A common reason for nonuse of modern contraceptives is concern about side effects and health complications. This article provides a detailed characterization of the belief that modern contraceptives cause infertility, and an examination of how this belief arises and spreads, and why it is so salient. We conducted focus group discussions and key informant interviews in three rural communities along Kenya's eastern coast, and identified the following themes: (1) the belief that using modern contraception at a young age or before childbirth can make women infertile is widespread; (2) according to this belief, the most commonly used methods in the community were linked to infertility; (3) when women observe other women who cannot get pregnant after using modern contraceptives, they attribute the infertility to the use of contraception; (4) within the communities, the primary goal of marriage is childbirth and thus community approval is rigidly tied to childbearing; and, therefore (5) the social consequences of infertility are devastating. These findings may help inform the design of programs to address this belief and reduce unmet need.

In India, 50% of women of reproductive age, compared with 23% of men, have iron deficiency anemia. Extant research focuses on biological, not social, determinants of this disparity. The aim of this study was to examine how gender norms may affect anemia prevalence among women in rural India. We conducted 16 focus group discussions (N = 124) with women of reproductive age, husbands, and mothers-in-law and 25 key informant interviews in four villages in Odisha, India. We identified the following themes that help explain how inequitable gender norms exacerbate anemia among women from different castes and tribes: Due to a double burden of work outside the home and completing the majority of unpaid work in the home, women lack time to visit health centers to get tested for anemia and to obtain iron supplements. Women are expected to prioritize the health of their family over their own, thus affecting their access to health care. Women's autonomy to leave the house to seek health care is limited. Men are the primary breadwinners for the family, but often spend their money on alcohol, rather than on iron-rich food for the household. Intra-household food allocation favors men, in-laws, and children, thus women serve their family first, often being left with little food. Anemia reduction interventions need to include examination of the whole social context to successfully increase iron supplement use and iron-rich food intake. Understanding how gender norms contribute to anemia could change the narrative from a biomedical to a social justice issue.

Background: To reduce the prevalence of anemia, the Indian government recommends daily iron and folic acid supplements (iron supplements) for pregnant women and weekly iron supplements for adolescents and all women of reproductive age. The government has distributed free iron supplements to adolescents and pregnant women for over four decades. However, initial uptake and adherence remain inadequate and non-pregnant women of reproductive age are largely ignored. The aim of this study is to examine the multilevel barriers to iron supplement use and to subsequently identify promising areas to intervene. Methods: We conducted a qualitative study in the state of Odisha, India. Data collection included key informant interviews, focus group discussions with women, husbands, and mothers-in-law, and direct observations in health centers, pharmacies and village health and nutrition days. Results: We found that at the individual level, participants knew that iron supplements prevent anemia but underestimated anemia prevalence and risk in their community. Participants also believed that taking too many iron supplements during pregnancy would “make your baby big” causing a painful birth and a costly cesarean section. At the interpersonal level, mothers-in-law were not supportive of their daughters-in-law taking regular iron supplements during pregnancy but husbands were more supportive. At the community level, participants reported that only pregnant women and adolescents are taking iron supplements, ignoring non-pregnant women altogether. Unequal gender norms are also an upstream barrier for non-pregnant women to prioritize their health to obtain iron supplements. At the policy level, frontline health workers distribute iron supplements to pregnant women only and do not follow up on adherence. Conclusions: Interventions should address multiple barriers to iron supplement use along the socio-ecological model. They should also be tailored to a woman’s reproductive life course stage: adolescents, pregnancy, and non-pregnant women of reproductive age because social norms and available services differ between the subpopulations.

The role of mass media in promoting social norms surrounding contraceptive use among adolescents in developing countries has not received much attention. Hence, program planners have little guidance on how to design media messages that take advantage of existing social norms in promoting contraceptive use. We analyzed data from the Demographic and Health Surveys in Ethiopia and Tanzania, restricting our sample to 15- to 24 year-old adolescents (N = 6,230 and N = 5,138, respectively). We proposed and tested the hypotheses that collective norms around contraception use would be associated with individual contraception use in that area and that this relationship would be stronger when media use is low, than when media use is high. Logistic regressions were run to predict individual-level contraception use from collective norms for contraception use, media use, and their interaction, controlling for age, urban versus rural location, marital status, wealth, and education, taking into account intraclass correlations within clusters. Collective norms were associated with individual contraception use in both samples. Media use attenuated the association between collective norms and contraception use in Ethiopia but not in Tanzania. (β = -.22, p = < .01 in Ethiopia and β = -.08, p = .10 in Tanzania). Mass media can serve as external agents of change to attenuate the impact of collective norms on individual behavior. A deeper examination of how and why media use attenuates the relationship between collective norms and individual contraception use in some subpopulations more than others is warranted.

The belief that contraceptive use causes infertility has been documented across sub‐Saharan Africa, but its quantitative association with actual contraceptive use has not been examined. We collected and analyzed sociocentric network data covering 74 percent of the population in two villages in rural Kenya. We asked respondents to nominate people from their village (their network), and then we matched their network (alters) to the individual participant (ego) to understand how their beliefs and behaviors differ. We asked about contraceptive use and level of agreement with a statement about contraceptive use causing infertility. We calculated the average nominated network contraceptive use score and the average nominated network belief score. Holding the individual belief that contraceptive use causes infertility was associated with lower odds of using contraceptive (AOR = 0.82, p = < 0.01); however, when one's own nominated network connections held this belief, the odds of using contraceptive were even lower (AOR = 0.75, p <0.01). Our findings show that this belief is associated with lower odds of contraceptive use and highlights the role that other people in one's network play in reinforcing it. Sexual and reproductive health programs should address this misperception at the individual and social network level.

Background: More than half of women in India are anemic. Anemia can result in fatigue, poor work productivity, higher risk of pre-term delivery, and maternal mortality. The Indian government has promoted the use of iron-folic acid supplements (IFA) for the prevention and treatment of anemia for the past five decades, but uptake remains low and anemia prevalence high. Current programs target individual-level barriers among pregnant women and adolescents, but a more comprehensive approach that targets multiple levels among all women of reproductive age is needed to increase uptake of IFA and iron-rich foods. Methods: The Reduction in Anemia through Normative Innovations (RANI) project is a norms-based intervention to reduce anemia among women of reproductive age. We will evaluate the intervention through a clustered randomized controlled trial in Odisha, India. We will collect data at three time points (baseline, midline, and end line). For the study, we selected 89 clusters of villages, which we randomized into treatment and control on a 1:1 basis. The treatment arm will receive the RANI project components while the control arm will receive usual care. Fifteen clusters (40–41 villages) were selected and 4000 women (2000 in each arm) living in the selected clusters will be randomly selected to take part in data collection. Women in both study arms will have their hemoglobin concentrations measured. They will also complete in-person surveys about their knowledge, attitudes, perceptions of iron folic acid supplements, and nutritional intake. We will also select a smaller cohort of 300 non-pregnant women (150 in each arm) from this cohort for additional physical activity and cognitive testing. We will conduct both within- and between-group comparisons (treatment and control) at baseline, midline and end line using t-tests. We will also conduct structural equation modeling to examine how much each factor accounts for IFA use and hemoglobin levels. Discussion: This RCT will enable us to examine whether a social norms-based intervention can increase uptake of iron folic acid supplements and iron rich foods to reduce anemia. Trial registration: This trial was registered with Clinical Trial Registry- India (CTRI) (CTRI/2018/10/016186) on 29 October 2018.