate partner violence: results of a cluster randomized controlled trial among married adolescent girls and their husbands in Dosso, Niger.

BACKGROUND: Niger has the highest rate of adolescent fertility in the world, with early marriage, early childbearing and high gender inequity. This study assesses the impact of Reaching Married Adolescents (RMA), a gender-synchronized social behavioral intervention designed to improve modern contraceptive use and reduce intimate partner violence (IPV) among married adolescent couples in rural Niger. METHODS: We conducted a four-armed cluster-randomized trial in 48 villages across three districts in Dosso region, Niger. Married adolescent girls (ages 13-19) and their husbands were recruited within selected villages. Intervention arms included home visits by gender-matched community health workers (CHWs) (Arm 1), gender-segregated, group discussion sessions (Arm 2), and both approaches (Arm 3). We used multilevel mixed-effects Poisson regression models to assess intervention effects for our primary outcome, current modern contraceptive use, and our secondary outcome, past year IPV. RESULTS: Baseline and 24-month follow-up data were collected April-June 2016 and April-June 2018. At baseline, 1072 adolescent wives were interviewed (88% participation), with 90% retention at follow-up; 1080 husbands were interviewed (88% participation), with 72% retention at follow-up. Adolescent wives had higher likelihood of modern contraceptive use at follow-up relative to controls in Arm 1 (aIRR 3.65, 95% CI 1.41-8.78) and Arm 3 (aIRR 2.99, 95% CI 1.68-5.32); no Arm 2 effects were observed. Relative to those in the control arm, Arm 2 and Arm 3 participants were significantly less likely to report past year IPV (aIRR 0.40, 95% CI 0.18-0.88 for Arm 2; aIRR 0.46, 95% CI 0.21-1.01 for Arm 3). No Arm 1 effects were observed. CONCLUSIONS: The RMA approach blending home visits by CHWs and gender-segregated group discussion sessions is the optimal format for increasing modern contraceptive use and decreasing IPV among married adolescents in Niger. Trial registration This trial is retrospectively registered with ClinicalTrials.gov, Identifier NCT03226730.

Although Niger has both the highest levels of fertility and of child marriage in the world, as well as substantial gender inequity, there have been no high-quality evaluations of public health programs aiming to increase contraceptive use or decrease intimate partner violence. In this study, we conducted a high quality, randomized controlled trial to evaluate whether the Reaching Married Adolescents public health program could increase modern contraceptive use and decrease intimate partner violence among married adolescent girls (13­19 years old) and their husbands in the Dosso region of Niger. The results of this evaluation provide evidence of the value of individual home visits for wives and their husbands in increasing modern contraceptive use, the value of small group discussions in reducing intimate partner violence, and the combined value of receiving both approaches at the same time for both increasing modern contraceptive use and decreasing intimate partner violence. The current study advances the state of evidence regarding contraceptive use and IPV among married adolescents and their husbands in Niger, highlighting the importance of engaging male partners in such public health programs, as well as of using multiple modes of delivery of programs. The success of this intervention in the high-risk context of Niger suggests that other countries in the region may benefit from testing this approach to improve the health and well-being of young wives.

Measuring social norms of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy: an item response modelling of the IPV-ASRA scale.

BACKGROUND: The field of violence prevention research is unequivocal that interventions must target contextual factors, like social norms, to reduce gender-based violence. Limited research, however, on the social norms contributing to intimate partner violence or reproductive coercion exists. One of the driving factors is lack of measurement tools to accurately assess social norms. METHODS: Using an item response modelling approach, this study psychometrically assesses the reliability and validity of a social norms measure of the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy with data from a population-based sample of married adolescent girls (ages 13-18) and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019. RESULTS: A two-dimensional Partial Credit Model for polytomous items was fit, showing evidence of reliability and validity. Higher scores on the "challenging husband authority" dimension were statistically associated with husband perpetration of intimate partner violence. CONCLUSIONS: This brief scale is a short (5 items), practical measure with strong reliability and validity evidence. This scale can help identify populations with high-need for social norms-focused IPV prevention and to help measure the impact of such efforts.

Long-term prevention of gender-based violence, like intimate partner violence and reproductive coercion, requires efforts to change the social environment that facilitates violence against women, yet limited research is available on how to change social environments. One reason is that there are few tools to accurately measure social environments, including social norms, which are the unspoken rules about what behavior is acceptable and what behavior is not. The present research assessed a new social norms measurement tool on the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy using data from a population-based sample of married adolescents and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019. We found that this scale had strong reliability and validity, and that the group of questions about challenging husband authority were related to husband perpetration of intimate partner violence against his wife. This brief scale is a short (5 questions), practical measure with strong reliability and validity evidence that can help identify populations with high-need for social norms-focused prevention and to help measure the impact of such efforts. This evidence strengthens the current set of measurement tools on social norms available to researchers and practitioners.

Qualitative assessment of providers' experiences with a segmentation counseling tool for family planning in Niger.

INTRODUCTION: This study examines experiences with a family planning segmentation counseling tool that is used during the provision of family planning services. Based on answers to a series of questions, women are segmented into one of five categories of family planning users and counseled based on their identified segment. This study aimed to qualitatively assess provider perspectives on implementation of the tool. METHODS: Semi-structured in-depth interviews took place in the Dosso region of Niger among 16 family planning providers who had been trained in segmentation and were currently using the segmentation tool. The facilities chosen for interviews were part of a larger mixed methods study assessing the impact of using the segmentation approach. Interview questions focused on training, supervision, how segmentation occurs at the health facility, how segmentation changes provider-client interactions, and any difficulties faced with implementation. Interviews were translated and transcribed into French and data were coded and thematically analyzed. RESULTS: All providers in the study reported positive outcomes associated with segmentation. While providers acknowledged that the segmentation approach added time to the clinic visit, they did see the benefit of this extra time in providing more meaningful interactions between clients and providers, leaving clients with a deeper understanding of family planning and of the different methods available. The implementation of the tool did not change other aspects of service delivery, except that a segmentation sheet was required to be filled in and kept in each patient's file. Difficulties reported included translating the segmentation tool questions into local languages, training enough health care providers and avoiding stock outs of the segmentation sheets. CONCLUSION: The segmentation process is of benefit to family planning clients in Niger and the scale-up of the strategy could bring higher quality services to women. If this approach is brought to scale the implementation challenges uncovered need to be addressed, especially adequate training. Further research is needed to determine if segmentation leads to changes in family planning use outcomes.

This is a study about what nurses and other health care staff in Niger think about a segmentation counseling tool that is used during family planning services. Segmentation means that during counseling each woman is asked a series of questions and, depending on her answers, she is segmented into one of five 'client type' categories and counseled based on that 'client type' or segment. Face-to-face interviews with health care staff took place in the Dosso region of Niger among 16 staff who were using the tool with their patients. The facilities chosen for interviews were part of a larger study assessing how well segmentation was working. Staff were asked about training, supervision, how segmentation occurs at the facility, how segmentation changes how they interact with patients, and any difficulties faced with implementation. All the interviews were then analyzed. All providers in the study had positive things to say about segmentation, including the benefit of spending extra time with each client. This extra time results in more meaningful interactions between clients and providers, leaving clients with a deeper understanding of family planning and of the different methods available. Difficulties reported included translating the segmentation tool questions into local languages, training enough health care providers and avoiding stock outs of the segmentation sheets. The segmentation process is of benefit to family planning clients in Niger and can contribute to higher quality family planning services for women. The challenges that were found need to be addressed, especially adequate training.

Characterizing Nigerien men's social networks and their influence on family planning-related attitudes and behaviors.

This work uses data from a family planning (FP) program evaluation and social network study among men married to adolescent girls (ages 13-19) in Dosso, Niger to explore who influences their FP and through which social mechanisms. We asked men (N = 237) to nominate and describe their perceptions of key social contacts (alters). We sought to interview the most influential alter (N = 157 interviewed alters), asking them about their own FP-related attitudes and behaviors. Men primarily nominated male friends as alters. We found that men participating in the program were more likely to perceive alters to hold attitudes supportive of gender equitable FP decisions (AOR: 4.36, 95% CI: 1.83, 10.35) and FP use (AOR: 4.22, 95% CI: 1.72, 10.35). Alters' attitudes supporting FP were related to those of the men who nominated them (1-unit increase in alters' attitudes score related to a 0.48 unit increase in men's attitudes; 95% CI: 0.32, 0.63). Men who perceived their alters would support gender equitable FP decisions were more likely to have ever used FP methods (AOR: 10.43, 95% CI: 2.50, 43.58) as were those who perceived their alters would support their own FP use (AOR: 12.76, 95% CI: 2.55, 63.81). Men who perceived their alters would support gender equitable FP decisions were more likely to report spousal communication (AOR: 8.71, 95% CI: 3.06, 24.83), as were those who perceived that alters would support their own FP use (AOR: 9.06, 95% CI: 3.01, 27.26). Alters' and men's behaviors (contraceptive use and spousal communication) were not associated. These results demonstrate that perceived approval from network members may be critical to FP-related attitudes and behaviors. However, since FP promotion programs may affect perception and/or composition of social networks, future research should include larger sample sizes and longitudinal data to understand the effect of changing norms on social relationships.

"I Got What I Came for": A Qualitative Exploration into Family Planning Client Satisfaction in Dosso Region, Niger.

Background: Client satisfaction is recognized as an important construct for evaluating health service provision, yet the field of family planning (FP) lacks a standard approach to its measurement. Further, little is known about satisfaction with FP services in Niger, the site of this study. This study aims to understand what features of FP visits were satisfactory or dissatisfactory from a woman's perspective and reflect on the conceptualization and measurement of satisfaction with FP services. Methods: Between February and March 2020, 2720 FP clients (ages 15-49) were interviewed across 45 public health centers in Dosso region, Niger using a structured survey tool. The focus of this paper is on a random sub-sample of 100 clients who were additionally asked four open-ended questions regarding what they liked and disliked about their FP visit. Responses were audio-recorded, translated into French, transcribed, translated into English, coded, and analyzed thematically. Results: FP clients described nine key visit attributes related to their satisfaction with the visit: treatment by the provider, content of the counseling, wait time, FP commodity availability, privacy, cleanliness/infrastructure, visit processes and procedures, cost, and opening hours. The reason for FP visit (start, continue, or change method) was an important driver of the dimensions which contributed to satisfaction. Pre-formed expectations about the visit played a critical role in shaping satisfaction, particularly if the client's pre-visit expectations (or negative expectations) were met or not and if she obtained what she came for. Conclusion: This study makes a significant contribution by identifying visit attributes that are important to FP clients in Dosso region, Niger, and highlights that satisfaction with FP services is shaped by more than just what occurs on the day of service. We propose a conceptual framework to understand satisfaction with FP services that can be used for future FP programming in Niger.

Assessment of segmentation and targeted counseling on family planning quality of care and client satisfaction: a facility-based survey of clients in Niger.

BACKGROUND: Niger demonstrates high fertility and low contraceptive use that are typical in much of the West and Central African region. The government of Niger has committed to increasing modern contraceptive use as part of its health strategy. Designing and testing strategies to improve quality of care and satisfaction of family planning clients is important for addressing low contraceptive use in contexts like Niger. METHODS: This study uses recently collected client exit interview data from 2720 clients surveyed in the Dosso region of Niger to examine whether implementation of segmentation-based counseling leads to improved quality of services and client satisfaction. We compare three scenarios: a) facilities where segmentation counseling was implemented since 2017; b) facilities where segmentation counseling began in late 2019; and c) facilities without segmentation counseling. Bivariate and multivariate analyses are undertaken to determine if there are differences in quality of services and client satisfaction between the facility groups and between clients that were segmented and those who were not segmented in the first two scenarios. RESULTS: Results demonstrate that clients in facilities with segmentation generally received better quality services than clients in facilities without segmentation. Clients in facilities implementing segmentation longer reported higher quality services than the recent segmentation facilities. Clients who were segmented compared to those who were not segmented also reported better quality services. New clients reported higher quality services than returning clients and among new clients, those who were segmented also reported higher quality services. No differences were found in client satisfaction between facility scenarios or between segmented and non-segmented clients. CONCLUSIONS: These findings demonstrate that segmentation or another targeted counseling strategy could be useful to the government of Niger to improve the quality of services offered. As part of the scale up process, the government needs to consider strategies that ensure that all new clients are segmented and design an approach that is sustainable and does not risk failing should there be stock-out of segmentation sheets or loss of counseling cards. This type of targeted counseling could improve the quality of services offered and ideally lead to increased contraceptive use in Niger.

Social network and social normative characteristics of married female adolescents in Dosso, Niger: Associations with modern contraceptive use.

In this study we analysed the social networks of a sample of married adolescent girls (ages 13-19 years) residing in Dosso, Niger (N = 322); data were collected for evaluation of a family planning (FP) intervention. Participants were asked to name individuals important in their lives (alters) using three name generating questions as part of a larger survey on reproductive health, social norms, and FP. One alter per girl was then recruited to be separately interviewed (N = 250). This provided us with two separate datasets: one with data from each respondent regarding each person that they nominated, and one with the interviewed alters matched with the respondent who nominated them. We found that married adolescent girls who were nulliparous were more likely to have no alters and that those in the intervention had the most alters. Alters of treatment participants were more likely to have used FP. Respondents were more likely to have used FP when their sisters or in-laws had, but there was no correlation with use by friends. Our results provide evidence of diffusion of the FP program to those close to intervention participants. Future research should study these dynamics, crucial to understanding intervention costing, impact, and normative change.

Protocol for cluster randomized evaluation of reaching married adolescents - a gender-synchronized intervention to increase modern contraceptive use among married adolescent girls and young women and their husbands in Niger.

BACKGROUND: Early marriage and early childbearing are highly prevalent in Niger with 75% of girls married before age 18 years and 42% of girls giving birth between ages 15 and 18 years. In 2012, only 7% of all 15-19-year-old married adolescents (male and female) reported use of a modern contraceptive method with barriers including misinformation, and social norms unsupportive of contraception. To meet the needs of married adolescents and their husbands in Niger, the Reaching Married Adolescents (RMA) program was developed with the goal of improving modern contraceptive method uptake in the Dosso region of Niger. METHODS: Using a four-arm cluster randomized control design, the RMA study seeks to assess whether household visits only (Arm 1), small group discussions only (Arm 2), or a combination of both (Arm 3), as compared to controls (no intervention - Arm 4), improve modern contraceptive method use among married adolescent girls and young women (AGYW), age 13-19 years-old, in three districts of the Dosso region. Intervention conditions were randomly assigned across the three districts, Dosso, Doutchi, and Loga. Within each district, eligible villages were assigned to either that intervention condition or to the control condition (12 intervention and 4 control per district). Across the three intervention conditions, community dialogues regarding modern contraceptive use were also implemented. Data for the study was collected at baseline (April - June 2016), at 24 months post-intervention (April - June 2018), and a final round of data collection will occur at 40 months post-intervention (October - December 2019). DISCUSSION: The RMA intervention is a gender-synchronized and community-based program implemented among married adolescent girls and their husbands in the context of rural Niger. The intervention is designed to provide education about modern contraception and to promote gender equity in order to increase uptake of modern contraceptive methods. Results from this cluster randomized control study will contribute to the knowledge base regarding the utility of male engagement as a strategy within community-level approaches to promote modern contraceptive method use in the high need context of West Africa. TRIAL REGISTRATION: Registered October 2017 - ClinicalTrials.gov NCT03226730.