Voluntary Use of Contraception among Older Adolescents and Young Adults

What norms contribute to this behavior?

Social norms are the perceived, informal rules that define acceptable, appropriate, and obligatory actions within a given group or community. Some social norms are specific to a particular context, while others may be broad enough to span multiple contexts; even seemingly contradictory norms may exist in the same context.1

The following examples represent social norms relevant to voluntary use of contraception for older adolescents and young adults (ages 15-25) that emerged from across the literature. They are not meant to be a comprehensive list of all relevant social norms or norms relevant in all contexts. 

  • Large families are desirable in many communities, meaning young couples may be reluctant to use contraception.2–13 Son preference norms within communities may impact family spacing and size, as couples try to achieve an ‘ideal’ family composition.14–17 Delayed marriage and therefore delayed childbearing can result in shorter birth intervals, indicating a desire to “catch up” to develop a large family size.18
    Meta-Norms: Gender Ideology; Protection; Social Status
  • Child spacing is viewed as acceptable in many religious communities, though not always through modern methods.5,7,8,13,19,20 Some communities have protective norms against having children too close together–for example, norms against getting pregnant while still breastfeeding.5,8,21 However, child spacing may also be seen as unacceptable in other religious communities.12
    Meta-Norms: Gender Ideology; Protection; Social Status
  • Norms associated with femininities, such as women must prove they can get pregnant, and that they prove womanhood through large families, are associated with deciding to use –or not use– contraception to space pregnancies.2–5,12,13,20,21
    Meta-Norms: Gender Ideology; Protection; Social Status
  • Norms that promote men as the head of the household discourage shared decision-making regarding the timing of births and family size and can lead husbands to impose control over contraception –either forcing or prohibiting its use.9,11,22–25
    Meta-Norms: Authority; Control and Violence; Gender Ideology; Social Status
  • Couples may feel pressure to conceive soon after they get married to allay concerns about infertility, leading to a delay in contraceptive uptake.12,26 Because of this pressure, contraceptive use and even discussion may be seen as appropriate only after a first child.6,13,20,21,27
    Meta-Norms: Control and Violence; Gender Ideology; Social Status
  • Child spacing is seen as improving quality of life and health of families in communities.2,5,6,8,12,19
    Meta-Norms: Gender Ideology; Protection; Social Status
  • Women are considered responsible for contraceptive use, including for child spacing,4,15,28 but often lack the agency or household decision-making power to practice it.2–6,8,13 Women may see it as common or acceptable to covertly use family planning methods to space pregnancies.5,29
    Meta-Norms: Gender Ideology; Privacy; Social Status
  • Norms associated with social hierarchies between medical providers and young couples, especially young women, may impact contraceptive use. Due to the power hierarchy inherent in the relationship, young women may not feel comfortable discussing sexual and reproductive health with their medical provider. 13,30–32
    Meta-Norms: Gender Ideology; Protection; Social Status
  • Seeking or discussing family planning may be considered taboo, creating barriers to contraceptive use, due to the perception that it promotes promiscuity and infidelity among women,4,21,24,28,29,33 that it is a private matter,13  or that communicating about contraception is inappropriate or taboo.7,24,30
    Meta-Norms: Gender Ideology; Protection; Social Status
  • Norms related to the uncleanness of menstrual blood may prohibit women from using contraception for fear of irregular bleeding as a side effect.21,29
    Meta-Norms: Gender Ideology; Protection; Social Status

What other factors affect this behavior?

Family planning use among older adolescents, especially for delaying first birth and spacing births, depends on a number of factors. For example, these may include the following:

Individual

  • Nomadic pastoralist women vs semi-nomadic pastoralist women1

Interpersonal

  • Couple and Community Education2–5
  • Polygamy3,6–9
  • Couple and Community Socio-economic Status4,5,10
  • Migrant vs resident husbands11,12

Community

Who influences this behavior?

Certain groups or individuals influence young people to use family planning methods, including their partners, friends, and peers, as well as local and religious leaders. Families, especially parents and in-laws, are also important reference groups depending on the context.

Selected interventions addressing norms and behaviors

  • Girl Power-Malawi (GPM) was implemented by UNC Project-Malawi from February 2016 to August 2017 across four health clinics in Lilongwe, Malawi. The project aimed to improve care-seeking and reduce sexual risk behaviors among adolescent girls and young women. Major intervention components included youth-friendly healthcare, empowerment sessions and cash transfers. Youth-friendly care consisted of health clinics with a separate space for integrated sexual and reproductive health care, provided by staff who had received training for confidential, non-judgmental care. 12 monthly, group-based, interactive empowerment sessions were offered by a trained counselor, addressing romantic relationships, financial concepts, and skills like problem-solving and communication. Finally, conditional cash transfers were provided to girls after attending each empowerment session. The intervention was evaluated through a multi-arm study to evaluate the effectiveness of the intervention activities alone and in combination. Findings showed improvements in young women’s communication with others including their partners about contraception and family planning method use. Young women in the empowerment sessions had positive associations with using contraception, a relationship mediated by communicating about contraception.1,2
  • Masculinité, Famille, et Foi, part of the Passages Project, was implemented by Tearfund in Kinshasa, DRC, between 2015-2020. The program sought to reduce gender-based violence and increase family planning use among newly married couples and first-time parents through creating protective normative religious environments and working with religious leaders as agents of change. The intervention consisted of engaging faith leaders, building capacity of mentors (called Gender Champions), hosting community dialogues, conducting organized diffusion, and fostering an enabling service environment. Faith leaders and Gender Champions received gender transformative training before organizing and leading regular group discussions, including service linkages to local health clinics. Community mobilization included stories of change, and supportive sermons to the entire congregation. Researchers used factor analysis to measure how social norms influenced participant intentions to use modern family planning, which showed that women were concerned about social sanctions resulting from contraceptive use whereas men were influenced by perceptions of contraceptive use among their peers. An evaluation of the intervention using baseline and endline surveys found an increase in family planning acceptability for first-time parents including increased use, personal attitudes, self-efficacy, perceived social norms and couple communication around modern contraception. First-time parents also reported reduced experience and perpetration of violence to discourage modern contraception use.3,4

This web feature was written by the Institute for Reproductive Health with volunteer experts through the YouthPower2 Learning and Evaluation Gender Community of Practice. Additional content review was provided by colleagues at IRH and UCSD.

This web feature was created by Karin Smith and Anneka Van Scoyoc of the Population Reference Bureau. Charlotte Greenbaum, Raquel Wojnar, and Rachel Yavinsky, all of PRB, provided review.

© Institute for Reproductive Health 2022. All Rights Reserved.

Institute for Reproductive Health
Georgetown University

irhinfo@georgetown.edu
202-687-1392

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About Passages

About the Behavior Studies

The Passages Project is a USAID-funded seven-year implementation research project that aims to address a broad range of social norms, at scale, to achieve sustained improvements in family planning (FP), reproductive health (RH), and gender-based violence. Passages seeks to build an evidence base and contribute to the capacity of the global community to strengthen normative environments that support RH and well-being, especially among young people at key life stages transition points, including young adolescents, newly married couples, and first-time parents. As part of this effort, the Passages Project conducted a scoping review of evidence related to social norms affecting adolescents and young adults in low- and middle-income countries.

To conduct the scoping review, Passages Project consortium members first developed consensus around a list of priority behaviors for each of three age groupings: very young adolescents (VYA; 10-14 years); older adolescents (OA; 15-18 years); and young adults (19-25 years). For each of these groups, consortium members outlined behaviors from three broad thematic areas: 1) RH and FP, focusing on puberty for VYA and voluntary use of contraception for OA and young adults; 2) primary and secondary education for VYA and OA; and 3) family violence, focusing on child marriage for VYA and OA, and intimate partner violence for OA and young adults. Experts on adolescent social and behavior change (SBC) were engaged to rank priority behaviors based on criteria including current evidence gaps, their importance to thematic area outcomes, and promise for norms-shifting approaches.

This process resulted in seven priority behavior-age group combinations that were subsequently re-organized in five behavior studies, with some age groupings combined due to lack of specific evidence or lack of disaggregation compatible with Passages’ original groupings. These five behavior studies are:

  • Adolescent education: Ages 10-25; includes very young adolescents, older adolescents and young adults; a majority of the available evidence focused on adolescent girls and young women.
  • Puberty among very young adolescents: Ages 10-14.
  • Voluntary use of contraception among older adolescents and young adults: Ages 15-25; includes groups of young adults such as first-time parents and newly married couples.
  • Intimate partner violence among older adolescents and young adults: Ages 15-25; includes groups of young adults such as first-time parents and newly married couples.
  • Child marriage among very young adolescents and older adolescents: Ages 10-18; includes very young adolescents and older adolescents; a majority of the available evidence focused on very young adolescent girls.

Scoping reviews were conducted for each priority behavior/age grouping combination. This phase reviewed four databases (PubMed, Embase, CINAHL, and PsycINFO) of peer-reviewed literature focusing on literature from 2010 – 2021. Over 5,000 studies were screened, of which 521 met the inclusion criteria in at least one priority behavior/age grouping. After further evaluating each study that met the initial inclusion criteria, Passages selected studies that:

  1. Investigated the influence of specific social norms on the priority behavior and age groupings, and/or how these norms are held in place; and/or
  2. Described or evaluated promising approaches to address or shift these social norms for a given behavior and age grouping.

The resulting literature base for each behavior study was analyzed by Passages project staff and volunteers with expertise in SBC programming for adolescents and young people. Each behavior studies include information on:

  • Social norms relevant to the behavior that emerged from across the literature for the age grouping. These are ‘tagged’ by the identified underlying meta-norms they reflect, using terminology from the Learning Collaborative’s Social Norms Atlas and Passages’ Social Norms Lexicon.
  • Other, non-normative variances that affect the behavior or practice within the age grouping.
  • Influential reference groups. In reporting findings, there are differences in the specificity of naming these influential groups (i.e., religious leaders versus communities at large) that directly reflect the literature.
  • Two selected relevant interventions that described addressing norms related to the priority behavior for the age grouping, or contained a norms-shifting component, regardless of rigorous measurement of this norms-shifting component. Each selected intervention is ‘tagged’ with the identified norms-shifting approaches in their programming, using terminology from the Passages Theory of Change).

 

Literature Gaps

The majority of published literature focuses on investigating the influence of social norms on target behaviors, often finding a strong influence of gender and other social norms on target behaviors. However, many of these studies did not disaggregate or analyze data by age or gender.

It is therefore challenging to understand either the influence of norms on the behaviors and practices of and for young people or how these norms may be shifted– and especially for different and distinct stages of youth. Adolescence, marriage, and first pregnancy are key transitional phases in the life course in which norms are likely different; it is thus vital to disaggregate findings by age or life stage and gender. Few of the studies measured norms rigorously, and many used attitudes as a proxy for norms. For example, many studies used the Gender-Equitable Men (GEM) scale to measure norms, although the scale measures individual attitudes rather than social expectations.

Only a few of the studies reviewed included a definition of social or gender norms, discussed formative work to identify existing norms, or outlined a named framework or their program theory of change. Social norms were conceived in various manners and according to various disciplines, and were not always consistent with the Passages Project’s definition of social norms as “what I think people do and what I think people should or should not do in my community.” It was not common for studies to report the boundaries of the communities (for example, ‘parents of very young adolescents within X region,’ rather than just ‘parents’) within which norms, or proxies, where measured. Nor was it common for studies to explicitly identify reference groups (see the Passages Social Norms Lexicon for full definitions).

Most of the interventions included in the review were multi-component interventions, of which norms-shifting activities were often only a small component of the overall activities. Very few studies evaluated the effect of norms-shifting interventions on target behaviors, and fewer still measured norms or norm changes over time.  Asa a result, it is challenging to attribute behavioral changes to norms-shifting activities. More work is needed to evaluate norms-shifting interventions using valid and reliable social norms measures, measuring norm shifting against a comparison group to better understand the added effect of norms-shifting activities on norms and behaviors.

All said, the review affirmed that promising practices to address youth behavior across these three domains exist. We believe that it is possible, feasible, and important to design and evaluate norms-shifting interventions for adolescent and youth sexual and reproductive health behaviors based on understood and accepted definitions, strong formative work to identify norms and meta-norms, and outlining the communities, influencers, and pathways through which norms impact behaviors.