Scaling Up Normative Change Interventions for Adolescent and Youth Sexual and Reproductive Health: Literature Review Findings and Recommendations

EXECUTIVE SUMMARY
The Passages Project conducted a literature review of published grey and peer-reviewed literature to explore parameters of normative change interventions going to scale that were focused on adolescent and youth sexual and reproductive health. Forty-two (42) of 303 identified projects were eventually included in the review because they were going to scale and indicated an important focus on influencing community norms to achieve individual behavioral outcomes. Most projects were community based (35 of 42, or 83%) and employed social mobilization/community mobilization approaches, were designed to reach girls as well as boys, and were scaled up after evaluation of a pilot phase (39 of 42). Over half the reviewed projects (23 of 42, or 54%) employed evaluation designs that included comparison groups. Most assessed changes in knowledge (37), attitudes (39), and behaviors (41); relatively few assessed individual agency (14) and even fewer (12) assessed changes in perceptions of community norms, that is, perceptions of others’ behaviors and social expectations for their own behavior. Of these 12, only four (4) were explicit about what norms were being measured.

Most documentation was related to pilot efforts – only 13 focused on scale-up and seven of the 13 discussed institutionalization efforts (versus expansion). Almost three-quarters (30 of 42) of reviewed projects were scaled up by the same organization engaged in the pilot effort. Even though by definition the projects were in scale-up phase or operating at scale – the documents reviewed did not describe well the process of scaling up, how pilots were adjusted for new scale-up environments, indicators used to track scale-up activities, or methods to ensure intervention fidelity at scale. Still, the review highlighted several factors that projects cited as important during scale-up or during both pilot and scale-up phases.

 Effective strategies revolved around community-centered SBCC approaches and their potential for starting and sustaining normative shifts. Authors noted the importance of public discussion to create the critical mass needed to achieve sustained social change and the importance of community-driven collective action to diffuse new ideas within the community. Interventions were designed to be relevant and interesting, thereby engaging communities in the SBCC effort. They linked community actions to policies and programs to legitimize community-driven efforts.

 Attention must be paid to scale up implementation supports. In particular, interventions need to strategically engage influential community and government stakeholders, and to develop tools and guidelines for new users of the interventions.

 Staff must have mindsets and skill sets reflective of normative change. Periodic reflection is critical to create personal clarity on how norms affect staff as well as communities they serve, and to encourage agility and capacity to manage scale-up processes in changing environments without compromising intervention fidelity.

 Measurement of normative change and sustained impact is a challenge. The need to measure normative change and the absence of such measures in reviewed documents indicate it is not well understood and/or not prioritized as an outcome. Measuring the extent that normative change is sustained post-intervention is critical but not being done.
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Revising the Script: Taking Community Mobilization To Scale For Gender Equality

For those in the world of international human rights and development programming seeking to eliminate harmful social norms and practices at a global level, the steps to scale up seem relatively clear. Step one: Develop an innovative new approach to solve a pressing social problem. Step two: Prove the effectiveness of the approach through rigorous evaluation techniques. Step three: Having established the approach’s “evidence-based” credentials, share it widely!

Innovate, evaluate, scale up.

Of course, this is a heavily curtailed presentation of this process, which includes many additional steps, stresses, and potentially decades of demands on program teams. But its essence is undeniably compelling all the same, even common sense. New innovations are needed to solve unsolved problems. These innovations can only be proven to be effective if they are subjected to high scrutiny. And if they do work, then perhaps there is even an ethical or moral obligation to share them widely. In the case of a new vaccine for a widespread infection, for instance, this central script is tried and true. Previously devastating diseases have become historical footnotes thanks to some variety of “innovate, evaluate, scale up.” But not all innovations are as easily replicable as vaccines, of course, and practitioners and scholars in the human rights and development world are starting to uncover particular challenges in trying to follow this script for their innovations.

This brief exploratory study aims to inform the nascent conversation about the challenges of applying the “innovate, evaluate, scale up” script in one compelling field of recent innovation: community mobilization approaches to address socially and politically sensitive issues, particularly but not exclusively intimate partner violence. Intimate partner violence, for instance, is different in important ways from many other development and human rights challenges. This form of violence rest upon unequal power among the genders, and the central importance of power to this challenge makes preventing this violence more of a political issue than, for instance, eradicating polio. If ending intimate partner violence almost certainly requires transforming historic and deeply held social norms and power structures, what exactly does “scale up” mean? Who could or should undertake it?

Secondly, community mobilization approaches are likely effective precisely because of certain factors – among them, leadership by local activists and a central message of re-imagining power in society – that are difficult to reconcile with the realities of the public or private sectors that may be best placed to operate “at scale.” Ministries of health exist at least in part to support large-scale efforts to eradicate diseases, for instance; at least as yet, national governments don’t tend to feature Ministries of Dismantling the Patriarchy or Ministries of Gender Justice!

The authors of this study recognized that, at the outset, very little about these precise dilemmas had been written. As such, we set out to answer three guiding research questions at the heart of these dilemmas, with a balance of literature review and conversations with programmers who had faced similar challenges:

1. How have implementers of community mobilization initiatives attempted to “scale up” their efforts to shift attitudes about intimate partner violence and other socially and politically sensitive issues?

2. To what extent have any such approaches achieved success and effectiveness in “scaling up” to a national, regional, or international level?

3. What are the most salient obstacles, challenges, and lessons that have emerged from prior efforts to take these community mobilization approaches to scale?
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CONTRACEPTIF ARRÊT: RAISONS, DÉFIS, Et SOLUTIONS

Executive Summary

Analyses of Demographic and Health Survey (DHS) data indicate that 38% of women with an unmet need for modern contraception have used a modern method of contraception in the past but have chosen to discontinue use. This phenomenon, called contraceptive discontinuation, is defined as starting contraceptive use and then stopping for any reason while  still at risk of an unintended pregnancy. Discontinuation for reasons other than wanting to become pregnant contribute to unwanted fertility and can lead to pregnancies that may be terminated through unsafe abortion. Not all discontinuation is necessarily problematic. Some women discontinue a particular method because it is difficult to use or its use is unacceptable to the woman or her partner (for example, due to side effects) and subsequently switch to another method—one that is more suitable to them and oftentimes more effective. This evidence review focuses on the incidence of and reasons for discontinuation, on interventions to reduce discontinuation and/or enhance switching, and on the measurement and monitoring of discontinuation.

On average, over one-third of women who start using a modern contraceptive method stop using within the first year, and over one-half stop before two years. More than half of discontinuations are among women experiencing contraceptive failure or have method-related problems with its use, and so are still in need of effective contraception to prevent an unintended pregnancy. The likelihood of discontinuation is fairly similar across all methods except IUDs and implants, for which lower rates of discontinuation (other than for pregnancy or no further need, and for failure) are likely due to their greater contraceptive efficacy and the need for removal by a health care professional. A lack of robust longitudinal studies and limited qualitative research, however, limits our understanding of individual and couple decision-making that contributes to discontinuation, especially in developing countries.

The majority of women who discontinue for reasons other than wanting a child or no longer needing protec- tion report that they do so due to “method-related concerns.” These primarily comprise side effects such as prolonged bleeding or amenorrhea, which can concern or frighten women (and their partners), espe- cially if they are unexpected and experience problems with using the method, expressed by the woman or her partner. Side effects may also have adverse sociocultural consequences. In some cases discontinuation occurs when abnormal bleeding or spotting limits a woman’s ability to pray, prepare food, or have intercourse when bleeding or spotting, especially among clandes- tine users. Myths and rumors (e.g., causing infertility or cancer) also contribute to discontinuation.

Concerns around side effects or myths can be reduced through interventions such as:

  1. Enabling  women   to   discuss   potential   side   effects: When women are given the opportunity to discuss side effects with their providers and with members of their social networks, continuation can increase and switching can be facilitated through better understanding of the nature of side eff
  1. Engaging male partners: Enhancing couple communication about method characteristics can be effective in supporting continued use, particularly in the postpartum
  1. Ensuring client  confidentiality:  In some settings, male opposition to family planning may cause discontinuation of any method, thus ensuring client confidentiality is a priority int
  1. Dispelling misconceptions:  Service  providers  need to dispel misconceptions about the timing of initiating a method, especially when switching, through the pregnancy checklist or testing, and also for the perceived need for occasional “rest periods” from using hormonal
  1. Counseling  women   who   experience   prolonged amenorrhea: Knowing that their menses will return and the average time for this to happen can reassure women who want to plan to become pregnant in the future.

DHS data indicate that between seven and 27% of women stop using a contraceptive method for reasons related to the service environment, including service quality, availability of a sufficient choice of methods, commodity stock-outs, and ineffective referral mechanisms. Interventions to address these include:

  1. Increasing  the   number   of   methods   available: Broadening the method mix available to women during consultations or through referrals is Adding one method or its equivalent to a program is associated with an eight-percentage-point decrease in contraceptive discontinuation.
  1. Enabling  women   to   switch   immediately:   Women must be able to continue protection against unintended pregnancy by starting use of a more acceptable and effective method immediately if they experience
  1. Ensuring  effective   partnerships   between alternative  sources  of  supply  and/or  providers: For example, through task sharing, to facilitate wider options for selecting an acceptable method and/or switching to

 

  1. Improve follow-up mechanisms: Reminding women of appointments for resupply methods, for

example through mobile technology, can reduce unintentional discontinuation due to missing the clinically allowable grace period for resupply.

  1. Bringing the  methods  to  women:  Women can incur significant time and transport costs for resupply leading to discontinuation or late resupply; community-based, workplace-based, or outreach services that take the method to the woman can enhance c

Adolescents have higher rates of discontinuation than older women, but the obstacles to consistent use are poorly understood and often context-specific. For example, providers may have negative views about premarital sexual activity or erroneous perceptions about the suitability of long-acting methods for nulliparous women. Discontinuation among adolescents has significant personal and societal consequences, especially for countries with burgeoning youth cohorts, as high levels of adolescent unwanted fertility will impede young people’s participation in the education and employment opportunities needed to achieve a demographic dividend. Moreover, frequent starting and stopping of contraceptive use may reflect the sporadic nature of many adolescents’ sexual activity that could be protected through pericoital methods (e.g., condoms, emergency contraception pills [ECPs]).

Individuals’ and couples’ motivation, intentionality, and ambivalence for desiring or avoiding a pregnancy and its influence on discontinuation remains poorly understood. Incorrect understanding about physiology and the perceived meaning and significance of regular menstruation may govern women’s use of contraception over and above providers’ medical advice about a method. Better understanding of how women perceive whether they have discontinued is crucial, therefore, to inform appropriate counseling and information so that women do not completely stop using contraception when they do not want to conceive. Lessons can potentially be learned from approaches for enhancing adherence with other preventive commodities, for example to antiretroviral medication, to support women who are ambivalent about continued use of a method.

Despite discontinuation being what Jain and col- leagues have termed the “leaking bucket” that reduces the impact of family planning programs, FP2020 does not track a dedicated indicator that measures all-method or method-specific continuation rates (Jain 2014a). Several program indicators, including those used by Family Planning 2020 (FP2020) and Performance Monitoring and Accountability 2020 (PMA2020), do measure the various factors associated with discontinuation (usually through DHS-type surveys), but capturing client-specific information about method use over time is challenging because data need to be collected prospectively. Most current measures of discontinuation and switching are retrospective through questionnaire surveys and contraceptive calendars, and health and demographic surveillance systems (HDSS) have rarely measured contraceptive use dynamics. Health management information systems that follow clients longitudinally do exist (e.g., DHIS2, CLIC) and could be adapted to measure, detect, and potentially reduce discontinuation and/or facilitate switching, but mainstreaming such systems, especially in public sector programs, would require a major investment and reorientation of existing client registration systems. Given the significant influence of discontinuation on achieving  FP2020’s goal, however, such investment would seem to be not only warranted but an urgent priority.

We propose a theory of change that identifies several pathways through which interventions addressing heath systems, service quality, and the sociocultural environment could reduce unnecessary discontinuation. Al- though many of these are based on evidence demonstrating their feasibility and effectiveness in certain contexts, implementation research is needed urgently to determine their utility in specific national settings and among various subpopulations. Research using quasi-experimental designs is also needed to test the effectiveness of promising interventions that may (or may not) enhance continuation. Social science research is also needed to better understand fertility intentions and contraceptive use within specific contexts.

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