Measurement of Social Norms Affecting Modern Contraceptive Use: A Literature Review

"In 2017, as part of the USAID-funded Passages Project, we set out to systematically assess what empirical evidence exists around the relationship between social norms and use of modern family planning methods. The results are detailed in, “Measurement of Social Norms Affecting Modern Contraceptive Use: A Literature Review,” a new report published in Studies in Family Planning."

This review of evidence on social norms and use of modern family planning methods, published in Studies in Family Planning, used keyword searches to find original research focusing on family planning and norms, as well as "additional lexical searches, title screening, and abstract screening to identify studies that met the following criteria:

• measured use of a modern family planning method as a primary study outcome
• measured either a behavioral or an attitudinal norm using a specified reference group
• purposefully included social norms as part of a theoretical framework for the study."

Against a background of progress on the supply side of family planning methods, barriers to behaviour change appear to be slowing uptake. Recognised barriers, including social pressures, sanctions, and approval of family members and community, arise from social norms, which govern behaviours of those who wish to fit into their group (family, community). Behavioural ethicists suggest that behaviour can be altered by altering the expectations of about how others behave and how others think one should behave. These beliefs about expectations of common practices (empirical expectations or descriptive norms) can be measured by asking respondents what they believe others do. And shared attitudes about social approval (normative expectations, injunctive norms, or subjective norms) can be measured by asking respondents what they believe other should do.

Of the 17 studies that met these criteria, most were sub-Saharan studies on condom use (15) as the behavioural outcome, but terminology was inconsistent and no common measure of social norms was found to be consistent across the studies. For example, some measured consistent condom use, some measured condom use at last sex. They asked about different types of partners and offered various response options. Studies used various behaviour theories or models, some constructing their own frameworks. Notably, many theories were interrelated. 

Most studies pre-identified influencers, including reference groups. However, two asked participants to identify these individuals and groups and then asked if the respondents believed these "confidants" used condoms. Five studies measured both descriptive and subjective norms. Some used scales to measure norms, but no two scales were the same. This lack of standardisation revealed a need for practitioners to use more consistent terminology and tospecify the type of norms they are seeking to measure in order to bring greater calibration and comparability to social norm measures.

The top recommendations from the manuscript are summarised as follows on the associated blog "If you don’t measure it, how do you know if it changed?!" on the Institute for Reproductive Health website:

1.  "Additional research is needed to bolster the evidence base around social norms and family planning use, particularly looking at methods other than condoms. There is also a need for data collection on social norms that uses robust study designs, including studies that randomize selection and are conducted longitudinally.
2. Researchers should allow respondents to identify the type of people or the specific people in their lives who influence their behavior (e.g. rather than assuming “friends” are the most relevant influencers or “reference group”). Studies and programs can also distinguish between reference groups for who’s doing the behavior and those who approve of the behavior.
3. Authors should clearly specify the type of norms they are seeking to measure and the theoretical framework they are using to conceptualize their measure to help reduce conflation around terms like social norms, gender norms, normative beliefs, etc. In turn, journal editors and reviewers should require this type of clarity in submitted manuscripts and should advocate increased use of standardized or commonly used terms and measurement approaches.
4. We encourage researchers and practitioners to consider measuring social norms at a more collective level. In other words, as opposed to relying solely on individual, self-reported data – like we collect in most surveys and program evaluations – instead think about looking for data that evidences changes at more macro program or policy-levels. With these data, there may be fewer concerns with biases and reference groups and thus they may be more easily obtained and a more accurate representation of norms."