Addressing Norms, Promoting Reproductive Health

ADDRESSING Norms,
PROMOTING Health

Top-level findings

Women and men were more likely to use FP methods and seek RH services and to communicate with peers about FP and RH.
Women and men were more likely to support shared decision-making about FP and RH.
Community normative environments were more likely to support FP use and spacing of pregnancies.

ADDRESSING Norms,
PROMOTING Health

Interventions that improved family planning, reproductive health, and healthy timing and spacing of pregnancies

HUSBANDS’ SCHOOLS

Husbands’ Schools is a male engagement intervention that works with married men who lean toward supporting RH care (also called “model husbands”) in Niger who sensitize other men in their networks and the broader community on the importance of RH, reducing generalized male mistrust in services and increasing men’s support for their wives’ use of RH services.

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TÉKPONON JIKUAGOU

Tékponon Jikuagou/Terikunda Jékulu (TJ) is a social network-based approach that works with socially-influential groups and leaders to increase the acceptability of discussing and using FP by engaging women and men in reflective discussions on fertility, spacing of pregnancies, and FP use. The TJ intervention was first implemented and evaluated in Benin (as Tékponon Jikuagou) and later scaled in Mali (as Terikunda Jékulu).

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REAL FATHERS

Responsible, Engaged, and Loving (REAL) Fathers is a mentorship program that works with young fathers in Northern Uganda and Karamoja to shift norms, teach skills, and promote behaviors that enable couples to discuss and make decisions about FP and to prevent intimate partner violence (IPV) and violent discipline of children.

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GROWING UP GREAT!

Growing Up GREAT! (GUG!) works with very young adolescents along with their parents and caregivers, teachers, and health providers in Kinshasa, Democratic Republic of the Congo, to create peer spaces to reflect on the rapid physical and social transitions of adolescent girls and boys during puberty and to foster positive attitudes about puberty and RH, reduce bullying, increase gender-equitable behaviors, and support improved adolescent RH and well-being.

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MASCULINITÉ, FAMILLE ET FOI

Masculinité, Famille et Foi (MFF) works with faith leaders and gender champions in congregations in Kinshasa, Democratic Republic of the Congo, through sermons and couples’ dialogues, to shift norms and increase awareness of male and female attitudes and roles relating to fertility and family well-being, leading to discussions and decisions on the use of FP methods and reductions in IPV among newly married couples and first-time parents.

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ADDRESSING Norms,
PROMOTING Health

Which norms mattered?

Working with communities, Passages conducted explorations of social norms to identify and prioritize norms for each of the interventions using the Social Norms Exploration Tool. Across Passages interventions, the following norms emerged as key to FP and RH:

Talking about spacing of pregnancies and using FP methods in public settings is not acceptable.

Men are household decisionmakers, including for FP and RH decisions.

In some communities, certain religious beliefs are seen to prohibit the use of modern FP methods.

Having many children is valued in communities; couples should have a first child before using FP methods.

Discussion of or information-seeking for puberty, sexuality, and other RH topics and services is taboo.

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For more norms—and behaviors and attitudes—related to FP and RH, please see the Social Norms Learning Collaborative’s Social Norms Atlas.

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Common strategies used to shift norms to improve family planning and reproductive health

The Passages interventions’ program strategies are intentionally designed to lead to norms-shifting in communities as part of behavior change through working with men, women, girls and boys. Each of the interventions sought to shift norms as part of a multi-level, multi-component social and behavior change approach that also addressed other factors. Across interventions, the following strategies were integral to shifting social norms:

Engaging in gender-synchronized interpersonal dialogue and reflection on beliefs, values, and behaviors.
Fostering positive role models within communities, including faith communities.
Working with communities to engage in social mobilization to promote shifts in beliefs and norms and new behaviors.
Hosting collective celebrations, pledges, and testimonials.
Creating linkages to RH care and services.
Supporting individual and community training and capacity building.

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For more information, the Passages Theory of Change lays out how norms-shifting approaches are part of our pathway to change.

View Theory of Change

ADDRESSING Norms,
PROMOTING Health

Results

Evaluation results from Husbands’ Schools, Tékponon Jikuagou/Terikunda Jékulu, REAL Fathers, Growing Up GREAT!, and Masculinité, Famille et Foi suggest that these programs led to a more supportive normative environment for the use of modern FP methods and RH care and increased use of FP methods.

INDIVIDUAL

MASCULINITE, FAMILLE ET FOI

Within intervention groups, participants reported improvements in norms and attitudes related to the use of modern FP methods at endline.

There was a significant increase (12%) in first-time parents in intervention groups agreeing that it is appropriate for first-time parents to use modern FP methods.
The portion of intervention respondents who felt their partner would approve of using modern FP methods also increased significantly, by 10%.

MASCULINITE, FAMILLE ET FOI

Intervention participants were more confident in their own and their partner’s ability to use modern contraception at endline.

The share of first-time parents reporting confidence in their ability to use modern FP methods if desired rose by 6%, a significant increase.
The share of first-time parents in intervention groups reporting confidence in their ability to suggest the use of modern FP methods to their partner also increased significantly, by 20%.

GROWING UP GREAT!

GUG! participants demonstrated improved knowledge of fertility and pregnancy prevention strategies, compared to the control group.

In-school very young adolescent girls and boys had significantly higher scores on a pregnancy knowledge index than those in the control group.
In-school girls participating in GUG! were almost one-and-a-half times more likely to know where to go to get contraception, and out-of-school girls in GUG! were three times more likely.
Two years post intervention, embarrassment about getting contraception among GUG! participants had fallen significantly among girls in the out-of-school intervention groups compared to controls, for whom embarrassment increased.

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RELATIONAL

HUSBANDS’ SCHOOLS

In a 2019 Passages’ qualitative gender study, Husbands’ Schools members and their wives who previously reported no discussion of RH-related topics said they discussed RH issues as a couple after intervention.

Participating couples reported more gender-equitable communication about FP and some increase in joint decision-making.
Women reported newfound agency within their relationship to act on their intentions to access FP.

REAL FATHERS

In both Northern Uganda and Karamoja, REAL Fathers participants reported better communication and cooperation in their marriage.

This led to more meaningful conversations among couples and an increase in joint decision-making that respondents associated with a more harmonious home and relationship.

GROWING UP GREAT!

Subgroups of GUG! participants were more likely to report communicating with a trusted adult or peer about RH topics.

Compared to a control group, out-of-school very young adolescent girls were over four times more likely to report communicating about sexual relationships with a trusted adult or peer.
These girls were also over two times more likely to report communicating about contraception with a trusted adult or peer. This effect was very strong for those under 12 years old, who were over 13 times as likely to communicate about contraception compared to peers in the control group.

GROWING UP GREAT!

Qualitative interviews with GUG! parents and caregivers demonstrated increased communication between them and their children about puberty and other sensitive topics.

GROWING UP GREAT!

Teachers and health care practitioners who participated in GUG! interventions saw a more supportive normative environment for very young adolescents (VYAs) to ask questions about puberty, sexual relationships, and contraception.

There were more positive experiences with VYAs’ knowledge and openness about puberty and related topics.
Relationships with students and patients improved, as did perceived agency and independence among VYAs to ask health providers about puberty and body changes.

MASCULINITE, FAMILLE ET FOI

Participants in intervention groups reported more communication with their partners about modern FP than in the previous year as well as increased partner communication compared to those in control groups.

The share of first-time parents reporting discussing modern FP use with their partners increased by 14%.
Among first-time parents, there was also a significant increase (14%) in the share reporting specifically discussing obtaining a modern FP method.

TÉKPONON JIKUAGOU

In Benin, Tékponon Jikuagou (TJ) participants reported increased communication in public fora, with peers, and within couples about FP and RH.

About 47% of women in the intervention group spoke to network members about FP, while 9% of women in control sites reported social discussions on family planning.

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COMMUNITY

HUSBANDS’ SCHOOLS

In a 2019 Passages’ qualitative gender study, intervention communities reported increased social acceptance and support for FP and RH.

There was increased acceptance of the importance of women accessing RH services and more trust in RH providers compared to before the intervention.
There was increased acceptance of men playing important advocacy and support roles, and women information-sharing roles, around FP and RH.
Communities reported increased sharing of information about RH care and services and increased knowledge about their value.

TÉKPONON JIKUAGOU

In Mali, the TJ approach was successfully adapted and scaled in a new country and socio-normative context.

Evaluation of initial implementation in Mali showed the TJ approach had similar normative effects as in Benin, decreasing social and gender barriers to the use of FP methods.

MASCULINITE, FAMILLE ET FOI

At endline, intervention respondents were significantly more likely than control respondents to feel confident that their communities would approve of the use of modern FP methods.

Ninety percent of intervention respondents thought that their reference groups would approve of their use of modern FP, a significantly higher share than comparison respondents (81%).
Seventy-two percent of intervention respondents thought that their faith leaders would approve of their use of modern FP, significantly more than the 67% of comparison respondents.

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BEHAVIORAL

HUSBANDS’ SCHOOLS

In a 2014 impact evaluation of Husbands’ Schools in Niger (prior to the start of the Passages Project), significant increases in women's use of antenatal care, delivery, and FP were recorded in services data where the intervention operated.

TÉKPONON JIKUAGOU

Rigorous studies in Benin (prior to the start of the Passages Project) found a statistically significant increase in the use of modern FP methods and reported met need for FP at the study endline.

TÉKPONON JIKUAGOU

In Mali, the TJ approach was successfully adapted and scaled in a new country and socio-normative context.

REAL FATHERS

Intervention fathers in Northern Uganda reported a significant increase in the use of FP methods.

MASCULINITE, FAMILLE ET FOI

Among newly married couples in both intervention and comparison groups, there was an increase in FP use from baseline to endline. In addition, first-time parents in intervention groups reported a significant increase in FP use compared to control groups at endline.

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EXPLORE THE COMPLEMENTARY WEB FEATURE

This infographic was written by Jamie Greenberg (IRH) with technical contributions from Anjalee Kohli, Courtney McLarnon, Susan Igras, and Bryan Shaw (IRH); Rebecka Lundgren and Kathryn Barker (Center on Gender Equity and Health at the University of California San Diego); and Jennifer Gayles (Save the Children).

Additional valuable content review was provided by Christine Power of Population Reference Bureau (PRB). This product was edited by Raquel Wojnar, and designed and produced by Anneka Van Scoyoc, both of PRB.

Institute for Reproductive Health
Georgetown University

irhinfo@georgetown.edu
202-687-1392