Community Dialogue to Shift Social Norms and Enable Family Planning: An Evaluation of the Family Planning Results Initiative in Kenya

"[A]n intervention that supports open and public dialogue about gender, sexuality, and family planning may increase use of family planning among couples in settings where the prevalence of use is relatively low."

Research has highlighted the ways in which use of family planning (FP) in various contexts around the world is shaped by social and gender norms, such as those that limit women's autonomy and restrict communication and decision-making between men and women. Despite such evidence, the lack of consensus about how to best measure these complex social constructs hampers the ability to compare programme effects across studies, populations, and cultural contexts. Thus, the objective of the research described in this article was to evaluate the impact that an intervention centred around community-level dialogues had on household-level gender dynamics and reported use of FP in Kenya. The evaluation used several scales from WE-MEASR (Women's Empowerment-Multidimensional Evaluation of Agency, Social Capital, and Relations), a tool CARE developed following multi-year research into the effects and impact of their women's empowerment programming.

Implemented in Siaya County, Nyanza province, Kenya, the Family Planning Results Initiative (FPRI) was grounded in CARE's Social Analysis and Action approach. In brief, CARE trained about 150 community-based facilitators, who then held 759 dialogues over a 3.5-year period that were meant to normalise communication about gender norms and FP and to catalyse participants' critical analysis of how gender norms and dynamics restrict FP acceptability and use. Held in an array of settings, such as markets, churches, women's groups, and village meetings, the dialogues often featured performances by local theatre groups and role modeling by community leaders and satisfied FP users.

The researchers used both qualitative and quantitative methods to evaluate the intervention. At baseline (February 2009: 650 women; 305 men) and again at endline (December 2012: 305 women; 285 men), they conducted household surveys to collect data about men and women's socio-demographic characteristics, pregnancy intentions, FP knowledge, beliefs, attitudes, and use. At endline only, they measured key gender-related beliefs and behaviours and exposure to the intervention and conducted in-depth interviews with 10 purposively selected couples to further explore enablers and barriers to FP use.

Selected quantitative findings:

• At baseline, 34.0% of women and 27.9% of men used a modern FP method, compared to 51.2% and 52.2%, respectively, at endline (p0.05).
• Exposure to FP dialogues was associated with 1.78 (95% confidence interval (CI): 1.20-2.63) times higher odds of using a modern FP method at endline for women; in fact, exposure to any topic covered during the intervention increased the odds of women using any method of FP by 62% and the odds of using a modern method by 60%.
• None of the intervention exposure measures was significantly associated with men's reports of current use of FP. For men, approval of FP, more equitable (less traditional) beliefs about gender roles, and a desire to not have more children were the strongest predictors of FP use.
• Women's use of modern FP was significantly associated with higher spousal communication, control over own cash earnings, and FP self-efficacy.

Selected qualitative findings:

• The intervention offered exposure to discussion of the benefits of FP: One woman recounted how her peers not only described, but provided "living proof", of positive experiences.
• Dialogues appear to have increased the acceptability of not only talking about, but also using FP, especially when chiefs/religious leaders both advocated for and modeled open communication with spouses and use of FP. The involvement of these prominent male opinion leaders may have helped legitimise men's participation in communication and decision-making about FP.
• Women described shifts towards more equitable household roles, with husbands beginning to help with household duties. Furthermore, some couples described starting to manage household budgets together and making more joint decisions about household purchases and assets. However, both men and women stated that women still did the majority of household work and that men maintained the majority of household decision-making power.
• It appeared that public discourse precipitated conversations on FP in the household, as couples discussed what they heard and learned. Consequently, men and women reported more open and equitable communication about FP.
• While women described many benefits of having partner support for using FP, including increased relationship harmony, they also discussed the importance of being able to independently access FP methods when faced with partner opposition.

Comparing the findings to the intervention's theory of change (above), the study found that couple communication and self-efficacy are 2 of 3 key variables the researchers expected to be positively associated with exposure to the intervention. However, the third key variable - women's greater participation in household decision-making - was not a significant predictor of FP use.

Of note, the 2 areas with the most striking differences in men's and women's responses at endline were reproductive intentions (60.0% of men and 30.2% of women wanted another pregnancy at the time of the interview or within the next 12 months) and approval of women's use of FP without her partner's permission (66.3% of women and only 11.6% of men approved of such use). These results might suggest that when men's intentions are more closely aligned with women's, the couple is more likely to use FP.

In conclusion, by catalysing open dialogue about gender and FP, the intervention shifted social norms, enabled more equitable couple communication and decision-making, and, ultimately, increased use of FP, especially for women. The researchers urge "smaller scale studies to examine the impact of specific types of dialogues and experience sharing on specific outcomes. Future studies should consider the local context and, if possible, use a similar mixed-method approach."