Social norms and family planning decisions in South Sudan

Background: With a maternal mortality ratio of 789 per 100,000 live births, and a contraceptive prevalence rate of 4.7%, South Sudan has one of the worst reproductive health situations in the world. Understanding the social norms around sexuality and reproduction, across different ethnic groups, is key to developing and implementing locally appropriate public health responses. Methods: A qualitative study was conducted in the state of Western Bahr el Ghazal (WBeG) in South Sudan to explore the social norms shaping decisions about family planning among the Fertit community. Data were collected through five focus group discussions and 44 semi-structured interviews conducted with purposefully selected community members and health personnel. Results: Among the Fertit community, the social norm which expects people to have as many children as possible remains well established. It is, however, under competitive pressure from the existing norm which makes spacing of pregnancies socially desirable. Young Fertit women are increasingly, either covertly or overtly, making family planning decisions themselves; with resistance from some menfolk, but also support from others. The social norm of having as many children as possible is also under competitive pressure from the emerging norm that equates taking good care of one’s children with providing them with a good education. The return of peace and stability in South Sudan, and people’s aspirations for freedom and a better life, is creating opportunities for men and women to challenge and subvert existing social norms, including but not limited to those affecting reproductive health, for the better. Conclusions: The sexual and reproductive health programmes in WBeG should work with and leverage existing and emerging social norms on spacing in their health promotion activities. Campaigns should focus on promoting a family ideal in which children become the object of parental investment, rather than labour to till the land – instead of focusing directly or solely on reducing family size. The conditions are right in WBeG and in South Sudan for public health programmes to intervene to trigger social change on matters related to sexual and reproductive health; this window of opportunity should be leveraged to achieve sustainable change.

A qualitative exploratory study was conducted. Data were collected through focus group discussions (FGDs) and semi-structured interviews (SSIs) conducted with a variety of purposefully selected informants, as detailed in Table 1. The following sections further explain the sampling and recruitment principles and processes. Overview of study participants and data collection aParticipants were either In Union or Not In Union at the time of the study; we articulate relationship status this way because in WBeG, one would publicly state one’s status as married only if the relationship was formalised either in a traditional ceremony, or in the church. However, for the sake of convenience we use the terms married/unmarried in the paper Topic guides for FGDs and SSIs were developed using de Francisco et al.’s [13] conceptual framework. The topic guides included questions exploring social norms and beliefs about sex, sexuality, roles and relations between men and women, reproduction, and what shapes the decision-making on matters related to reproduction. The topic guides also included questions about preferences and expectations from, and views about, current SRH services. The topic guides for health and other workers included questions along the same lines, but with a view to exploring the situation from their perspective. The FGD and SSI topic guides for community members were prepared in English and translated into Wau Arabic (by investigators MR and AM). The topic guides were defined further during the initial stakeholder workshops, pre-tested in the study site and also adapted iteratively as the study progressed. The FGDs and SSIs with community members were conducted in Wau Arabic, a language spoken by all around Wau, including the Fertit people; interviews with health and other workers were conducted in Wau Arabic or English, depending on the preference of the health worker. The analytical framework provided by the theory of planned behaviour (TPB) [14, 15] was used to critically analyse factors shaping behaviour and decision-making related to family planning among the Fertit people in WBeG. According to TPB, three major antecedent domains influence a person’s intention to perform a behavior: 1) attitude towards and belief that performing the behaviour will lead to the desired outcomes; 2) social norms related to the behavior; and 3) one’s perceived control over or perceived ability to perform the specified behaviour. The TPB contends that a positive attitude and positive outcome expectations alone are not enough to shape decisions and behaviour; the two domains, the prevalent social norms and one’s beliefs about own ability and capacity to act, also operate concomitantly to affect individuals’ decisions and actions. The TPB is a mid-range theory which has been widely used and is well suited to describe the antecedents of particular behavioural intentions [16]. Recognizing that in many situations individuals and groups defy what appear to be strong social norms [17], and that norms both shape actions of agents and are at the same time themselves being constantly shaped by these actions, we draw on the critical realist explanatory tradition to go one step further to discuss and explain norm congruence, norm defiance and, thereby, norm maintenance or transformation [18]. To do so, we draw on Archer (1998, Ch 14, p20) [17], who argues for an analysis which approaches structure and agency through “analytical dualism”, wherein “the structural, cultural and agential components are analyzed separately, with a focus on their logical relations and the conditions and possibilities that these allow”. The analytical emphasis is thus twofold: explaining how the social structures shape the actions and interactions of individuals, and how at the same time the social interactions between agents also shape the social structures and social relations, both maintaining or reproducing and transforming them. The study was conducted in Wau county in the state of WBeG in South Sudan. Two locations were selected based on the homogeneity of the residents (all Fertit). Further, the locations were also within the coverage area of health services, particularly SRH services. This was important, as the geographical coverage of health services remains poor in many parts of WBeG. Finally, the two locations represented two different settings in Wau county: one in Wau town and the other a rural area. The a priori assumption behind choosing these two locations was that perhaps within the same social group the way norms related to behaviour and decisions might be moderated differently in different settings. The main categories of study participants are summarized in Table 1. Community members were purposefully selected with the help of village elders, health workers from a local non-governmental organization (NGO) and the county health department. Among community members, only those aged 18 years and above were included in this study; a separate but linked study has been conducted among adolescents. We purposefully categorized participants into those between 18 and 35 years and those above 35 years — the assumption being that the former would be more subject to the norms related to sexuality and reproduction, and the latter would be the ones involved in enforcing the norms, shaping preferences, setting expectations and influencing the decision-making and health-seeking behaviours of the former. Data collection began with FGDs among community members to identify different aspects of the subject, and differences in views among participants on the subject. This was followed by SSIs to obtain more in-depth understanding. For FGDs with community members, participants were homogenous in terms of age and marital status, yet diversity was sought in terms of social and economic status (based on: inputs from elders related to social identity, ownership of assets such as bicycles, level of education). FGD participants were not involved in the SSIs. Health facility personnel working in the local health centre of the study sites were included in the study. First, an FGD was conducted to identify different aspects of the subject, and differences in views among health workers on the subject. Participants included a clinical officer, two nurses, a health assistant and two community health workers. The FGD was followed by SSIs with those personnel specifically responsible for reproductive health at the health centre. FGD participants were not involved in the SSIs. Key informants were also purposefully selected for inclusion in the study; they were selected based on their active SRH-related role within the health system and the study community, and identified through the initial stakeholder consultations. Key informants included traditional leaders, traditional birth attendants, state- and county-level SRH service managers and NGO representatives. Given the serious shortage of health and social workers in South Sudan, the pool of managers and NGO representatives was small — in fact there was only one SRH-related officer at both county and state health department level, and both were interviewed. Similarly, all three NGO representatives working on SRH in Wau county were interviewed. Data were collected between October 2014 and April 2015, from three visits to Wau. FGDs and SSIs with community members, traditional leaders and traditional birth attendants were conducted by research team members who hailed from the study area, were fluent in the local language and had experience in conducting qualitative research; interviewers and participants were matched by sex. FGDs and SSIs with health workers, managers and NGO representatives were done in English. Data were collected until data saturation was reached and no new insight emerged; this was possible to assess, as at the end of each day of data collection, the research team debriefed and discussed the emerging findings. In total, 5 FGDs (with 38 participants) and 44 SSIs were conducted. This is congruent with the general experience on saturation; according to Creswell [19], a sample size of around 30–50 is generally sufficient to achieve analytical saturation in a qualitative study. SSIs and FGDs were digitally recorded, translated from Wau Arabic into English (where applicable) and transcribed verbatim; the translations were independently checked. Analysis of the transcripts was carried out using a comprehensive thematic matrix to facilitate the identification of common patterns and trends arising from the narratives, using NVivo 10 software. This was done in parallel by three researchers (SK, MK, MR), and emergent conceptual categories were arrived at through a process of argumentation and consensus. Validity of findings and of the analysis was further assured through a data validation workshop (n = 10) and interviews with key informants (n = 2), and also through follow-up interviews with some (n = 4) of the study participants in both study sites. The daily debriefing sessions and insights from these validation interviews and workshop were also used to develop and further clarify emerging analytical themes. The study was approved by the Independent Ethics Committees of KIT Royal Tropical Institute, Amsterdam, and the national Ministry of Health of the Government of South Sudan. Administrative approval was given by the WBeG Ministry of Health. Informed consent was taken from all participants. Consent was sought only after the person had been contacted to participate (and had in principle agreed), but before any of the interview questions were asked. For those who could read, the consent form was given to them and also read out to them to seek both their written and oral consent. For those who could not read, the consent form was read out to them, and their consent was recorded. Confidentiality was maintained throughout, and steps were taken to anonymize the data and to minimize risk of accidental disclosure and access by unauthorized third parties. Sex, sexuality and reproduction are sensitive, intimate and yet social issues. At the beginning of the consent process, participants were informed of their right to refuse to answer any questions they might find intrusive. The interviewers were also very conscious of this, and did not press ahead with a line of inquiry if they noticed the participant was not comfortable. Furthermore, given the sensitive nature of the topic, there is a risk of opening up hitherto closed, yet painful chapters and experiences in the person’s life. To ensure support if such a situation arose, a trained counsellor was available, as were medical referral services. No such situation requiring counselling or medical referral emerged during data collection. However, there were many instances of people in the community seeking help to get treatment for individuals, and this was provided — for example, on two occasions, the research team used its car to take a child and his mother to the state hospital for further treatment.

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• Dima Health