Adapting the Social Norms Exploration Tool in the Democratic Republic of the Congo to Identify Social Norms for Behavior Change

Kathryn Sugg; Florence Mpata; Radha Rajan; Dominick Shattuck; Dédé Aliango Marachto; Peter J. Winch

doi:10.9745/GHSP-D-24-00058

Figures & Tables

Tables

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TABLE 1.

Adaptation of the SNET Toolkit for Application in the Democratic Republic of the Congo

SNET Component

Process of Adaptation

Step 1: Planning and preparing

Two SNET activities were selected to determine root causes of low contraceptive prevalence:

Problem tree analysis: Staff wrote a selected behavior of interest as the tree trunk and enumerated reasons why people did or did not perform the behavior as the roots and the consequences of performing or not performing the behavior as the branches.
Five Whys activity: Team members paired up to pose a “why” question related to the behavior of interest. They asked each other “why” again for every answer for 5 iterations of “why.”

Data collection instrument for Phase 1: Identifying reference groups

SNET activity adapted: “My Social Networks”
Central question: “When discussing family planning methods - whether it is questions about what they are, where to get them, how to use them, or whether you or your partner should use them - with whom do you feel comfortable discussing these topics?”
The respondent was read a list of options to probe specific attributes of the person chosen. For example, if he said a family member, the questionnaire would skip to questions about how the person was related, if they were a spouse, whether they were older or younger than the participant, and on which side they were related (maternal or paternal).
Adaptation: Unlike the example in the SNET, we asked only 1 question, and the participant was only able to share 1 influential person.
Recruitment: systematic household sampling rather than convenience sampling.
Implementation: A tablet-based digitized questionnaire to quickly analyze responses by site rather than the manual analysis template.

Data collection instruments for Phases 2 and 3: Exploring social norms

The decision of activities to include from the SNET for the qualitative data collection was informed by input from IRH staff.
SNET activities selected: 5 Whys activity and vignettes.
“Five Whys” activity: Questions were based on barriers identified through the problem tree analysis, and the activity was conducted in small groups with a facilitator rather than in pairs without a facilitator. Participants in focus groups were divided into subgroups and asked 2 initial questions. The second question that all focus group participants were asked was the same: “When a couple has decided to use family planning, some men do not allow their wife or partner to choose freely or independently which family planning method to adopt. Why is this?”
Vignettes were developed and shared with the in-country team to be validated for cultural appropriateness and contextual accuracy. During the individual interviews, a vignette was read in full. It described a couple deciding whether to use a family planning method for birth spacing. A shortened version of the vignette was used with the focus groups.

Abbreviations: IRH, Institute for Reproductive Health; SNET, Social Norms Exploration Tool.

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TABLE 2.

Data Collection Methods Used in Social Norms Exploration Tool Adaptation, 2022, Democratic Republic of the Congo

Phase

Data Collection Method

Objective

Population

No.

Rapid, tablet-based questionnaire

Identify reference groups who influence men around family planning

Married and unmarried men aged 15–39 years and 18–39 years, respectively

317

Semistructured, individual interviews

Examine how social norms affect male involvement in family planning

Examine men’s experiences with family planning, their involvement in the family planning process, and their perception(s) of the male role in this process

Married and unmarried men aged 15–39 years and 18–39 years, respectively

Focus group discussions with identified reference groups

Understand how reference groups communicate their attitudes, beliefs, and behaviors about family planning to the men they influence

Friends (of population of interest): men aged 15–39 years

Wives (of population of interest): women aged 15–39 years

Nurses

Doctors

Religious leaders

144

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TABLE 3.

Demographic Characteristics of Men Recruited to Identify Reference Groups, Democratic Republic of the Congo

	No. (%) (N=317)
Age, years
15–19	32 (10.1)
20–24	64 (20.2)
25–29	62 (19.6)
30–34	73 (23.0)
35+	86 (27.1)
Marital status
Married	239 (75.4)
Not married	78 (24.6)
Province
Kasaï Central	105 (33.1)
Lualaba	101 (31.9)
Sankuru	111 (35.0)

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TABLE 4.

Reference Groups Identified by Province and Health Zone, Democratic Republic of the Congo

	Reference Group Cited, No. (%)					Total, No.
	Family Member	Friend	Community or Religious Leader	Health Care Provider	Other/Do Not Know	Total, No.
Kasaï Central	26 (24.8)^a	14 (13.3)	8 (7.6)	55 (52.4)^b	2 (1.9)	105
Bilomba	7 (26.9)^a	0 (0)	1 (3.9)	18 (69.2)^b	0 (0)	26
Kananga	6 (21.4)^a	3 (10.7)	4 (14.3)	14 (50.0)^b	1 (3.6)	28
Mikalayi	8 (30.8)^a	5 (19.2)	2 (7.7)	11 (42.3)^b	0 (0)	26
Ndesha	5 (20.0)	6 (24.0)^a	1 (4.0)	12 (48.0)^b	1 (4.0)	25
Lualaba	26 (25.7)	38 (37.6)^b	4 (4)	27 (26.7)^a	6 (6)	101
Dilala	8 (32.0)^a	12 (48.0)^b	0 (0)	5 (20.0)	0 (0)	25
Fungurume	8 (32.0)^a	9 (36.0)^b	2 (8.0)	5 (20.0)	1 (4.0)	25
Kanzenze	6 (24.0)^a	8 (32.0)^b	1 (4.0)	7 (28.0)	3 (12.0)	25
Manika	4 (15.4)	9 (34.6)^a	1 (3.9)	10 (38.5)^b	2 (7.7)	26
Sankuru	12 (10.8)	24 (21.6)^a	7 (6.3)	67 (60.4)^b	1 (1)	111
Bena Dibele	6 (21.4)	7 (25.0)^a	0 (0)	15 (53.6)^b	0 (0)	28
Dikungu	0 (0)	8 (29.6)^a	4 (14.8)	15 (55.6)^b	0 (0)	27
Lodja	3 (11.1)	8 (29.6)^a	1 (3.7)	14 (51.9)^b	1 (3.7)	27
Omendjadi	3 (10.3)^a	1 (3.5)	2 (6.9)	23 (79.3)^b	0 (0)	29
Total	64 (20.2)	76 (24.0)	19 (6.0)	149 (47.0)	9 (2.8)	317

↵a Second most cited reason.
↵b Most cited reason.

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TABLE 5.

Normative and Other Factors Affecting Family Planning: Themes and Exemplary Quotes

Theme	Illustrative Quotes
Norms around birth spacing	It’s always good to have children who don’t follow each other, that we don’t conceive while the other is still little. Because if you can conceive early for a child, it can cause you to suffer a lot; when he will be always sick, today, sick tomorrow…you will only spend money. —Man, Kasaï Central
Knowledge of family planning methods	To avoid the woman conceiving while the child is still too young, you can abstain from lying with your wife, or you buy condoms; if you don’t want to buy condoms, you can bring the wife there to the hospital, get an [intrauterine device]. —Man, Kasaï Central
Benefits of birth spacing methods	Since the woman has seen that her child is 6 months, instead of having the pregnancies close together and causing her child to suffer, she prefers to use a method so that her child will grow up well. —Man, Kasaï Central
Concerns about modern family planning methods	My friend came to show me the facts of his wife, who they gave the injection, and that hurt, it really had a bad effect, a lot of hemorrhaging, hemorrhaging that lasted a month. —Man, Kasaï Central] He must know the methods favoring the woman to engage in prostitution, that is to say that for the man when the woman takes a method, for him the woman will no longer be afraid of engaging in prostitution. —Man, Sankuru They refuse because the woman can choose a method that lasts many days, many years. They want it to be fewer years. —Woman, Lualaba
Gender norms	If she goes alone to the health center to get the [contraceptive method], there it’s as if she is a free woman or as if she is the authority in her household…it’s as if her husband has become the wife and she the wife has become the husband. —Man, Kasaï Central
Reference groups	There are 2 types of friends. There’s a friend and a close friend. He could have spoken with his close friends, those who he says, night or day, I must talk to them. Those friends, he can tell, sometimes they say, “Don’t do that” and he really listens to their advice. —Man, Kasaï Central
Sources of information	Because the woman understands, we give advice, she retains it; or her friends can tell her, or her grandparents; it’s that that she retains and comes to speak to the man, to see how to avoid early pregnancy while the children are still young. —Man, Kasaï Central
Sanctions for those who act contrary to social norms	The man can think of taking another wife. Since he sees that his wife has become difficult, he can think about taking another wife. —Nurse, Sankuru

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TABLE 6.

Strengths and Weaknesses of Each Methodologic Feature of the SNET

Method	Research Questions	Advantages of This Method	Threats to Validity	Key Insight or Recommendation
Problem tree analysis	What are the root causes that prevent couples from using modern contraception?	Sparked a conversation about causes of a behavior of interest.	The project team, based in Kinshasa, must try and represent the perspectives of all regions (many far from Kinshasa) and subgroups (a wide range of religious, economic, and ethnic backgrounds).	The project team had to repeatedly reference the SNET to discuss whether causes discussed did or did not focus on norms but felt they had limited resources in the SNET to make those determinations. The root causes often surfaced common sayings (e.g., “children are wealth”); even among project staff, it was difficult to produce answers to why these sayings are widely believed and repeated. It may be easier to derive root causes from examples, experiences, or observations than to enumerate them directly.
Identifiction of reference groups	Were the reference groups identified consistent with the definition of reference groups in the social norms literature?	Rapid analysis of which community members men consider influential to their behavior around family planning. Sample frame is tailored to each site.	Groups identified were not limited to reference groups but included sources of family planning information such as health care providers. Influential groups with whom men do not feel comfortable talking about family planning were not captured	Men are influenced not only by social norms but also by knowledge of family planning methods. To keep the study focused on norms, inclusion criteria for what constitutes a reference group should be developed. Questions should attempt to identify enforcers of social sanctions as well as supporters of the behavior of interest.
Vignette of a couple making decisions about family planning	Did scenarios serve to identify ways in which reference groups influence men’s involvement in and decisions about family planning?	Present a specific scenario for men to respond to rather than an abstract concept. Men may feel more comfortable responding to questions about someone else rather than talking about their own experiences.	Certain aspects of the scenario were confusing or not well understood. Too many hypotheticals made the scenario overly complicated. Some men may not feel comfortable responding to certain questions.	Vignettes were well received overall, during both interviews and FGDs. The version used in the interview guide had too many plot points. Future applications of the SNET should keep the vignette short and straightforward and could use a “fill-in-the-blank” framing to allow participants to co-create the scenario with the facilitators.
Focus groups with site-specific reference groups	Did focus groups effectively identify ways in which reference groups influence men’s involvement in and decisions about family planning?	Triangulation between men’s perceptions of what others in the community expect of them and what these influential persons actually expect. Different reference groups may hold different norms.	Groups identified were not limited to reference groups but included sources of family planning information, such as health care providers. Influential groups with whom men do not feel comfortable talking about family planning were not captured in Phase 1, although the decision to include them was made by the team during data collection.	Health care providers, such as doctors and nurses, while not necessarily reference groups in the way, are defined in the SNET and are still privy and subject to the social norms operating in their communities. Findings from the FGDs provide a fuller picture of the context around family planning norms and practices.
Five Whys exercise	Did exercise identify root causes of why men do or do not engage with family planning decision-making or allow their partners to choose a method independently?	The goal of the exercise was to delve a level further with each “why?” to deepen understanding of why a norm or behavior exists.	In many cases, the 5 Whys provided were 5 separate responses to the initial “why” instead of digging into the underlying norms.	This exercise was too complicated, requiring the moderator and note-takers to decide in the moment which reasons were most in line with a normative framework and pursue that line of questioning. We would not recommend this method in future applications of the SNET.
Participatory analysis workshop	How well did participants understand concepts like social norms, injunctive norms, and sanctions? Did participants benefit from introduction of these concepts? Was the workshop productive in identifying interventions?	Collaboration between different stakeholders. Intercoder discussion at various levels to compare findings from urban and rural sites. Validation of themes developed through inductive coding before workshop.	Participants did not have a deep understanding of social norms, and certain concepts (e.g., the idea of social sanctions) were misunderstood. Social norms are not intuitive, and participants did not find social factors to be the most important influence on behavior. Insufficient time was given for the analysis.	Hosting a participatory analysis workshop may increase buy-in from stakeholders and decision-makers. However, if participants do not see social norms as a priority, it will be difficult to maintain a focus on social factors throughout. Workshops should be longer than 5 days or based only on a subset of data or data that has been distilled or pre-coded.