Measuring Women's Agency and Gender Norms in Family Planning: What Do We Know and Where Do We Go?

"...increased clarity and recognition of the importance of gender equity on family planning, particularly as gender equity relates to woman and girls' agency and gender equitable social norms operating at multiple levels. To that end, measurement has lagged and needs our greater attention..."

It is increasingly recognised that, to achieve sexual and reproductive health (SRH) goals and rights, including Sustainable Development Goal (SDG) 5, we need to address gender inequalities in health care and in community and family practices, and the restrictive and gendered social norms that reinforce these inequalities. This White Paper presents a landscape analysis of measures on women's agency and gender norms in family planning (FP) research in order to develop insights for FP programmes in low- and middle-income countries (LMICs). It was created by EMERGE (Evidence-based Measures of Empowerment for Research on Gender Equality), a project focused on gender equality and empowerment measures to monitor and evaluate health programmes and to track progress on SDG 5.

The landscape analysis is rooted in EMERGE's Can-Act-Resist framework of women’s agency and gender norms:

• Can refers to the capacity (perceived or actual) of the individual or collective to engage in actions against or inconsistent with social norms placed upon them due to their social standing or position (e.g., self-efficacy to decide and discuss fertility and contraceptive preferences). Critical consciousness of this action is an important precursor for perceived capacity to move toward action.
• Act refers to giving voice or communicating one's goals, decision-making about issues affecting one's goals, or simply engaging in direct actions to achieve one's goals - with or without knowledge and input from others or those in authority (e.g., voicing consent on FP goals).
• Resist refers to persisting in desired actions against negative external feedback or backlash (e.g., alienation or abuse due to using contraception or not becoming pregnant); this can be through negotiation, bargaining, and action without consent.

The EMERGE Empowerment Measurement Framework further defines norms affecting the empowerment process as Learn-Adhere-Enforce:

• Learn happens throughout the life cycle as individuals observe how others behave and internalise social expectations of them. These socialisation mechanisms align with categorisation of norms into descriptive (perceptions of what people do) and injunctive (perceptions of what people should do) norms.
• Adhere follows learning of social norms, where the individual or collective either complies with or challenges the norm.
• Enforce occurs via sanctions (rewards or punishments) for adherence to or deviation from a social norm. Measurement of a sanction should consider its sensitivity and strength, as felt by the affected individual. Sensitivity is the degree to which an individual cares about the given sanction; strength is the perceived level of benefit of a reward or cost of punishment given for adherence or non-adherence to a norm.

The landscape analysis was conducted in three phases:

1. Key informant interviews were conducted with over 40 field experts in SRH research and programmes. There was much agreement on the need for greater clarity on conceptual frameworks and definitions, as well as to improve measurement rigor through mixed methods formative research and psychometric testing. Field experts indicated that agency concepts in FP were diverse in content coverage; in contrast, gender norms constructs within FP research remained a gap. Experts also suggested that the need for context adaptation or validation of measures needed to be balanced against greater harmonisation of measures through cross-national efforts.
2. A scoping review of peer-reviewed published literature was conducted to examine the constructs covered by measures and to identify knowledge gaps. A total of 664 journal articles were identified, which provided 152 unique measures (Appendix 4: Table 5 provides the full list of measures). Measurement development and testing is occurring globally, but the United States remains overrepresented in this work. Findings indicated that the largest pool of measures focused on contraceptive use, particularly in the area of attitudes and beliefs, quality of care, and male support and engagement. Dimensions of agency in fertility emerged as an underrepresented area, with existing measures focusing on external response to action measured via reproductive coercion. Measures on attitudes related to FP emerged frequently in the review; in contrast, measurement of norms in FP research requires more study inclusive of understanding the role of sanctions and power holders in FP norms.
3. EMERGE carried out quality appraisal of the 152 identified measures, 34 of which provided psychometric data and were tested in one or more LMICs. Further review of the items using a gender lens showed 10 strong/rigorous measures that could be integrated in field surveys or harmonised in cross-national studies based on study priorities. An additional 21 measures showed promise; these measures tapped clearly into a coherent construct but needed psychometric testing in an LMIC setting or cross-national validation to increase generalisability and use.

In short, this White Paper on the state of measurement of agency and norms in FP shows:

• Several measures exist that demonstrate conceptual clarity, methodological rigor in development, and cross-contextual validation that can be readily used or harmonised through in-country or cross-country surveys. These measures have operationalized key agency constructs such as self-efficacy, voice, and decision-making, as well as on restrictions to agency such as reproductive coercion. These measures offer insight into demand-side gender-focused determinants of FP behaviours or health-seeking at the levels of the individual, couple, community or systems. An example of a measure with a high psychometric score is the Sexual Relationship Power Scale (SRPS), which is a 23-item measure of individual perception and experience of power within an intimate relationship, separated into two domains. Different features captured by the relationship power scale include the use of violence, sexual freedom, and decision making about daily activities.
• The field demonstrates a number of promising measures for key agency and norms constructs within underrepresented FP domains that need investments of conceptualisation, adaptation, and testing. In particular, the review found good understanding of some agency constructs of contraception use, but there is a need for deeper insight into the preferences and motivations guiding fertility, use, non-use and unmet need. Measures to study FP norms and stigma regarding contraception use and abortion also need further development for FP programming in LMICs.
• The field shows measurement gaps in several domains of agency and norms in FP that have global and national relevance in the implementation and evaluation of FP programmes and services. These include: agency in fertility and FP service access and use; resistance against fertility pressures and covert use; positive masculinity; bargaining and negotiation; sanctions and backlash; mistreatment and abuse; and abortion communication, agency, and quality.

Based on this review, EMERGE concludes that the FP community of practice cannot afford to shy away from investing and engaging in complex topics around agency and gender norms that influence FP preferences, uptake, and experiences - and, consequently, women's health and lives and the well-being of their families. EMERGE recommends the following next steps: (i) ensuring greater inclusion of meaningful and rigorous measures of agency and norms in FP programmes and survey opportunities; (ii) instituting forums and conversations on measurement within the FP community of practice; and (iii) creating measurement resources for this community of practice of researchers and implementers, especially focused on prioritised areas and contexts.

Per EMERGE: "These steps can feed into designing and delivering better family planning programs as well as conducting more rigorous and meaningful evaluations, thereby enhancing the quality and dignity in family planning access for women and their communities. They also provide an opportunity to improve the quality of family planning services on the ground that communities need now more than ever."

EMERGE Project Members include: Anita Raj, PhD (Principal Investigator); Nandita Bhan, ScD (Co-Principal Investigator); Lotus McDougal, PhD; Rebecka Lundgren, PhD; Jay G. Silverman, PhD; Arnab Dey, MBA; Nabamallika Dehingia, MBA; Anvita Dixit, MA; Jennifer Yore, MPH; Namratha Rao, MPH; Meredith Pierce, MPH; Gennifer Kully, MPH; and Edwin E. Thomas, BA.