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 TJs 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 Pearsons 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: womens 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. Mens 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.

PROGRAM DESCRIPTION: Growing Up GREAT! (GUG) is a sexual and reproductive health (SRH) program for adolescents aged 10-14 years in Kinshasa, Democratic Republic of the Congo (DRC). The multilevel program takes an ecological approach to foster community examination of gender inequitable norms and to increase adolescents SRH knowledge, skills, and gender-equitable attitudes. GUG design, piloting, and scale-up were informed by a theory of change and responsive feedback mechanisms (RFMs) during piloting and scale-up. RESPONSIVE FEEDBACK MECHANISMS: The program engaged stakeholders via quarterly learning meetings to review monitoring data, evaluation results, and practice-based knowledge and to subsequently identify challenges and develop solutions. The program commissioned rapid research on specific intervention elements to improve implementation and documented scale-up learnings using the World Health Organization/ExpandNet framework. ACHIEVEMENTS: RFMs used in the pilot period allowed the program to address community concerns by intensifying orientation activities with parents and schools, shifting the calendar of activities to increase male engagement, and increasing facilitator training length to improve facilitation quality. Using RFMs during scale-up prompted further adaptations for program sustainability, including recommendations for task-shifting from NGO facilitators to community health workers. CONCLUSION: GUG used RFMs from pilot through scale-up to foster a learning culture among local partners, implementers at headquarters, and global research partners. Using responsive feedback (RF) enabled timely response to the evolving implementation context, resulting in strategic program adaptations that fostered increased community support of the project. Other successes due, at least in part, to this RF approach include incorporation of the program into DRCs national adolescent health strategy, and rapid response to the COVID-19 pandemic in educational strategies for program beneficiaries.

This study aimed to understand whether maternal child marriage and past year intimate partner violence (IPV) impact stunting among Sri Lankan children under 5 years old, and, secondarily, whether proximity to conflict is associated with stunting. Additionally, we assessed whether proximity to conflict moderates the relationships between maternal child marriage and past year IPV (sexual, physical, and emotional). We tested these questions using logistic regression analyses of the 2016 Sri Lankan Demographic and Health Survey (n = 4941 mother-child dyads). In country-wide adjusted analyses, we did not find associations between maternal child marriage or IPV and stunting (p > 0.05). Children in districts proximal and central to conflict were significantly less likely to be stunted compared to children in districts distal to conflict (proximal adjusted odds ratio/aOR: 0.43, 95% confidence interval/CI: 0.22-0.82; central aOR: 0.53, CI: 0.29-0.98). We found significant interaction effects on stunting between proximity to conflict and both sexual and emotional IPV, which we further explored in stratified analyses. In districts distal to conflict, maternal sexual IPV was significantly associated with increased odds of stunting (aOR: 2.71, CI: 1.16-6.35), and in districts central to conflict, maternal emotional IPV was significantly associated with increased odds of stunting (aOR: 1.80, CI: 1.13-2.89). Maternal emotional IPV was significantly associated with decreased odds of stunting in districts proximal to conflict (aOR: 0.42, CI: 0.18-0.96). Maternal child marriage and physical IPV were not associated with stunting in Sri Lanka. Variations in associations between maternal IPV and stunting across Sri Lanka may reflect the lasting and differential impact of conflict, as well as differential humanitarian responses which may have improved child nutrition practices and resources in districts central and proximal to conflict. Policies and programs addressing stunting in Sri Lanka should consider the role of maternal IPV as well as community-level variations based on proximity to conflict.

Background

Studies from many contexts indicate that proximity to conflict is associated with increased likelihood of intimate partner violence (IPV), and girl child marriage is associated with both proximity to conflict and increased IPV. In this study, we consider whether girl child marriage acts as a mediator of the association between proximity to conflict and IPV in the context of Sri Lanka, which sustained long-term conflict until 2009.

Methods

We analyzed responses of currently partnered women between ages 18 and 49 in the 2016 Sri Lankan Demographic and Health Survey (N = 13,691). Using logistic regression analyses, we measured associations between proximity to conflict (residence in districts which were central, proximal, or distal to the regions where the war occurred) and the outcomes of IPV and girl child marriage, and secondarily assessed girl child marriage as a possible mediator of the association between proximity to conflict and past year IPV.

Results

Women residing in districts central to conflict, as compared to districts distal to conflict, had increased odds of past year sexual, physical, and emotional IPV, with the odds of sexual IPV increasing the most (adjusted odds ratio/aOR 4.19, 95% confidence interval/CI 2.08-8.41). Residing in districts proximal to conflict compared to those distal to conflict was associated with lower odds of past year physical and emotional IPV, with the greatest decrease in emotional IPV (aOR 0.31, CI 0.18-0.54). Girl child marriage was more likely in districts central to conflict as opposed to those distal to conflict (aOR 1.89, CI 1.22-2.93), and partially mediated the relationship between centrality to conflict and IPV.

Conclusions

Our findings demonstrate that residing in districts central to conflict compared to those distal to conflict is associated with greater odds of IPV and girl child marriage in post-conflict Sri Lanka, with girl child marriage partially mediating the association between centrality to conflict and IPV. Residence in districts proximal to conflict appears protective against IPV. Future research should investigate what factors are responsible for decreased IPV in districts proximal to violence, and whether these factors can be reproduced to mitigate the increased prevalence of IPV in districts central to conflict.

Social norms related to fertility may be driving pregnancy desire, timing and contraceptive use, but measurement has lagged. We validated a 10-item injunctive Fertility Norms Scale (FNS) and examined its associations with family planning outcomes among 1021 women and 1020 men in India. FNS captured expectations around pronatalism, childbearing early in marriage and community pressure. We assessed reliability and construct validity through Cronbachs alpha and exploratory factor analysis (EFA) respectively, examining associations with childbearing intention and contraceptive use. FNS demonstrated good reliability (α = 0.65-0.71) and differing sub-constructs by gender. High fertility norm among women was associated with greater likelihood of pregnancy intention [RRR = 2.35 (95% CI: 1.25,4.39); ARRR = 1.53 (95% CI: 0.70,3.30)], lower likelihood of delaying pregnancy [RRR = 0.69 (95% CI: 0.50,0.96); ARRR = 0.72 (95% CI: 0.51,1.02)] and greater ambivalence on delaying pregnancy [RRR = 1.92 (95% CI: 1.18,3.14); ARRR = 1.99 (95% CI: 1.21,3.28)]. Womens higher FNS scores were also associated with higher sterilization [RRR = 2.17 (95% CI: 1.28,3.66); ARRR = 2.24 (95% CI: 1.32,3.83)], but the reverse was noted for men [RRR = 0.61 (95% CI: 0.36,1.04); ARRR = 0.54 (95% CI: 0.32,0.94)]. FNS indicated better predictive value among women compared to men for key reproductive outcomes. This measure may be useful for social norms-focused evaluations in family planning and warrants cross-contextual study.

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.

INTRODUCTION: Non-consented care, a form of obstetric violence involving the lack of informed consent for procedures, is a common but little-understood phenomenon in the global public health arena. The aim of this secondary analysis was to measure the prevalence and assess change over time of non-consented care during childbirth in Mexico in 2016 and 2021, as well as to examine the association of sociodemographic, pregnancy-, and childbirth-factors with this type of violence. METHODS: We measured the prevalence of non-consented care and three of its variations, forced sterilization or contraception, forced cesarean section, and forced consent on paperwork, during childbirth in Mexico for 2016 (N = 24,036) and 2021 (N = 19,322) using data from Mexicos cross-sectional National Survey on the Dynamics of Household Relationships (ENDIREH). Weighted data were stratified by geographical regions. We performed adjusted logistic regression analyses to explore associations. RESULTS: The national prevalence of non-consented care and one of its variations, pressure to get a contraceptive method, increased from 2016 to 2021. A decrease in the prevalence was observed for forced contraception or sterilization without knowledge, forcing women to sign paperwork, and non-consented cesarean sections nationally and in most regions. Women between the ages of 26 and 35 years, married, cohabiting with partner, living in urban settings, who do not identify as Indigenous, and who received prenatal services or gave birth at the Mexican Institute of Social Security (IMSS) facilities experienced a higher prevalence of non-consented care. Being 26 years of age and older, living in a rural setting, experiencing stillbirths in the last five years, having a vaginal delivery, receiving prenatal services at IMSS, or delivering at a private facility were significantly associated with higher odds of reporting non-consented care. CONCLUSION: While a decrease in most of the variations of non-consented care was found, the overall prevalence of non-consented care and, in one of its variations, pressure to get contraceptives, increased at a national and regional level. Our findings suggest the need to enforce current laws and strengthen health systems, paying special attention to the geographical regions and populations that have experienced higher reported cases of this structural problem.

Social expectations play a crucial role in shaping dietary practices among women and children. However, despite significant attention to promoting social and behavioral change in nutrition-focused programs and research, the influence of social norms on womens agency in enhancing nutrition practices is often overlooked. In this perspective, we advocate for a paradigm shift by incorporating a norms aware approach. This underscores the importance of recognizing, measuring, and addressing the societal constraints and barriers that women and children encounter in their journey to improved nutrition. Drawing on insights from the United States Agency for International Development-funded Kulawa project in Niger, we highlight the implications of using social norms diagnosis tools to understand the contextual dynamics within child-feeding practices, informing intervention design, and targeted populations. Integrating a norms perspective into nutrition programming and research does not require an overhaul, but rather a nuanced application of understanding of contextual drivers, such as social norms and agency, that have been underemphasized. We delve into the role of the socio-ecologic system, underscore the importance of addressing power imbalances related to gender and social hierarchy, and emphasize that programs targeting norms should aim for community rather than individual-level change. We provide guidance for programs and research integrating a norms perspective, as well as examples of how tools, such as the Social Norms Exploration Tool and Social Norms Analysis Plot framework, can be applied to identify and prioritize social norms, facilitating the design of norms aware programs. Additionally, we highlight the critical role of community engagement and discuss the value of using qualitative and quantitative approaches to document the process and outcomes of social norms research, program design, and implementation. When we recognize the role of social norms in nutrition as a missing ingredient in nutrition research, programming, and social and behavior change strategies, we create opportunities for more effective and contextually relevant research and interventions that address the complexities of enhancing nutrition practices among women and children.

Womens contraceptive decision-making control is crucial for reproductive autonomy, but research largely relies on the Demographic and Health Survey (DHS) measure which asks who is involved with decision-making. In India, this typically assesses joint decision-making or male engagement. Newer measures emphasize female agency. We examined three measures of contraceptive decision-making, the DHS and two agency-focused measures, to assess their associations with marital contraceptive communication and use in rural Maharashtra, India. We analyzed follow-up survey data from women participating in the CHARM2 study (n = 1088), collected in June-December 2020. The survey included the DHS (measure 1), Reproductive Decision-Making Agency (measure 2), and Contraceptive Final Decision-Maker measures (measure 3). Only Measure 1 was significantly associated with contraceptive communication (adjusted odds ratio [AOR]: 2.75, 95 percent confidence interval [CI]: 1.69-4.49) and use (AOR: 1.73, 95 percent CI: 1.14-2.63). However, each measure was associated with different types of contraceptive use: Measure 1 with condom (adjusted relative risk ratio [aRRR]: 1.99, 95 percent CI: 1.12-3.51) and intrauterine device (IUD) (aRRR: 4.76, 95 percent CI: 1.80-12.59), Measure 2 with IUD (aRRR: 1.64, 95 percent CI: 1.04-2.60), and Measure 3 with pill (aRRR: 2.00, 95 percent CI: 1.14-3.52). Among married women in Maharashtra, India, male engagement in decision-making may be a stronger predictor of contraceptive communication and use than womens agency, but agency may be predictive of types of contraceptives used.

Objective

To assess the impact of the Gender Roles, Equality and Transformations (GREAT) intervention: a narrative-based, resource-light, life-stage tailored intervention package designed to promote gender-equitable attitudes and behaviours, and improve sexual and reproductive health (SRH) and gender-based violence (GBV) outcomes among adolescents and their communities.

Design

Repeated cross-sectional evaluation study, using propensity score matching combined with difference-in-difference estimation.

Setting

Two postconflict communities in Lira and Amuru districts in Northern Uganda.

Participants

Male and female unmarried adolescents (10-14 years, 15-19 years), married adolescents (15-19 years) and adults (over the age of 19 years) were selected using a stratified, two-stage cluster sample of primary and secondary schools and households (baseline: n=2464, endline: n=2449).

Primary outcome measures

Inequitable gender attitudes and behaviours; GBV; and SRH knowledge and behaviours.

Results

Statistically significant intervention effects were seen across all three outcomes-gender equity, GBV and SRH-among older and newly married adolescents and adults. Among older adolescents, intervention effects include shifts on: inequitable gender attitudes scale score: -4.2 points ((95% CI -7.1 to -1.4), p<0.05); Inequitable household roles scale score: -11.8 ((95% CI -15.6to -7.9), p<0.05); Inequitable attitudes towards GBV scale: -1.9 ((95% CI -5.0 to -0.2), p<0.05); per cent of boys who sexually assaulted a girl in past 3 months: -7.7 ((95% CI -13.1 to -2.3), p<0.05); inequitable SRH attitudes scale: -10.1 ((95% CI -12.9 to -7.3), p<0.05). Among married adolescents, intervention effects include shifts on: Inequitable household roles scale score: -6.5 ((95% CI -10.8 to -2.2), p<0.05); inequitable attitudes towards GBV scale: -4.7 ((95% CI -9.8 to -0.3), p<0.05); per cent who reacted violently to their partner: -15.7 ((95% CI -27.1 to -4.4), p<0.05); inequitable SRH attitudes scale: -12.9 ((95% CI -17.3 to -8.5), p<0.05).

Conclusion

The GREAT intervention model demonstrates the promise of a resource-light, life-stage tailored programme that employs culturally appropriate, participatory and narrative-based techniques to advance gender equity and adolescent health. This type of programming contributes towards reductions in GBV and improved adolescent SRH outcomes.