South Sudan Social Norms Assessment

"Gaining insights into social norms and their key drivers is important for designing SBC [social and behaviour change] programs and activities that are locally appropriate and culturally sensitive to the diverse South Sudanese population, as well as understanding what behaviors can be most effectively targeted."

There is growing evidence that understanding the social norms that influence behavioural intentions and actions is critical to effective messaging and programming for family planning (FP) interventions. Social norms include norms about "what I think others typically do" (descriptive norms) and norms about "what I think others expect me to do" (injunctive norms). The goal of this assessment was to inform the development of the United States Agency for International Development (USAID)/South Sudan's social and behaviour change (SBC) efforts related to increasing voluntary use of FP and reproductive health (RH) care, awareness of gender-based violence (GBV), and health-seeking behaviour. Assessment recommendations are provided and include: building on positive norms as an asset to promote FP; supporting male engagement strategies; engaging influencers as change agents in social norms transformation; and including health providers as partners in SBC and social norms transformation.

Conducted by the USAID-funded MOMENTUM Integrated Health Resilience in 2021, the assessment investigated social norms related to FP choice and decision-making, menstrual hygiene and management (MHM), attitudes towards GBV, and health-seeking behaviour, as well as on influencers and gatekeepers of social norms in South Sudan. Prior to initiating data collection, key informant interviews (KIIs) were conducted with USAID/South Sudan staff and implementing partners, including Intra-Health and Breakthrough ACTION. Then, the cross-sectional, descriptive assessment was conducted, drawing on stakeholder KIIs and in-depth interviews (IDIs) conducted in 5 counties: Budi, Wau, Bor, Leer, and Yambio. In total, 120 women and 83 men, 34 FP/RH providers (16 women and 18 men), 31 key influencers (10 women and 21 men), and 7 stakeholders took part.

The assessment employed the Theory of Planned Behavior (TPB) for its orienting framework. By explicitly linking beliefs and behaviour, the TPB holds that intention toward behaviour (such as FP use), subjective norms, and perceived behavioural control together shape an individual's behavioural intentions and actions.

Selected findings include:

• Some sections of the community are conscious or aware of the benefits of contraceptive use and hold supportive behavioural expectations on child spacing embedded in community values and aspirations on child well-being. However, this awareness is infrequently translated into decisions on modern contraceptive use, mostly due to restrictive social norms on childbearing, decision-making, and modern contraceptives that constrain women's autonomy and decision-making power related to their reproductive health choices.
• Some women, adolescent girls, and FP providers exercise agency through negotiations, resistance, and discrete practices, mainly seeking services secretively. However, these forms of agency have not achieved community-wide change on modern contraceptive use. In some instances, these actions have instead reinforced women's limited FP autonomy and decision-making. Some of these practices have also made women and girls susceptible to physical and psychological GBV.
• Women and young people's intention to use modern contraceptives is constrained by social norms that place the decision-making responsibility with the man and his family. The inclusion of the family engenders RH decisions as aspects of collectivism. Given that FP providers are part of the social network of the community and bounded by the restrictive social norms, they are cautious in their attempt or decisions to provide FP services to women and girls.
• Social and gender norms on menstruation define appropriate behaviour for girls in their menses, including dietary restrictions and social exclusion from certain social spaces and activities. The norms also define the identity of girls that have started menstruating: as mature, ready for marriage, and adults. There are several sources of materials for MHM, ranging from relatively more domestic-oriented sources, such as at home, to out-of-home sources, such as riversides or streams. Mothers and peers are the primary source of information on management of menses. Elders, health care providers, and female teachers support mothers in their role.
• There is a shared expectation that sex before marriage is prohibited. Arranged marriages are a common, acceptable practice in the community. Parents take the lead in negotiations for marriage of their sons and daughters. There are socioeconomic connotations that are associated with marriages, with daughters being perceived as a source of such wealth as cows and money.
• GBV in the RH context manifests in the form of reproductive coercion, controlling behaviours, physical violence, forced/early marriages, and psychological violence. Certain types of GBV, such as physical and psychological violence, constitute part of the social sanctions prescribed by social norms that hold in place limited autonomy and decision-making of women and girls on RH. These negative social sanctions also extend to FP providers: Several providers cited instances where they had been physically assaulted, verbally abused, or threatened for providing FP services to women without consent of the male spouse.
• A range of key influencers of decisions to use modern contraceptives, sexual debut, health-seeking behaviour (in relation to FP), and MHM were identified. They are in a position to execute different functions critical to social norm change. The key influencers reinforce in a significant way the dominant attitudes, social norms, and practices common in their communities.
• Positive or alternative norms, beliefs, attitudes, and practices on modern contraceptive use, MHM, sexual debut, health-seeking behaviour, and GBV are beginning to emerge in some sections of communities, especially in the urban areas. These alternatives challenge the existing restrictive social and gender norms and can serve as building blocks for planned SBC activities.

Selected overall recommendations based on the assessment include, for example:

• Increase women's and girls' agency to initiate conversations with FP providers in order to promote more meaningful interactions between the providers and women and girls in need of FP.
• Strengthen the capacity of service providers to provide adolescent-friendly sexual and reproductive health (SRH) services, particularly contraception services, and in establishing adolescent- and youth-friendly corners or spaces to increase discussion and access to SRH information and FP services.
• Given the GBV risks associated with women and girls seeking FP services in secrecy, combine programming for promoting uptake of FP with interventions geared toward prevention and response to GBV.
• Build on positive norms, especially on child spacing and the values related to healthy children and child welfare, as assets for promoting FP - avoiding any harmful, unintended outcomes on the rights and well-being of women, adhering to "do-no-harm" principles, and promoting gender justice.
• Provide key influencers with comprehensive information and relevant tools to engage audiences to foster normative change, and engage key influencers as change agents in SBC work and social norms transformation.
• Include health providers as partners in SBC and social norms transformation through capacity building and involvement in co-creation workshops for SBC interventions.
• Given the male domination in RH decision-making, emphasise innovative male engagement strategies that can harness men and boys as partners in promoting the use of SRH services, including modern contraceptives.
• Ensure that SBC activities unpack respected community values and gender norms, such as child well-being, maternal health, the importance of healthy children, and healthy fertility, and allow for co-creation of feasible solutions within households and communities.
• Ensure audience segmentation within MIHR activity areas, which could facilitate tailored programmes and messages during project implementation (e.g., county/payam-level co-creation of SBC activities) in collaboration with Breakthrough ACTION and other key implementing partners.

Among the specific recommendations related to SBC design, programming, and messaging are to incorporate findings into collaborations with Breakthrough ACTION's innovation teams to integrate SBC messages into information sessions for mothers at health facilities and in community outreach. This approach could involve identifying influential women leaders to organise mothers' groups (including mothers-in-law when appropriate) to facilitate a series of dialogues prioritised by the mothers on topics such as MHM, sexual debut and marriage, and FP care seeking. When planning such dialogues, "It is important to carefully study the values that embody restrictive norms so that the positive norms being promoted are in line with these values, especially if they promote gender equality. The Community Action Cycle, developed by the Institute of Reproductive Health and Save the Children, is a suitable approach to adapt..."

MOMENTUM Integrated Health Resilience suggests that, "as each county undertakes participatory workshops to develop county-specific, strategic SBC action plans, the recommendations are unpacked with relevant stakeholders at the payam and boma levels who will help to co-design and assist in the implementation and monitoring of SBC and gender activities."

Editor's note: On September 21 2022, MOMENTUM Integrated Health Resilience held a webinar (conducted in English - see video link below - with French interpretation) to discuss the findings of this social norms assessment in South Sudan. Presentations focus on: the use of vignettes to understand social norms; social norms related to FP, GBV, and other thematic areas; and how MOMENTUM is using the findings to develop, implement, and monitor county-specific SBC action plans with key stakeholders..