Sexual and Reproductive Health: How Can Situational Judgment Tests Help Assess the Norm and Identify Target Groups? A Field Study in Sierra Leone

"Knowing what the perceptions related to sexual and reproductive health are allows us to identify...who needs to be convinced to change..., who is supporting of healthy behaviors...and what are the (false)-beliefs, values, and perceptions of the population that need to be addressed to build effective interventions."

Sexual and reproductive health is a challenge worldwide but especially in Sierra Leone, where 2019/2020 data indicate that half of women aged 25-49 give birth for the first time before they are 20 years old, 61% of women experience physical violence, and 83% of women and girls aged between 15 and 49 years have undergone genital cutting. Social and behaviour change (SBC) interventions are a way to modify the behaviour behind these and other challenges. Data on what the priority group believes and which social norms underlie their behaviour are is crucial to building effective SBC interventions that go beyond simply supplying information and education to raise awareness. This paper presents cross-sectional data collected in Sierra Leone on sexual and gender-based violence (SGBV), family planning (FP), child, early, and forced marriage (CEFM), and female genital mutilation (FGM) using situational judgment tests (SJTs) to provide a picture of the norms related to those topics among men and women of various ages. The hope is that using the SJT method for norms and beliefs could help ensure that future SBC interventions are tailored to the specific needs of priorty populations.

As the researchers explain, existing studies of community beliefs and norms mainly use Likert scale agreement with statements. However, this methodology has been criticised as not necessarily optimal for this type of research. For example, elements of the format, such as the ascending or descending order of the response options, have been found to influence the answers. Other researchers have reported cases where participants of non-western origin had difficulties choosing one option among the scale and instead answered "yes" or "no" to each degree of the scale. In contrast, SJTs, which have been chiefly used in education and occupational psychology, are considered to be less prone to bias associated with self-report, such as respondents trying to give an answer they suspect the enumerator will think is the best choice.

The SJT tool was integrated into a household survey being used as a baseline survey for the BRIDGE project in Sierra Leone. The BRIDGE project is implemented by Sierra Leone Red Cross and supported by the Finnish Red Cross and Icelandic Red Cross in six districts: Bo, Bonthe, Kenema, Kono, Moyamba, and Pujehun. Thirty villages were randomly selected from 62 villages where the project would be implemented, with five villages selected from each district. In each of the six districts, four enumerators were trained in the survey and assigned a team leader who was also present at the training. For five days, team leaders and enumerators went to one village per day. Each enumerator was asked to collect at least five surveys per day. Among the villages, households were randomly selected, and potential respondents were visited in their homes to see if they were willing to participate. Data were collected from 566 respondents using KoBo Toolbox software, with all enumerators using their own smartphones loaded with the survey.

The enumerators presented ten SJTs to respondents: three SJTs about FGM (two for female respondents, one for male respondents), three about CEFM, two related to FP/adolescent pregnancy, and two about SGBV. The response options include one action that is the most appropriate for the question asked in that situation (coded to have the highest value, that is, 5), one or two actions that are somewhat appropriate (coded to an intermediate value, between 2 and 4), and one or two actions that would be inappropriate for the question asked in that situation (coded to the lowest value, that is, 1). Each response option is intended to be logically possible for the specific scenario. Example: "Tell Fatmata that she should get contraceptive pamphlets from the clinic and talk with Musa about the options they have as a couple" is one possibility for the scenario "Imagine that your oldest brother, Musa, is planning to marry one of your friends, Fatmata. Fatmata said she wants to wait to have babies until she has finished school. She wants to use contraceptives and asks you what she should do. Which of the following are you most likely to do?" Respondents were instructed to choose the option that is closest to what they would do.

The results provide insights for future SBC interventions, such as that FGM in particular would be a priority topic, in comparison to the other topics (for which the norms seem to be stronger against those practices). For example, in response to an STJ scenario that began, "Imagine that you were cut when you were 12 years old....You are talking with a small group of women about when they have children - whether they will allow their daughters to be cut....One of the women says that she will 'definitely cut' her daughter, saying it is tradition..." Only 11.9% said they would "Explain the physical and psychosocial problems that many girls and women suffer from cutting and explain that you, too, still suffer these effects" (coded 5). The majority of respondents (42.4%) chose the option "Agree with the friend publicly just to get her to stop talking about it" (coded 2), and nearly a third (28.8%) answered "Agree that traditions are strong around cutting and that women should suffer to maintain these customs" (coded 1).

Two SJTs were presented to respondents of both gender (one on SGBV and one on FP), but in both cases no significant difference was detected on the responses according to gender. This lack of difference might come as a surprise; however, other studies have showed that gender inequitable norms are often shared by both men and women. Age differences emerged and suggest priority groups to be reached  - for example, on the topic of FGM, younger female respondents and older male respondents gave the lowest coded responses, which reflected less-appropriate behaviour in the coding.

In terms of validity of the measurement methods, SJT answers correlated positively with other items in the survey, but the magnitude of the association is often small, and sometimes not significant. Thus, more studies are needed to further explore the validity of this measure by comparing against a reference value.

As reported here, the SJTs were a helpful tool for Sierra Leone Red Cross to ascertain where to focus their efforts for each topic, including with which priority group within a specific community. It is also possible to use SJTs to identify who is supportive of the desired behaviour and could act as peers in an SBC programme.

The researchers recommend methods to change social norms, such as mass media role modeling and mobilisation of social networks, and methods to change communities, such as community development and social action. Intervening not only at the individual level, but also at interpersonal, community, and policy levels, could increase the chances of success, as individual behaviours are embedded within a wider context.

After being used for baseline assessment (as done in the study reported here), the same SJTs could be used again after an SBC intervention. The answers' evolution (or lack thereof) would indicate if the intervention reached its goal or not in terms of modifying norms and beliefs, though questions remain (e.g., do people "allow" themselves to answer differently to the same vignette when presented the second time? Is there any bias associated with the use of SJTs for monitoring?).

In conclusion, using SJTs could offer SBC practitioners a new perspective on sexual and reproductive health themes and a more targeted approach to assessing and responding to existing beliefs, attitudes, and behaviours. This methodology could complement other community assessment data collection tools and could orient the direction of the programme in its planning phase.