Addressing stigma through social networks to reduce unmet need for family planning: A conceptual framework

Background: Unmet need for family planning (FP) continues to increase across sub-Saharan Africa, despite high rates of knowledge and efforts to increase access. Evidently, unmet need does not represent demand, nor does 20 years of programming translate to adoption and sustained use. The Tékponon Jikuagou project in Benin tests an innovative approach to reduce unmet need by leveraging social networks to influence attitudes, beliefs, and social/gender norms around fertility and FP.

Methods: Formative research was conducted in Mali and Benin to better understand network dynamics and the social context in which couples make FP decisions. Quantitative methods included household census and social network analysis. Qualitative methods included ethnography, participatory community mapping, in-depth interviews, focus groups, and key informant interviews. Additionally, a literature review of theoretical and conceptual stigma frameworks was conducted.

Results: Formative research revealed that perceived disapproval of FP by one's spouse, family, and community members presents formidable barriers to contraceptive uptake. The literature review returned no existing theoretical models of FP-related stigma. Using models from other domains (HIV, abortion, mental health), a new theoretical framework of FP stigma was developed based on our research results and knowledge of unmet need in sub-Saharan Africa. Accompanying evaluation measures were also developed and validated via cognitive interviewing.

Conclusions: Tacit stigma about FP use may represent a key barrier among those with unmet need. Applying a conceptual framework of FP stigma may better elucidate the social processes and context of contraceptive decision-making and ultimately lead to more effective intervention design and outcomes.