EXECUTIVE SUMMARY

Social and behavioral change are important factors to consider and incorporate into family planning, even before a woman enters a provider’s office.

  • Social norms and opinions of the surrounding community can affect a woman’s attitude toward family planning.
  • Some social and behavioral change tactics include shared decision-making, ideational models, multifaceted community campaigns, and value clarification exercises.
  • Social and behavioral changes also need to be implemented by clinicians and providers to ensure they hold their own biases back when counseling.

Pregnancy rates in U.S. adolescent and young adult women declined by 71% from 1990. However, these pregnancy rates are two to seven times higher than rates in other high-income countries, and the unintended pregnancy rate among women ages 15-17 years is 57 in 1,000.1-4

Social and behavioral change techniques might help women improve adherence to contraceptives, but this approach has not received as much attention as warranted. As the authors of one recent paper on family planning programs noted, the global family planning community’s 2012 goal of enabling 120 million more women and girls to use contraceptives by 2020 fell short by 60 million. More work needs to be done and it needs to be done better, the authors concluded.5

“We’re essentially trying to shine more light on social and behavioral change and the behavioral factors in family planning,” says Joanna Skinner, MA, MHS, lead author of the paper and population and reproductive health technical lead with the Breakthrough ACTION Project at the Johns Hopkins Center for Communication Programs. “We have three key messages that we’re trying to get across to those in the family planning phase. These are based on how there has been limited investment and attention to social and behavioral change in family planning. We’re looking to change that.”

The first message is that behavioral factors in family planning are a key barrier to family planning uptake, and need more attention. Secondly, social and behavioral change approaches need to be evidence-based. They also need proper investment.

“There have been more recent studies that explain how incorporating behavioral and social change is cost effective,” Skinner explains. “Our third message is that, essentially, we are not suggesting social and behavioral change should be done at the expense of service delivery, but that it complements that investment.”

This work does not begin and end at a family planning provider’s office. “We’re not only talking about what happens at a facility with a provider,” says Lynn Van Lith, MPA, technical director of the Breakthrough ACTION Project.

While some approaches are highly effective within a facility-based setting, there also is a great deal that happens before a woman even enters a provider’s office.

“A lot of the social and behavioral change programming we’re talking about happens outside of the facility,” Van Lith explains. “They can shape norms and other behaviors before someone gets to the facility.”

For instance, social and behavioral change techniques can have an outsized influence on social norms, including those involving family planning use and the ideal family size.

“That’s where we’ve seen that, although some women can make individual choices on using family planning, it is very hard to do if they don’t have support from the people in their families or from their partners and the broader community,” Skinner explains. “It’s more about the family members and the community members. Their opinions about family planning and family size, their attitudes toward gender norms and what it means to be a man or woman and how that relates to fertility — all of these things can influence a woman’s choice in whether to use family planning.”

Social norms influence whether a woman sees a particular provider for contraceptives or family planning services. The provider often is part of the woman’s community and shares similar opinions with the broader community.

“There are social change and behavioral techniques that can be integrated into that counseling,” Skinner says.

Social and cultural norms around menstrual changes might occur as a side effect of contraception. In some situations, social norms may make a particular contraceptive method unacceptable to a woman.

“Some hormonal contraception may change menstruation or make periods irregular, heavier, or absent completely,” Skinner explains. “There are misconceptions about what it means when a woman doesn’t have a period.”

Reproductive health providers can initiate these social and behavioral change techniques in their communities and clinics:

Shared decision-making. One technique for eliciting behavioral change is to engage in shared decision-making with patients, says Andrea Elena Bonny, MD, section chief in adolescent medicine and principal investigator, Center for Clinical and Translational Research at Nationwide Children’s Hospital in Columbus, OH. She also is an associate professor of pediatrics at The Ohio State University.

“The concept of shared decision-making has reached the forefront, where people are cognizant that the old idea is too patriarchal,” Bonny explains. “There is more movement in the process of shared decision-making and that the contraceptive decision should come from the patient.”

Reproductive health providers should be stewards of the decision-making process, she adds.

Shared decision-making and better counseling and communication skills are particularly important with adolescent patients, since they are at a different stage of neurocognitive development than adults, Bonny says. (See story on better contraceptive counseling in this issue.) The way a family planning provider communicates and interacts with a 14-year-old patient might be different from how the provider interacts with a 16-year-old, 18-year-old, and 30-year-old.

“We probably need to do contraceptive counseling differently as the patient matures and grows,” Bonny says.

Ideational model. The ideational model of behavior change uses components from different behavioral change theories, addressing how different factors influence individual behavior, says Paul L. Hutchinson, PhD, associate professor in the department of international health and sustainable development in the School of Public Health and Tropical Medicine at Tulane University in New Orleans.

Social norms, attitude, knowledge, and social influences all play a role in how a person behaves regarding contraceptive use, he adds. One of the most important attitudes is approving of family planning.

“It is absolutely essential,” Hutchinson says. “If you don’t approve of family planning, you are much less likely to use it.”

A recent study revealed that husbands are a critically important influence on women’s family planning attitudes and actions. Women who discussed family planning with their husbands were three times more likely to use contraception or intend to start using contraceptives within the next six months.6

Multifaceted community campaigns. The Nigeria Urban Reproductive Health Initiative works to create social and behavioral change through mass media messages, community-level outreach, and practices within healthcare facilities.7

“Those social and behavioral [efforts] working in concert together tend to have the greatest impact,” Van Lith says. “Making sure the woman is at the center of any campaign is the fundamental starting point.”

The next step is to determine which channels or combination of channels will reach those audiences to address their needs and concerns, Van Lith says.

Hutchinson was part of a scientific team that evaluated a Nigerian project that encouraged dialogue within couples to help them agree on how many children they would have.

“We wanted to look at that specific outcome of whether or not the couple had discussed family planning,” Hutchinson says. “We would like to think that having that discussion positively relates to the couple deciding to use family planning.”

Whether there is a causal relationship between the couple having the discussion and improved family planning has not yet been determined. “There is a good bit of evidence of mass media shifting fertility outcomes and contraceptive use,” Hutchinson notes.

But research has not shown whether women noticed the media programs because they already were interested in family planning or if they developed an interest because of the programming.

“If you bought a car, you might be more likely to notice car commercials,” Hutchinson says. “We can’t necessarily say that those who are exposed to mass media may be just as amenable to family planning as those who are already using it or thinking about using it.”

Value clarification exercises. Clinicians and providers also could benefit from social and behavioral change techniques, particularly in the area of bias about certain patient populations.

“It’s relevant both for providers in this country and in the countries where we work that providers may hold their own bias about whether a young person should access contraception,” Skinner says.

One way to address this is to hold value clarification exercises, which help clinicians examine their own values and how those affect contraceptive counseling.

“In the countries where we work, there may be unmarried women, and there are biases around that or around the methods they use,” Skinner explains. “There is a value exercise that can be done to make sure providers are offering the highest-quality counseling that is not based on their own values.”

For example, the Nigeria project included work with providers and distant learning modules in which providers would see a video clip of a biased provider in counseling. This illustrated the effect of bias, she says.

The project asked providers how they felt viewing the video and how it might affect their own counseling.

“Across the board, we know that behavioral change is [challenging], and the social and behavioral drivers that affect family planning are complex,” Van Lith says. “But there has to be a growing recognition that social and behavioral factors really impact every aspect of family planning, and it is worth investing in.”

REFERENCES

  1. Hoopes AJ, Timko CA, Akers AY. What’s known and what’s next: Contraceptive counseling and support for adolescents and young adult women. J Ped Adol Gyn 2021;34:484-490.
  2. Livingston G, Thomas D. Why is the teen birth rate falling? Pew Research Center Aug. 2, 2019.
  3. Sedgh G, Finer LB, Bankole A, et al. Adolescent pregnancy, birth, and abortion rates across countries: Levels and recent trends. J Adolesc Health 2015;56:223-230.
  4. Finer LB, Zolna MR. Shifts in intended and unintended pregnancies in the United States, 2001-2008. Am J Public Health 2014;104 (Suppl 1):S43-48.
  5. Skinner J, Hempstone H, Raney L, et al. Elevating social and behavioral change as an essential component of family planning programs. Stud Fam Plann 2021 Jul 15. doi: 10.1111/sifp.12169. [Online ahead of print].
  6. Hutchinson PL, Anaba U, Abegunde D, et al. Understanding family planning outcomes in northwestern Nigeria: Analysis and modeling of social and behavior change factors. BMC Public Health 2021;21:1168.
  7. Nigerian Urban Reproductive Health Initiative. Johns Hopkins Center for Communication Programs.