Understanding How Social Norms Affect Modern Contraceptive Use

"[F]or donor interest to translate into an allocation of resources that systematically takes normative factors into account, it is important to locate social norms within a practical model of behavior change - one that is accessible to a broad range of stakeholders."

Studies show that perceived community disapproval of contraceptive use is a key reason for non-use of modern contraception among 15- to 24-year-old Nigerian women. "Disapproval" evokes the concept of social norms, which describe what people in a group consider to be a typical and appropriate behaviour in a particular context. There is a growing recognition that development efforts have underestimated the role of social factors, such as social norms, in behaviour change. This study uses the Fogg Behavior Model (FBM) to explore whether social norms are associated with modern contraceptive use among Nigerian women, and whether they affect behaviour through motivation or through ability. In other words, do social norms that discourage contraception lower women's motivation to use contraception, or do they lower women's ability to use contraception?

The researchers explain the value of this investigation by pointing to its implications for the design of public health interventions. For example, an intervention may increase a young woman's motivation to practice contraception by increasing community dialogue about the negative consequences of unwanted teenage pregnancy, while another intervention may increase her ability to practice contraception by making contraceptives widely available in the community and ensuring that she knows how to access contraceptive services.

In brief, the FBM states that behaviour happens when motivation, ability, and a prompt occur in the same moment. The FBM can be visualised in two dimensions, with motivation on the y-axis and ability on the x-axis. The three core motivators on the model are: sensation (characterised by pleasure and pain), anticipation (characterised by hope and fear), and belonging (characterised by acceptance and rejection). (In other words, motivation is conceptualised as stemming from a person's hopes and fears related to the behaviour, the pleasure or pain that they experience from the behaviour, and what the behaviour means for their sense of belonging.) The five core elements related to ability are: time, money, mental effort, physical effort, and routine. For a specific behaviour, motivation can range from high to low, as can ability. The FBM states that a person with high motivation and high ability will adopt a behaviour when prompted. By contrast, a person with low motivation and low ability will not adopt a behaviour when prompted.

This study uses data from a cross-sectional household survey of 1,916 Nigerian women, ages 14-24. The survey, which was conducted between February 19 2018 and March 4 2018, collected data on socio-economic and demographic characteristics of women, whether they were sexually experienced, and whether they used contraception. Modern contraceptive use was the outcome of interest for the study. The survey also collected data on descriptive and injunctive norms related to premarital sex and contraceptive use, where a descriptive norm is a person's perception of how widespread a specific behaviour is, while an injunctive norm is a person's perception of whether that behaviour is socially approved.

To operationalise the FBM, the researchers identified survey items that were consistent with Fogg's definition of motivation and ability. Concurrently, they reviewed the broader literature and identified motivation and ability factors that predict contraceptive use. Thirty-two survey questions in the survey were identified that reflected motivation and 25 that reflected ability. For example, the ability component measured in this study was the mental effort required to adopt contraception. This construct comprised the embarrassment associated with contraceptive use, the challenge women face in discussing contraceptive use with their partner, their lack of confidence in being able to obtain a contraceptive method when they need it, their lack of confidence in being able to convince their partner to use contraception, and their lack of knowledge of where to access contraceptive services.

The study found that women who were not currently using a modern contraceptive method had a higher score on the variable measuring social norms that discourage premarital sex and modern contraception (18.8 versus 16.0, p=0.000). Women who were currently using contraception had higher scores on variables measuring motivation (67.7 versus 58.0, p=0.000) and ability (46.5 versus 34.8, p=0.000) than women who were not.

Four models were used for the logistic regression analysis. The first model shows the odds of contraceptive use by socio-economic and demographic characteristics. The second model adds a variable measuring social norms that discourage contraceptive use. This model explains whether there is a relationship between social norms and contraceptive use, independent of other factors. The third model adds a variable measuring motivation to Model 2. The fourth model adds a variable measuring ability to Model 2. Models 3 and 4 help illustrate whether the effects of social norms are associated with motivation or with ability.

After adjusting for a range of socio-economic and demographic variables, the researchers found that social norms that discourage contraception had a statistically significant negative association with contraceptive use (adjusted odds ratio (aOR)=0.90, p <0.001). The analysis found that the negative association between social norms and contraceptive use remained statistically significant after controlling for motivation but did not remain statistically significant after controlling for ability. For example, Model 2 showed the negative association between being economically poor and modern contraceptive use. This association remained after adjusting for motivation (Model 3) but disappeared once ability was taken into account (Model 4). This finding suggests that the lower level of contraceptive use among the economically poorest Nigerian women stems from low ability to use contraception, rather than from low motivation.

While it is not possible to generalise from a study focused on a specific behavior (modern contraceptive use) whether social norms may influence ability for other behaviours as well, future empirical study could clarify this matter. The present study finds that "the FBM is an extremely useful model for exploring the pathways through which social norms affect behavior."

In terms of programmatic implications, these findings suggest that public health interventions may be able to counter the negative effects of social norms that discourage contraceptive use by increasing women's ability to practice contraception. "That social norms are associated with ability is a welcome finding because ability is easier to change than motivation...Motivation is less reliable than ability - it comes in waves. While a motivational boost can be useful in initiating a new behavior, it cannot be relied upon for sustaining that behavior..."

In conclusion: "Researchers and intervention designers should be careful and not assume that social norms influence behavior through motivation."