This qualitative study unveiled broader impacts of social norms and networks effects, which shape perception, attitudes, and behaviors on decision-making around family planning among men and woman in the Democratic Republic of Congo (Fig. 1).
By analyzing descriptive and injunctive social norms that contextualize participants' behavior, we identified three categories of norms: 1) family planning using both traditional and modern contraceptives, 2) birth spacing and family size, and 3) couple communication and decision-making (see table 4).
Table 4. Three categories of social norms – Extended version incorporating framework from Cislaghi & Heise(2019)
Factors
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Family planning/methods
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Birth spacing/family size
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Couple communication and decision-making
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Individual factors
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Knowledge, skills, self-efficacy related to contraception
Male and female education
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Aspirations
Attitudes
Religiosity
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Women’s empowerment
Male and female education
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Social factors
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Rumors about contraceptive side effects
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Social networks
Household and kin group structures and support
Positive deviants
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Power
Gender
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Material & institutional factors
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Method mix offered in public health services and in private sector
Marketing of contraceptives
Fees for services, cost of contraceptives
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Financial implications of larger & smaller families
Cost and availability of schools
Wealth, sources of income
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Laws – family inheritance, property, women’s rights
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↓
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Descriptive social norms
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Beliefs about what methods others in the community use
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Beliefs about birth spacing practices and family size of others in the community
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Beliefs about how others make decisions about family planning, and about how others seek FP information and services
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Injunctive social norms
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Beliefs about what methods others approve and disapprove
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Beliefs about birth interval and family sizes that others approve and disapprove
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Beliefs about ways of making decisions and seeking FP information and services that others approve and disapprove
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Within each category, reference groups or "norm setters" were recognized for their involvement in forming and maintaining social normative beliefs across all three categories.
One key finding, in line with other studies, is participants’ attitudes and perception towards traditional and modern contraception [16, 17]. In both focus groups and interviews, participants discussed their preference for traditional methods instead of modern contraceptives. This preference seems to largely stem from individual factors including limited knowledge and misconceptions on the risk and benefits of modern contraceptive methods. In a systematic review investigating the factors that influence contraceptive use in sub-Saharan Africa, it was concluded that misinformation and social normative beliefs such as those that link contraception with infidelity decrease uptake in modern contraception [16].
Further, our study revealed that social factors such as rumors about contraceptive side-effects further alienate men from adhering to modern methods. Similarly, a recent study conducted in Kenya reported that young men strongly adhered to social misconceptions around contraception thus decreasing their willingness to utilize modern contraception [18]. Modern contraception often carries unfavorable associations that do not always have a basis in scientific understanding, highlighting the necessity for targeted health education specifically among male peer groups. In the Malawi Male Motivator project, male outreach workers played a crucial role in facilitating community dialogues to promote contraceptive uptake among couples [19]. The sensitization of male peers to deliver contraceptive education positively impacted contraceptive usage. Further, mentorship programs for community health workers can assist in managing contraceptive side effects and addressing the concerns of couples during community visits, thereby improving access to and acceptance of contraceptives in the community [20].
The participants in our study supported the idea of birth spacing but were less favorable to family planning if it meant limiting family size. Our study participants understood birth spacing as a means of promoting maternal and infant wellbeing, but the use of modern contraceptives threatens their desire and, in some contexts, their religious mandate to produce more children. Despite the financial implications of a larger family unit, as indicated by our study, members in the community believe, “children are wealth.” As noted in other existing literature, the concept of birth spacing is more widely accepted whereas limiting family size threatens both descriptive and injunctive social-cultural norms that place value and significance on having a large family [20]. Rather than endorsing "family planning," we suggest advocating for "birth spacing" – a concept that supports individuals in achieving their objective of maintaining healthy spacing between pregnancies. Male champions and role models can be weaved into interventions to convince other men of financial, educational, and health-related advantages of birth spacing [20]. This concept aligns with the community's existing acceptance and desire for adherence.
As highlighted in our findings, community members perceive the number of children as a valuable resource. Consequently, birth spacing facilitates the attainment of desired family size while protecting the well-being of both mothers and children. Furthermore, the perceptions of family and peer groups appeared to strongly influence decisions regarding family size, with certain members advocating for birth spacing while others encouraged couples to "multiply and fill the earth”. Subjective norms, such as the belief that "children are a gift from God" and the perception that contraceptives are sinful, as demonstrated by a study in Eastern Congo, are found to have a negative and significant association with the intention to use family planning [21]. Further, injunctive norms highlighted in our study reveal that religious leaders and messages from religious institutions influence decision-making and perceptions about contraceptive use and family size. This finding aligns with other studies that concluded that there is a relationship between religious condemnation of contraceptives and underutilization of family planning services [22, 23].
Religious leaders can play a vital role in mobilizing interventions. Engaging these norm setters in a review of religious texts and highlighting passages that illustrate alignment with the concept of birth spacing and limitation can be instrumental in shifting community perceptions [20]. Extensive evidence supports the effectiveness of mass-media communication programs in enhancing the adoption of family planning and influencing reproductive behavior [24]. In a study conducted on gender and reproductive outcomes in Nigeria, which employed radio serial drama as a communication tool, the results indicate that the drama had a positive impact, particularly regarding reproductive outcomes and addressing concerns about contraceptives being, “against the will of Allah” [24].
In our third category, which pertains to couple communication and decision-making regarding contraceptive use, we identified strong gendered power dynamics within couples. Our study revealed that while it is common and sometimes necessary for couples to seek external input when disagreements arise concerning family planning, the final decision often rests with the male partner, who holds the role of the head of the household. Consequently, even if the woman possesses greater knowledge and education about contraceptive methods compared to her male partner, societal norms dictate that she should not make contraceptive decisions independently. Instead, she should first seek and obtain her husband's approval. This finding aligns with previous literature [25, 26], where researchers found that the decision-making authority of husbands negatively influenced women's contraceptive intentions in sub-Saharan Africa.
In a study of church-going young men in Kinshasa, DRC, the vast majority (92%) agreed that a man and a woman should decide together if they want children [27]. However, 94% of the men agreed that the man should have the final word about decisions in his home, and 79% agreed it was the woman's responsibility to avoid getting pregnant, which may limit couple communication and shared decision-making [27]. These findings underscore the importance of involving men in programs aimed at increasing the utilization of modern contraception and facilitating couple communication and information sharing. This can include community dialogues with male outreach workers [19]. One study in DRC demonstrated that men who are more involved in maternal healthcare are more likely to discuss postpartum FP with their partners [28]. This finding has implications for future interventions; to strengthen couple communication around birth spacing, men should be engaged in maternal healthcare throughout the pregnancy, including through delivery and neonatal care. By engaging men and the couple as a unit in positive reproductive health initiatives, men will have a better understanding of pregnancy and childbirth and the associated risks, which could in turn have an impact on contraceptive uptake.
In this study, both injunctive and descriptive norms were shown to be set by reference groups or the social networks of participants. The perception of others' contraceptive usage has a greater impact on an individual's adoption of contraceptives compared to the actual adoption of these methods by others [11]. Our study depicted that male friends and peers are highly influential in promoting and/or discouraging the use of family planning services. When a couple faces uncertainty regarding the decision to access family planning services—for example, if the woman wants to adopt a contraceptive method but the man refuses—descriptive norms suggest that it is socially acceptable to consult a trusted outside source. In the case of the man, this often involves turning to his friend or peer for advice. The third party engaged in the couple's decision-making can express either unfavorable or favorable opinions on contraception, thus swaying the man's viewpoint.
In a study on social network influence on FP behaviors in Nigeria, findings indicated that male respondents who held the belief that their social network would endorse their receptiveness to their spouse’s fertility preferences were more likely to be engaged with family planning services [11]. Moreover, the study unveiled that perceived level of social support was more significant than the explicit attitude of the social network regarding FP [11]. This further highlights the influence of male friends/peers in decision-making on contraceptive use. Participants in this study also disclosed that men risk being criticized if they do engage with family planning services, especially if the behavior is condemned by their social network. While an individual might profit from an intervention in terms of knowledge and attitudes, he will continue to be wary of others' disapproval unless he knows that they have been part of the same intervention. There is a strong need to engage reference groups in family planning interventions. The mobilization of influential members of the community such as male peer groups, health professionals and religious leaders can be effective in increasing uptake of modern contraceptives.
Given that birth spacing is already an accepted practice, future interventions should prioritize increasing acceptance of modern contraceptive methods among male peer groups and with religious leaders as a tool to space births more effectively. Interventions should work to engage men in situations where they congregate together, such that the inventions address social norms as well as knowledge and attitudes. Training male peer educators and elevating the voices of men who have experience with using contraceptive methods for birth spacing will be important to increasing trust in the messaging and framing contraceptive uptake as relevant to the lives of men in the community. Working with religious leaders to review specific sections of religious texts, such as the Bible, and identifying passages that endorse or support the concept of birth spacing and/or limiting, will also be a crucial step in reducing the strength of injunctive norms that frame FP as a sin (see Table 5).
Table 5. Reference groups for family planning behaviors impacted by descriptive and injunctive social norms
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Modern and traditional methods of contraception
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Birth spacing and family size goals
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Couple communication and decision-making
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Descriptive
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• Health providers
• Male peers
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• Family members
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• Family members
• Male peers
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Injunctive
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• Religious leaders
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• Religious leaders
• Male peer groups
• Health providers
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• Male peers
|
Implications for intervention design
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Engage men with their male peers. While an individual might profit from an intervention in terms of knowledge and attitudes, he will still be wary of others' disapproval unless he knows that they have been part of the same intervention and discussed the benefits of modern FP.
Providers should be mentored on addressing rumors and managing side effects of MCMs, as done with community health workers in Uganda [20].
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Focus messaging on CBS (childbirth spacing) rather than “family planning” or “limiting” [20].
Use male role models to promote the benefits of birth spacing (financial, education, health) to men [20].
Increase risk perception of closely spaced births through mass media for men, women, and family members [24].
Review aspects of religious texts (such as the bible) and highlight passages that aligned with approval or acceptance of birth spacing and/or limiting [20, 29].
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Men/male peers should be the primary focus of any intervention on couple communication. Women may feel unable to start conversations around contraception, while men may not be thinking about FP/CBS or fear stigma around initiating these conversations. Using men to facilitate the community dialogues will help reach husbands, and the message may resonate more coming from a male peer. Similar interventions in Malawi and Kenya saw greater couple communication and support for FP, as well as increased contraceptive uptake in Malawi [19, 30]
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Study Limitations
This study is not without its limitations. As for qualitative research, findings from our study do not represent all community members. Due to the interview questionnaire's framing, we may not have captured other key influential groups. It is important to note that, similar to any survey that explores sensitive topics related to gender equity and sexuality, despite assurances of participant anonymity, there is the possibility that some sensitive issues may have been either underreported or overreported.