Association of collective attitudes and contraceptive practice in nine sub-Saharan African countries

Abstract

Background There is ample evidence that gender norms affect contraceptive practice; however, data are mostly qualitative with limited geographical scope. We investigated that association quantitatively using collective community-level attitudes towards premarital sex and wife-beating as proxies for gender norms. Methods Data came from nationally representative Demographic and Health Surveys (2005-2009) for women of reproductive age (15-49 years) in nine sub-Saharan African countries. Using multilevel logistic models, controlling for individual covariates and community-level indicators of women' s empowerment, we assessed the community-level association of gender norms regarding premarital sex and wife-beating with individual contraception uptake and demand satisfied among fecund sexually active women. Norms were approximated as 'collective attitudinal norms' from female/male residents (aged 15-49 years) from the same community. We assessed the magnitude and significance of the community-level effects and attributed variance across communities. The same analysis was replicated for each country. Results In a fully-adjusted model with a pooled sample of 24 404 adolescent women, the odds of contraception use increased with a 1 standard deviation (SD) increase in the variation of collective permissive attitudes towards premarital sex of female (odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.02-1.15) and male (OR = 1.11, 95% CI = 1.05-1.17) peers (15-24 years), while odds of contraceptive use declined by 10% (OR = 0.90, 95% CI = 0.85-0.96) with collective accepting attitudes towards wife-beating of women aged 15-49 years. Similar results were found in separate models that controlled for adults' permissive attitudes towards premarital sex. The community-level attributed variance (V 2 = 1.62, 95% CI = 1.45-1.80) represented 33% (intra-class correlation (ICC) = 33.0, 95% CI = 30.0-35.4) of the total variation of contraception use, and attitudes towards premarital sex and violence jointly explained nearly 26% of that V 2 variance. The community-level shared of attributed variation of contraceptive use varied significantly across countries, from 3.5% in Swaziland (ICC = 3.5, 95% CI = 0.8-13.7) to 60.2% in Nigeria (OR = 60.2, 95% CI = 56.0-64.2). Conclusions Overall, significant positive associations of collective permissive attitudes of both adolescent and adult women towards premarital sex were found for use of, and demand for, contraception, whereas collective accepting attitudes towards wife-beating were negatively associated with the use and demand for contraception. Ours is the first study to define quantitatively the influence of proxies for gender norms at the community level on women' s family planning decisions. These findings offer new insights for understanding the role of sex-related attitudes and norms as important factors in shaping contraceptive practices and improving the effectiveness of family planning policies by targeting individuals as well as their groups of influence. Electronic supplementar...

A vignette-based approach to understanding social norms around family planning in three Nigerian cities

“…The pervasive belief that adolescents and young women should not have sex outside of marriage is not a new finding in Nigeria or in other settings (Alli et al, 2013;Bello et al, 2017;Mejia-Guevara et al, 2020;Paul et al, 2016) and must be considered during the design phase of youth FP programmes and policies. Study participants had noted that they were not aware of any FP programme in their areas that encouraged young people specifically to use contraception, and that church programmes for young people focused on abstinence.…”

“…Distinguishing between descriptive normsbeliefs about what other people doand injunctive normsbeliefs about what other people think one should do (Cialdini et al, 1991;Cialdini & Trost, 1998) is important for deconstructing how norms affect health behaviours and conceptualizing how to intervene on those norms to improve health outcomes (Ajzen, 2015). While there is ample evidence that gender norms influence contraceptive use (Okigbo et al, 2018;Mejia-Guevara et al, 2020;Adams et al, 2013), these norms are generally operationalised as attitudes towards gender equity or gender roles (Cislaghi & Heise, 2019a). Similarly, collective (social) norms also influence fertility and other FP-related behaviours (Kaggwa et al, 2008;Sedlander & Rimal, 2019;Storey & Kaggwa, 2009), but these are measured as the occurrence, or objective prevalence, of FP-related behaviours or attitudes.…”

Adaptation of a gender-transformative sexual and reproductive health intervention for adolescent boys in South Africa and Lesotho using intervention mapping

“…This suggests that while the original intervention theory of change was relevant for this new population and context, there was a need to consider more closely how the intervention might help young people challenge stigma and obtain equality in sexual decision-making, even in transactional relationships. Central to this is consideration of theories of power and stigma [48][49][50] and the literature on how gender attitudes are shaped in early adolescence [22,51] when adapting intervention activities for these new contexts.…”

Perceptions of contraceptives as factors in birth outcomes and menstruation patterns in a rural community in Siaya county, Western Kenya

“…5 Women's education in the community was found to be instrumental in addressing some of the unfounded fears and misconceptions related to contraceptives. 15 The developers of the hormonal injections and implants should also consider further research on how to address some of the widespread concerns such as effects on menstruation. This could significantly reduce the unmet need for contraceptives in rural communities in developing countries.…”

“…Some studies have documented challenges of access to contraceptives among the younger generation as the main obstacle to meeting their contraceptives needs while for the older generation, the obstacle is in their beliefs and perspectives of contraceptives. 15 Other literature cites cultural and social norms that emphasize traditional role of the woman as childbearing, prohibits contraceptive use, limits communication on reproductive health in the family and values large families. 16 There is a need to create more awareness and education especially to men and other categories of people who view contraceptives negatively to improve uptake of these methods.…”