Using Vignettes to Gain Insights Into Social Norms Related to Voluntary Family Planning and Gender-Based Violence in South Sudan

"Gaining insights into social norms and their key drivers is important for designing FP/RH [family planning/reproductive health] interventions that are locally appropriate and culturally sensitive to the diverse South Sudanese population."

Social norms are the shared expectations about behaviours that are held within collective groups. In South Sudan, social norms can affect the use of voluntary family planning and reproductive health (FP/RH). For example, 61% of respondents to a household survey conducted in South Sudan noted that gender-based violence (GBV) was acceptable under certain circumstances. Global studies have shown that women who experience intimate partner violence (IPV) - a category of GBV - often have little choice about sexual activity. Conducted in 5 counties in South Sudan, this cross-sectional study explored social norms related to FP/RH and decisions related to contraceptive use and GBV. It was carried out by MOMENTUM Integrated Health Resilience, a United States Agency for International Development (USAID)-funded project working to reduce maternal and childhood morbidity and mortality and increase health resilience in fragile settings, including South Sudan.

The study used vignettes, short stories that allow respondents to share their opinions and feelings without directly speaking about their own experiences, to explore social norms about "what I think others typically do" (descriptive norms) and about "what I think others expect me to do" (injunctive norms). Participants were asked to respond to vignettes about a fictional South Sudanese couple experiencing transitions from sexual debut and marriage through the time a couple has an established family with children. Respondents included community members, FP/RH providers, and key influencers (e.g., religious leaders, traditional leaders, elders). In total, 203 community members, 32 FP/RH providers, and 31 key influencers were interviewed.

Participants reported that it was culturally appropriate to expect married women to fulfill their biological roles by bearing children, which was linked to Christian directives in the Bible. Furthermore, they noted that having children was a community mandate for family and clan continuity. In line with South Sudan's patriarchal culture, the study identified restrictive social norms related to FP/RH, including entrenched, dominant gender roles (i.e., requiring male consent to use contraceptives) and risk for the woman and her provider if she accesses FP/RH services. Use of contraceptives without her husband's consent could put a woman at risk of physical assault, threats, verbal abuse, and/or divorce. Some respondents remarked that local chiefs were known to punish FP providers who offered services without male consent.

Key influencers reflected the dominant community attitudes, beliefs, and practices and, therefore, reinforced existing community, social, and gender norms. Social norms articulated by study respondents were imbued with various community values related to male privilege, family honour, fertility, and collectivism, among others. However, the study also identified emerging social norms that support the use of FP. For instance:

• Interviews revealed that supportive social norms are gaining acceptance regarding women's voice and agency; it was found that some women can negotiate their reproductive choice with their partners and participate in planning their families, which has not always been a widely accepted norm.
• Across most respondent groups, postpartum abstinence (for 2-3 years after birth) was a commonly held social norm, mainly to support the child's health and well-being.
• The importance of education, especially for girls, was mentioned by several respondents, particularly by those living in urban settings, as well as younger adults and some FP providers. They emphasised the role of contraceptives in school completion. Relatedly, although early marriage is common, some began to question this practice.

Per the researchers: "The use of vignettes led to a more comprehensive understanding of the social norms associated with FP/RH, as well as the risk of GBV, that a survey or semistructured interviews would not have achieved." They recommend the use of vignettes to explore social and gender norms among other populations and other sensitive topics, including in contexts beyond South Sudan.

Findings from this study were shared with stakeholders and the communities included in the study sample. The communities are now working with MOMENTUM Integrated Health Resilience to develop and implement FP/RH programmes that address constraints presented by existing social norms and that build on and strengthen supportive social norms (e.g., the value of male engagement). The researchers explain: "This dissemination of findings and community dialogues can lead to an organic movement of collective agency. Individuals and groups will then carry these findings and solutions toward social norm transformation to their families, social groups, and networks. As they gather in the market, at water pumps, churches, and other centers for meeting, they will informally generate new discussions and generate solutions through this snowball manner. Through this informal process of collective agency social norms transformation can occur, engaging women, youth, men, and all segments of the community." Such engagement has led communities, with support from MOMENTUM Integrated Health Resilience, to implement social and behaviour change (SBC) and client-defined quality activities.

These actions reflect MOMENTUM Integrated Health Resilience's conviction that "Social norms transformation can only occur through a collective or participatory approach. Individuals and collective groups must own the need for social norms transformation and the importance for women seeking FP/RH services and decide solutions aimed at increasing use of FP/RH."

The researchers conclude that, to reduce inequalities in access to FP/RH, "it is essential that programs working to promote FP in South Sudan consider the challenges presented by social norms and the risk to the women and their FP/RH providers. FP programming often addresses gender inequities but does not consider the risk presented by existing, incompatible social norms. An FP/RH program in South Sudan should build upon and expand supportive and emerging social norms while making sure they do no harm."