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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