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The O2O Project

The potential of online networks to initiate social norms change about family planning in offline communities during COVID-19 in Nairobi, Kenya.

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About

The O2O Project investigated the potential of online networks to initiate social norms change about family planning in offline communities in Nairobi, Kenya during COVID-19.

This project was conducted between November 2020 and August 2021 in partnership with the Busara Center for Behavioural Economics and KhangaRue Media LTD. O2O was funded by TRANSFORM which is a unique joint initiative between Unilever, the UK's Foreign, Commonwealth & Development Office (FCDO) and EY.

Research

The O2O Project consisted of two phases:

  1. A qualitative formative phase and
  2. Two randomized behavioural trials. These phases explored the normative context surrounding family planning use and the influence of online networks in changing norms around family planning in offline settings.
Intervention mini-series

This project created a video mini-series based on formative findings which was used as the intervention material during the two behavioural trials. These videos were designed to reflect the normative context surrounding family planning in Nairobi – presenting both negative and positive norms and attitudes about family planning use.

Collaborators

O2O was a collaboration between the London School of Hygiene and Tropical Medicine and the Busara Center for Behavioural Economics. We also partnered with KhangaRue Media LTD to create the mini-series intervention materials based on the formative qualitative findings.

About
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Project description 

This project sought to explore the gender norms - the unwritten expectations of acceptable actions for men and women - that affect women’s ability to access modern methods of family planning (FP) in Nairobi, Kenya. While most attention to changing gender norms has gone into time-intensive community-based conversations, questions remain on whether changing gender norms can happen at a faster pace as a result of digital technologies (WhatsApp, Facebook, etc) that are increasingly being used in Sub-Saharan Africa, particularly by young people. 

Through this study, we explored: (1) gender norms and access to modern family planning methods (MFPM) in the context of the COVID-19 response in a low-income country, and (2) explore how digital media can be used to change gender norms that keep women from accessing family planning services and (3) explore how the delivery modalities of online interventions affect social norms outcomes. 

This study was conducted during COVID-19, as such the data collection stage was redesigned to be conducted remotely to protect the safety of data collectors and participants. The COVID-19 pandemic has affected women’s accessibility to and availability of gender-based violence and family planning services. As such, we sampled from wards within Nairobi which had operational local services during COVID-19 and during data collection. We also provided participants with information to these services at the screening for each phase of the study. 

Online to Offline Norms Diffusion (O2O) Theory

The conceptual framework for this study was based on the Online to Offline (O2O) theory of how attitudes and norms for modern contraception can spread in a social network. This study used this framework to guide the design of the research in understanding online and offline behaviors around modern contraception during COVID-19. 

Diagram showing change in offline community behaviour

In traditional community approaches to social norms change (see e.g. Linos et al. 2013) participants interact face to face, in person. These approaches help people to collectively uncover social norms that sustain harmful behaviours in their group (e.g. norms against FP, women’s mobility, or breastfeeding) and allow group members to identify strategies to change those norms. Although such interventions have been found effective in helping participants achieve greater health and justice in their communities, they have been criticized for being resource intensive and time consuming. In response to these criticisms, recent multi-case comparative research has pointed towards a solution to these challenges. A recent study showed that processes of “organised diffusion” where participants share new knowledge and understanding with others in their social network, can further progress community change beyond the boundaries of a defined group of participants. However, there is limited research on how delivery modalities affect the uptake of these interventions, and their effect on social norms.

Organised diffusion strategies therefore have the potential to facilitate changes in participants’ larger social networks, thereby increasing the reach of community change interventions with little additional investment. Findings on the potential of organized diffusion emerge at a time in which increased access to smartphones, including for women and young people, offers the opportunity to reach out to people’s larger social networks quickly and cost-effectively. Both individual and group level interventions that aim to change social norms can now leverage digital technologies to create online communities. The opportunities to use web forums, Facebook, WhatsApp, or similar platforms to:

  1. create online communities, and

  2. build links between offline and online communities. Knowing when and how online communities stimulate online change and also generate change in their offline community could greatly expand both the scope and scale of social norm change interventions.

 

Intervention description

Qualitative Formative Phase

We first developed a qualitative formative stage, which explored the normative context which young women in low-income wards in Nairobi experience. This stage was composed of in-depth interviews and focus group discussions which explored: social norms and attitudes of FP; identifying people in women’s social networks who supported and opposed FP; women’s digital media use; where and how women access and share information on FP; and how COVID-19 affected women’s privacy, relationships, and access to and use of FP. 

Behavioural Intervention Phase

We used the findings from the formative stage to develop the media materials and finalize the two intervention designs. The interventions were designed to explore how gender norms and access to modern family planning methods (MFPM) in the context of the COVID-19 response in a low-income country, and (2) explore how digital media can be used to change gender norms that keep women from accessing FP services and (3) explore how the delivery modalities of online interventions affect social norms outcomes. Given that COVID-19 has affected the accessibility and availability of gender-based violence and FP services, we will provide participants information for local services which are still operational during COVID-19 during data collection.

Graphic showing difference between experiment 1 and experiment 2

The first behavioural experiment tested how the gender composition of a perceived online community that reacts positively to MFPM media will affect attitudes and social norms about MFPM, via a controlled website environment. This experiment was entirely based online, where each condition would have access to the intervention media material through the developed microsite. Each microsite was structured in the same way, except for the gendered primes which were unique to each condition. Participants were able to view the media online, read the positive pre-created comments about the media and engage with the online community through comments, likes and sharing the media materials. Participants did not see each other’s comments. 

Experiment 2 tested if organized contact between the online and offline community strengthens norm change and O2O diffusion. This experiment was based entirely online for the control group and mixed online and offline for conditions 2.1 and 2.2, where each condition would have access to the intervention media material through the developed microsite. Each microsite was structured the same way and each was developed to show a female-only online community. In offline meetings, all participants and confederates were female as well. All participants had access to the microsite to view the media series and engage with the online community, however all microsites looked the same between conditions. Participants did not see each other’s comments. Participants in the conditions met offline to discuss the media materials between two to four times. 

We collected data through self-completed online surveys at baseline, midline and endline to measure social norms, attitudes and behaviours around family planning. Through the microsite, we also collected engagement metrics, such as how often participants liked, commented on and shared the media materials. 

Project Funding

This was funded by TRANSFORM which is a unique joint initiative between Unilever, the UK's Foreign, Commonwealth & Development Office (FCDO) and EY. TRANSFORM is a joint initiative between Unilever, the UK's Foreign, Commonwealth & Development Office (FCDO) and EY. Established in 2015, it works to accelerate impact enterprises, blending funding and support to deliver market-based solutions to the world’s biggest development challenges. TRANSFORM uses its capabilities and expertise in marketing, distribution, digital, and business resilience to deliver transformative market-based solutions to low-income households in sub-Saharan Africa and South Asia that last. For more information on TRANSFORM, visit their website, Twitter and LinkedIn.

Intervention mini-series
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This project created an eight part video mini-series based on the qualitative formative findings. This mini-series was used as the intervention material during the project's two behavioural trials, designed to reflect the normative context surrounding family planning in Nairobi – presenting both negative and positive norms and attitudes about family planning use. The mini-series was created in collaboration with KhangaRue Media LTD and the Busara Center for Behavioural Economics.

The series is about two young women living in Nairobi’s informal settlements/low income neighbourhoods, Nelima and Gathoni. Nelima, who is married with a young child, navigates the social norms in her community surrounding family planning with Gathoni, who has a boyfriend and is a social media influencer. The series begins when Nelima thinks she’s pregnant and takes a pregnancy test at the salon where she and Gathoni work. Nelima hides this pregnancy test in Gathoni’s purse from Nelson which causes Gathoni’s family to become worried about her having an early pregnancy. Gathoni supports Nelima to access information on family planning and posts a video online encouraging women to take control of their lives and seek family planning, causing her boyfriend, Matthew, to break up with her.

When Nelima expresses wanting to access family planning, her husband, Nelson is at first not supportive, saying that he believes women should not publicly speak about their family planning or seek it because it might make them barren or adulterous. Despite this, Nelima visits a family planning clinic with Gathoni for information and are seen leaving the clinic by a neighbour, Sally. Nelima anticipates a poor reaction from her mother-in-law, who soon after brings the church Apostle to visits Nelima and Nelson, to urge them not to seek family planning. Nelson defends Nelima’s decision to go to access family planning information and even agrees to visit the clinic with her so they can make this decisions together. Later, the couple’s house is robbed, causing Nelima to lose all the savings she had to open a new salon. However, Gathoni is able to win an entrepreneurship challenge by posting Nelima’s story on Instagram and the two women open their own salon. The series ends with Nelson and Nelima attending the family planning clinic together and Gathoni finding a supportive partner. 

Episode 1

Synopsis

The story begins in an informal settlement in Nairobi, where Nelima, a 24 year old woman, leaves her young child with her mother-in-law to go to the salon, where she and her friend Gathoni work. Nelima is worried that she is pregnant and approaches Gathoni, who is an outspoken advocate for family planning, for advice. Nelima feels that she is unable to speak to her husband, Nelson, since she doesn’t want to be pregnant and doesn’t want to use hormonal methods because she believes they will lead to infertility. Nelima shares that she doesn’t feel able to talk to Nelson about family planning because he does not approve of it. Gathoni encourages Nelima to start family planning and challenges various worries and fears that Nelima has about family planning. Nelima anticipates disapproval she would face from her mother-in-law for using family planning to space her children. Nelima is tense as the episode ends with the results being ready from a pregnancy test. 

Episode 2

Synopsis

Gathoni reads out the result from the pregnancy test Nelima took, when Nelson visits the salon causing Nelima to panic and hide the pregnancy test in Gathoni's purse. At home, Nelima puts her earnings from the day in her hidden savings box since she is saving up for her own hair salon. Meanwhile Gathoni, who is inspired by the conversation with Nelima about family planning, posts an empowering message about family planning on Instagram, encouraging everyone to take control and use family planning and to include men in the discussion about family planning. Nelson and Nelima watch Gathoni’s video together. Nelson disapproves of Gathoni publicly sharing her opinions regarding family planning, saying that women shouldn’t publicly discuss family planning as it will ruin their marriage prospects and reputation. Nelson doesn’t like the influence that Gathoni might have on Nelima, who defends her friend’s video, although she is not ready to share her own beliefs about family planning with Nelson. 

Episode 3

Synopsis

Gathoni wakes to her family planning video going viral and is excited to share the news with her mother, but her mother is angry about the pregnancy test Gathoni’s father found in Gathoni’s purse. Her mother shares her disapproval about early pregnancy and shares her experiences as a young mother and the challenges she faced as she advised Gathoni about family planning. Gathoni reassures her that she is not pregnant and watches her Instagram post with her mother. Gathoni’s mother disapproves of Gathoni talking about family planning publicly, but is supportive of Gathoni posting positive and informative messages for women. Gathoni goes to meet her boyfriend, Matthew, who is angry about the video. Matthew disapproves of Gathoni’s instagram post, suggesting that Gathoni is acting like a street girl and that her post could lead women to use family planning and cheat on their husbands. Gathoni counters Matthew’s negative attitudes about family planning and explains her intentions behind the post, but Matthew is not swayed and ends the relationship. On the bus home, Gathoni scrolls through the positive comments on her Instagram post and saves a post about an entrepreneurship challenge.

Episode 4

Synopsis

Nelima texts Gathoni for support before she decides to talk to Nelson about starting family planning together. Nelima’s neighbor, Sally, jokes that there will be lots of babies next year because everyone is at home during COVID-19. Nelson is affectionate with Nelima, but she stops him to share her worries about becoming pregnant during COVID-19 because she is concerned about their current state of finances and wants to live in a safer neighbourhood. Nelson gets angry, interpreting Nelima’s worries as complaints that he is not providing for the family and Nelima tries to keep the conversation quiet to prevent the neighbors from hearing their argument. Nelima says she wants to go to the clinic to get information about family planning after doing some research on the internet. Nelson disapproves of Nelima using family planning, saying that it makes women crazy, barren, and likely to be adulterous. Nelson accuses Nelima of hiding an affair, which hurts Nelima’s feelings. The couple goes to bed, but soon after hear a shout about a thief nearby and Nelima comforts their child. Nelson apologises for his negative reaction that led to their argument. 

Episode 5

Synopsis

Nelima and Gathoni arrive at the family planning clinic. Nelima is still unsure about the visit and expresses regret at coming, but Gathoni comforts Nelima with jokes and a reminder about why she is there. When they meet with the healthcare worker, Gathoni explains that Nelima is looking for contraceptives. Nelima becomes defensive, denying that she wants family planning. Just then, Nelima sees a woman in the waiting room who is distressed about using traditional methods of contraception, resulting in health complications and infertility. The healthcare worker reassures Nelima that family planning is safe, dispeling many myths around side effects, and emphasizing that ideally family planning would be a couple’s choice. Outside the clinic, Nelima and Gathoni encounter Sally, Nelima’s neighbour, who grabs the family planning pamphlet from Nelima’s hand. Sally disapproves of women using family planning since she thinks it is for women who seek attention, rather than respectable wives. Sally insinuates that she will tell Nelima’s mother-in-law about Nelima visiting the clinic for family planning, which causes Nelima to anticipate her mother-in-law's negative reaction.

Episode 6

Synopsis

The next day, Apostle Paul and Nelima’s mother-in-law visit Nelima and Nelson, after Nelima’s mother-in-law heard about Nelima and Gathoni going to the clinic for family planning. They remind Nelson and Nelima of the church’s values against family planning and describe the belief that God has a plan that shouldn’t be interfered with by artificial means. Nelima is shamed by both her mother-in-law and Apostle Paul about receiving counselling and information pamphlets on family planning, however Nelima stands up for herself and explains that she is doing what is best for the family. Nelson sides with Nelima, defending her visiting the clinic since it was his idea that she should get more information on family planning and that their decision is a private family matter. Apostle Paul and Nelson’s mother are shocked and are asked to leave by Nelson. In private, Nelson expresses his support for Nelima and listens to her reasoning. He agrees that there is no rush to have children during COVID-19 and offers to come with Nelima to the clinic for more information. 

Episode 7

Synopsis

At work, Nelima recounts the visit from Apostle Paul and her mother-in-law to Gathoni, who expresses relief that Nelson supported Nelima. Gathoni’s Auntie enters the salon, and Gathoni anticipates that her Auntie will scold her about the pregnancy test. To Gathoni’s surprise, her Auntie expresses pride about Gathoni’s Instagram post and shares her positive views and acceptance of family planning. She shares about her own experiences when she was younger and describes that stigma towards women who use family planning to delay pregnancies has not changed since she was young. Auntie gives advice to Nelima and Gathoni about advocating for themselves and complains that there is a double standard for men, who are allowed to have sex as they please and run away from pregnancy scares. At the end of the episode, Nelima receives an unexpected text that her house has been burgled. 

Episode 8

Synopsis

Nelima rushes home after finding out her house has been burgled. While no one was hurt,  many of their belongings were stolen, including Nelima’s savings for the salon. Gathoni comforts Nelima. Later, Gathoni scrolls through Instagram and comes across the entrepreneur’s challenge with a funded prize that she had saved earlier. This gives her an idea. The next day, Gathoni messages Nelima to check Instagram. Nelima purchases a data bundle, cutting back on purchasing food, to view Gathoni’s video. Gathoni’s Instagram post is about Nelima’s story to save up to buy a salon and move to a better neighborhood. Gathoni messages Nelima again and shares the good news that she had submitted to the entrepreneurship competition and had won. Gathoni proposes to split the money and open their own salon: G & N salon as equal partners. In the end, Nelson goes to the family planning clinic with Nelima and is surprised to see other men in the waiting room. He learns a great deal about family planning and the couple is happy that they made this decision together. Gathoni finds a partner who is supportive of her decisions on family planning.

Series Documents  

View the scripts used for these episodes.

View additional information about the intervention mini-series including the series credits and the descriptions of the full series, each episode and series characters.

 

Collaborators
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Busara Center for Behavioural Economics 

Busara is an advisory and research organization focused on evaluation and implementation of behavioral, economic, and social interventions in the Global South. Busara’s headquarters are in Nairobi, Kenya and conducts qualitative, experimental and quasi-experimental research to understand how social norms affect behaviour in a variety of areas. Busara has also worked extensively to develop novel measurement tools and a unique experimental approach to understanding human behavior in the region. Their team of associates and researchers have extensive experience conducting remote data collection in conditions similar to those presented by the COVID-19 response. 

For this study, Busara collaborated with LSHTM to design and conduct this study, where Busara led the data collection process within both the formative and experimental phases of this study through virtual and in-person data collection. Busara was also a co-creator of the media materials developed and used in this study. 

KhangaRue Media Ltd  

KhangaRue Media Ltd combines local knowledge and insights with international experience. They have a diverse, highly versatile team which has worked for a diversity of clients and campaigns, both on the agency side and the client side. They work with some of the most visible brands and corporations in East Africa across a range of sectors from FMCGs to telecoms and pan-African conglomerates. For this project, KhangaRue Media collaborated with LSHTM and Busara to create and produce the media intervention package.

Publications
O2O publications
Use of digital media for family planning information by women and their social networks in Kenya: A qualitative study in peri-urban Nairobi
Zinke-Allmang A, Hassan R, Bhatia A, Gorur K, Shipow A, Ogolla C, Shirley S, Keizer K and Cislaghi B
2022
Frontiers in Sociology. DOI: 10.3389/fsoc.2022.886548
Navigating family planning access during Covid-19: A qualitative study of young women's access to information, support and health services in peri-urban Nairobi
Hassan, R., Bhatia, A., Zinke-Allmang, A., Shipow, A., Ogolla, C., Gorur, K. & Cislaghi, B.
2021
SSM Qualitative Research in Health; 2. DOI: 10.1016/j.ssmqr.2021.100031