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Everyday conversations within various social groups can play an
important role in a person's decision to begin contraception. Because of
this, family planning programs can work with social groups to improve
their services.
Family, friends and neighbors are examples of typical social
networks. Others include women's groups; political, church or youth
associations; mutual aid and credit groups; and marketing associations.
Some experts believe communication through these social networks can
influence decisions to initiate contraception as much as media campaigns
or information provided directly to clients by family planning programs.
"For the most part, social networks have been ignored when
family planning programs are implemented," says Dr. Thomas Valente,
who has conducted extensive research on social networks. "But it is
wise to look at them more closely because they are an important force
driving human behavior."
Many individuals feel uncertain about the health, social and economic
consequences of using modern contraceptives. This uncertainty often
leads people to discuss matters with their peers, to seek more
information or just to be reassured about decisions to begin using
contraception, says Dr. Valente, an associate professor at Johns Hopkins
University, Baltimore, MD, USA.
"It is just human nature to be cautious," he says.
"People do not necessarily trust what they are told is the
contraceptive experience of people who may well be from distant
countries. People tend to turn to others like themselves for information
and advice." Targeting key individuals within social networks --
opinion leaders, men and couples, for example -- can help family
planning programs achieve reproductive health goals, he says.
Social learning
Social networks can have an impact on contraceptive use in two ways:
by spreading information and by influencing behavior.
The information that people need and seek, especially in settings
with low contraceptive prevalence, includes contraceptive efficacy, how
and where to obtain methods, and side effects of modern contraceptive
use. Many surveys indicate that women worldwide are concerned about side
effects.
Learning through informal conversations can also involve exchanges of
information about the advantages and disadvantages of fewer children.
Having fewer children can promote family well-being in many ways.
Smaller families can mean better food, clothing, shelter and care for
each family member. Proper spacing of births improves the health of both
mother and child.
A study in rural Kenya found that about three-fourths of 866 women
questioned in a household survey had talked to at least one person about
family planning, and many talked to more than one person. Approximately
95 percent of these family planning conversations involved other women,
especially a sister-in-law or co-wife, friend or sister.1
In focus group discussions and interviews, women in this study said
that the decision to start birth control, especially a modern method, is
part of a process. "Information obtained from family planning
professionals is weighed against discussions with other less socially
distant women about their experiences, concerns about side effects, and
relations with those (husband and mother-in-law) who have power over a
woman's life," says Dr. Susan Cotts Watkins, a sociology professor
at the University of Pennsylvania, Philadelphia, PA, USA, and coauthor
of the study.
In Bolivia, a media campaign to promote family planning and
reproductive health increased awareness and detailed knowledge of
contraceptive methods. However, exposure to personal networks was
associated not only with increased awareness and knowledge of methods,
but also with attitudes toward, intention to practice, interpersonal
communication about, and current use of contraception.2
Social influence can be exerted by individuals who wield power over
others and by pressures to conform to social norms. Social influence may
constrain use of contraception. Husbands or kin may forbid
contraception, or community norms may threaten ostracism of a woman who
uses birth control.
In an FHI study conducted in West Java and North Sumatra, Indonesia,
in collaboration with researchers at the University of Indonesia, women
said husbands were regarded as the head of the household, and few women
used contraception without their husband's knowledge. For some women,
contraceptive use was not an option if husbands did not approve.
Explaining why she did not use contraception, a woman from North Sumatra
said, "My husband does not permit me to use contraception. I am not
brave enough, so I follow his advice. We have many children
already."3
Other women in such a situation may resort to using contraception
secretly, risking abuse, divorce or abandonment if their husbands become
aware of this use.
In a Zimbabwean study conducted by FHI in collaboration with the
Institute for Development Studies, University of Zimbabwe, most married
men and mothers-in-law wanted their wives or daughters-in-law to bear
many children to extend the family lineage. Most opposed the use of
contraception until at least one or two children had been born. Many
mothers-in-law favored contraception only as a means to space
pregnancies or to prevent further pregnancies once there were numerous
children.4
Another social pressure that limits contraceptive use is the view
that adolescents should not be sexually active. In many areas of the
world, sexual activity is taboo for young, unmarried women. This social
norm limits access to some methods for sexually active adolescents,
since contraceptive use implies sexual activity. In cultures that allow
polygamy, this practice is another norm that may discourage
contraceptive use. A woman in a polygamous marriage may want to have
more children if her husband's other wives are doing so. Also, women
throughout the world say that motherhood brings respect, another social
pressure that discourages contraceptive use.
Powerful allies
Individuals who exert authority over a couple also have the potential
to facilitate contraceptive use. Older sisters-in-law, for example, are
powerful allies for new contraceptive users, according to a study
conducted by FHI in collaboration with the Centre d'Etudes et Recherche
sur la Population pour le Développement in Mali. In the study of new
users, sisters-in-law older than the wife shared their own family
planning experiences, often encouraged use, and tended to be advocates
for wives whose husbands disapproved of family planning. "She asked
me to speak about it first to my husband and, if he refused, to talk to
her and she would call him to make him understand," said one new
user about her sister-in-law. Said another: "My sister-in-law
intervened because of my son and then the twins that I had. She asked me
to use family planning. She told me not to stop, to continue with
it."5
In Cameroon, a 1993 survey of some 500 women belonging to social
associations found that women were more likely to use contraception when
they were encouraged by group members, or if members used the method
themselves. The likelihood of having ever used a contraceptive method
was eight times greater for a woman who thought members of her group
used contraception, and it was 17 times greater for a woman who was
encouraged by friends to use contraception. The associations, which
range from loose affiliations of friends to formal political and
economic organizations, comprised women whom survey respondents knew
well and with whom they often talked.6
Another study in Cameroon, featuring focus group discussions with 94
women who belong to associations, found that many had tried modern
methods, including the pill, intrauterine device, injections, male or
female sterilization and Norplant, as well as barrier methods (condoms
and spermicides) and traditional family planning (periodic abstinence).
Information about family planning spread quickly in these groups. One
notable exception was Moslem women, who said they needed their husband's
permission before discussing family planning.7
In Kenya, women's clubs or groups are very popular. Some men also
participate in social groups, mainly sports clubs. A study of more than
2,000 women and 2,000 men in Kenya, nearly half of whom belonged to
clubs, found that membership was associated with greater awareness and
approval of modern contraception. Female club members were also more
likely to have ever used or to be currently using modern contraceptives
than were women who did not belong to clubs.8
Furthermore, men and women club members in Kenya were more likely
than nonmembers to discuss family planning with friends and
acquaintances. Family planning discussions with both friends and
acquaintances, rather than with just close friends, were associated with
a much greater likelihood of using modern contraceptives. Women who had
discussed family planning with both types of individuals were eight
times as likely to be currently using modern contraceptives. Men who had
done so were three times as likely as were those who had limited family
planning discussions with close friends only. Contact with casual
acquaintances may offer better opportunities to consider new information
or viewpoints, since close friends tend to share similar views.
Considerable interpersonal communication about contraception also
takes place in Ghana. A study conducted in 1995 in southern Ghana of
some 300 men and 300 women found that individuals who had ever used
modern contraception were much more likely to have talked about
contraception with acquaintances than were non-users. Among men,
ever-users had discussed modern contraception with two acquaintances on
average, while never-users had such discussions with fewer than one
person (0.8 person) on average.9
Using social networks
"We know that information about reproductive health is actively
exchanged through social networks, and working with networks can help
some family planning programs," says Dr. John Casterline, a
researcher for the Ghana study and senior associate at the New
York-based Population Council. "But the degree to which social
networks affect contraceptive decision-making varies from setting to
setting, and the magnitude of the effect is still unknown. Social
scientists are continuing to try to measure this effect in order to
determine whether and how scarce resources should be invested in working
with social networks."
Meanwhile, family planning programs can take advantage of social
networks to promote contraception and reproductive health in several
ways.
First, "targeting opinion leaders, identified by the community
itself, is a way to accelerate change," says Dr. Valente of Johns
Hopkins University. "These opinion leaders tend to be conservative
because they know others depend on their advice. They may not quickly
promote change. But, if they eventually adopt an innovation such as
modern contraception, that signals change for the community."
"In northern Ghana, which is highly patriarchal, men who are
heads of compounds of 10 to 15 people are clearly gatekeepers for the
introduction of information and new behaviors," adds Dr.
Casterline. "It is essential to devote as much attention to the
influential senior men as to the target population of women."
Targeting men for contraceptive education, in general, is a good way
to increase male approval of contraception, he says. "We tend to
neglect one of the most fundamental social networks -- that of husband
and wife. But a woman supported by a social network of friends still may
not use a contraceptive method if her husband does not approve."
In a pilot project of community-based distribution of contraception
in Ghana, introduced by the Navrongo Health Research Centre in 1994,
social support for family planning and a woman's belief -- based on
talking with her husband -- that her husband supported her use of
contraception were the two most important factors leading to her
adoption of contraception. Conversation between husband and wife, and
social support influenced contraceptive use more than literacy level,
type of marriage or parity.10
When a woman walks in the door of a family planning clinic asking for
a specific contraceptive, providers need to be aware that her social
networks may be influencing her choice. They may be able to determine
this by asking, "Why do you want to use this method?" If a
social network is influencing a woman's choice, providers should not
fail to offer her a variety of other methods, since no one method is
ideal for everyone. The method that is most popular within a social
group may not be the best choice for a couple. Yet, a couple may choose
an inappropriate method if most of their acquaintances are using it.
Entire villages may encourage one contraceptive as the preferred
method, perhaps based on the choices of the village's first
contraceptive users. A 1984 census of 51 villages in Thailand, for
example, revealed that each village tended to have a most popular
contraceptive method, although the most popular method varied markedly
among villages. Furthermore, in focus group interviews conducted in
early 1991, village members were well aware of the most popular method
in the village and could recall the first users of contraception in the
village.11
"We believe people tended to adopt a method already being used
extensively in their village not because they felt social pressure to do
so, but because more was known about that method," says Dr. Barbara
Entwisle, principal author of a report on the work in Thailand and a
sociology professor at the University of North Carolina, Chapel Hill,
NC, USA. "Even when individuals were aware of side effects or
failures experienced by earlier users, they preferred methods about
which a great deal was known already."
However, the potential for shifts in method preference exists, adds
Dr. Entwisle. In one of the focus group villages, a doctor who initially
advised villagers to take the pill later made injectables available and
encouraged their use. Injectables then became the most popular method in
the village, illustrating how health workers can influence contraceptive
use within social networks.
Providers of contraception also need to be more aware that clients
commonly talk about reproductive health with members of their social
networks both before and after they talk to providers. "Because
these exchanges tend to be informal, rumors are all too easily spread
about modern methods," says Dr. Casterline. "So there is a
need for providers to correct misinformation circulating in the social
networks and give accurate information about all available
methods."
Clinic personnel should pay closer attention both to the information
being spread in such networks, and the influence the networks exert.
"Providers often dismiss social networks as spreading myths and
rumors," says Dr. Watkins of her research experience in Kenya,
"but some of the things network members say are, in fact, true.
Furthermore, the networks provide something that clinic personnel cannot
provide -- information and opinions from people like themselves."
Providers can encourage satisfied contraceptive users to talk about
their experiences with members of their social networks to accelerate
the spread of information. "This would be particularly effective if
providers were able to determine exactly which 'satisfied users' had the
largest social networks," says Dr. Valente.
"At the very least, before a woman who has adopted a method
walks out the door of a clinic, providers may want to find out who will
support her choice. If she has no support in her social network, she is
likely to discontinue use of the contraceptive."
-- Kim Best
References
- Rutenberg N, Watkins SC. The buzz outside the
clinics: conversations and contraception in Nyanza province, Kenya. Stud
Fam Plann 1997;28(4):290-307.
- Valente TW, Saba WP. Mass media and interpersonal
influence in a reproductive health communication campaign in
Bolivia. Commun Res 1998;25(1):96-124.
- Adioetomo SM, Toersilaningsih R, Asmanedi, et al. Helping
the Husband, Maintaining Harmony: Family Planning, Women's Work and
Women's Household Autonomy in Indonesia. Research Triangle Park,
NC: University of Indonesia and Family Health International, 1997.
- Francis-Chizororo M, Wekwete N, Matshaka M. Family
Influences on Zimbabwean Women's Reproductive Decisions and their
Participation in the Wider Society. Research Triangle Park, NC:
University of Zimbabwe and Family Health International, 1998.
- Konaté MK, Djibo A, Djiré M. Mali: The Impact
of Family Planning on the Lives of New Contraceptive Users in Bamako.
Research Triangle Park, NC: Centre d'Etudes et de Recherche sur la
Population pour le Développement and Family Health International,
1998.
- Valente TW, Watkins SC, Jato MN, et al. Social
network associations with contraceptive use among Cameroonian women
in voluntary associations. Soc Sci Med 1997;45(5):677-87.
- Jato M, van der Straten A, Kumah OM, et al. Women's
"Tontines" in Yaounde, Cameroon: Using Social Networks for
Family Planning Communication: Results of Focus Group Discussion
Research, December 1993. Baltimore, MD: Johns Hopkins School of
Public Health, Center for Communication Programs, Population
Communication Services, 1995.
- Boulay M, Valente TW. The relationship of social
affiliation and interpersonal discussion to family planning
knowledge, attitudes and practice. Int Fam Plann Perspect 1999;25(3):112-18,
138.
- Montgomery MR, Casterline JB. Social Networks
and the Diffusion of Fertility Control. Policy Research Division
Working Papers, No. 119. New York: Population Council, 1998.
- Phillips JF, Binka F, Adjuik M, et al. The
determinants of contraceptive innovation: a case-control study of
family planning acceptance in a traditional African society.
Presentation at the Population Association of America annual
meeting, New Orleans, May 9-11, 1996.
- Entwisle B, Rindfuss RR, Guilkey DK, et al.
Community and contraceptive choice in rural Thailand: a case study
of Nang Rong. Demography 1996;33(1):1-11.
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