Over the past few decades, reproductive health has been recognized as a cornerstone of human development and global public health [1]. Despite substantial investments and concerted efforts by governments, international organizations, and non-state actors, significant disparities in access to and utilization of reproductive health services persist, particularly in low- and middle-income countries. Marginalized populations especially those residing in rural areas or embedded within rigid socio-cultural contexts continue to encounter multifaceted barriers that hinder both the uptake of modern contraceptive methods and the utilization of maternal health services [2][3]. These barriers extend beyond economic constraints or insufficient health infrastructure, encompassing complex interplays of social norms, cultural beliefs, power dynamics, and deeply entrenched symbolic representations [4].

In Benin, the modern contraceptive prevalence rate stood at 15.5% in 2017-2018 according to the sixth Demographic and Health Survey (DHS-VI), while the maternal mortality ratio reached 391 per 100,000 live births (WHO, 2020). In the Couffo department, where the Aplahoué commune is located, these indicators are even less favorable due to geographic isolation and the strong influence of restrictive socio-cultural norms. These local realities underscore the urgent need for innovative, context-grounded approaches to reproductive health promotion.

In this context, conventional reproductive health promotion strategies have demonstrated notable limitations [5][6]. Rooted primarily in theoretical models derived from Western settings, these approaches often rest on oversimplified assumptions, such as a direct causal link between information access and behavioral change. Empirical evidence, however, indicates that even widespread information dissemination does not necessarily translate into actual adoption of reproductive health practices [5][6]. These approaches frequently overlook the intricacies of local socio-cultural realities, leading to resistance, misinterpretation, and in some cases, active rejection of interventions. This misalignment between intervention design and contextual realities perpetuates a pronounced gap between the reproductive health needs articulated by communities and the services they ultimately utilize.

It is within this landscape of conventional intervention shortcomings that the Inertial Resistance Cycle (IRC) emerges as a pivotal conceptual framework for understanding reproductive health behaviors [7]. The IRC characterizes a dynamic, cyclical process in which recognition of reproductive health needs fails to translate into actionable behavior. Specifically, it identifies a “latent demand” among individuals such as the desire to space births [8] which coexists with cognitive awareness of contraceptive options but does not result in their actual adoption [7]. This inertia is reinforced by socio-cultural (norms, taboos, beliefs), psychological (fear, mistrust), and relational (partner influence, familial pressure) factors, culminating in strategic inaction despite the availability of adoption opportunities.

Moreover, the IRC highlights mechanisms that entrench the status quo, including the gradual normalization of adverse outcomes (unintended pregnancies, maternal complications) and post-hoc self-justifications, which together sustain the cycle of inaction. Consequently, limited adoption of reproductive health services should not be interpreted merely as a problem of access or knowledge; rather, it represents a manifestation of deeply embedded behavioral inertia rooted within social and cultural structures. By shifting analytical attention from individual determinants to systemic and contextual drivers, the IRC offers a robust framework for comprehensively understanding reproductive health behaviors (see conceptual framework of the IRC → Figure 1).

In response to these limitations and the complexity of observed dynamics, the Contextual Reproductive Harmony Theory (CRHT) was developed as an innovative theoretical framework aimed at rethinking reproductive health promotion strategies in marginalized contexts. The theory is grounded in a central premise: sustainable adoption of reproductive health innovations can only be achieved through their harmonious integration into existing socio-cultural systems. Unlike top-down approaches, CRHT emphasizes alignment, co-construction, and the gradual transformation of social norms, taking local specificities into account [7].

Figure 1.Theoretical framework of the inertial resistance cycle [7].

The development of CRHT stems from a critical evaluation of dominant models and a desire to overcome their limitations. It draws on an interdisciplinary synthesis of theoretical frameworks from social psychology, anthropology, sociology, and development studies. This theoretical hybridization enables the creation of an integrated model capable of addressing the complex challenges of reproductive health in contexts with strong socio-cultural resistance.

CRHT is structured around four complementary principles. Dynamic Contextual Adaptation (DCA) involves designing interventions tailored to local socio-cultural realities [7]. Proactive Co-ownership (PCO) promotes active community engagement to enhance adherence and sustainability. Multilevel Harmonic Reinforcement (MHR) mobilizes stakeholders across all levels to generate a collective momentum for change [7]. Finally, Inclusive Resilience (IR) seeks to ensure the durability of interventions amid contextual constraints and evolving conditions.

Operationally, CRHT relies on several key tools: Social Harmony Mapping (SHM), which identifies cultural convergences and sources of resistance; Harmonic Engagement Circles (HEC), which facilitate community dialogue; the Ritual and Symbolic Approach (RSA), which promotes cultural acceptance; and the Digital Harmonization Platform (DHP), which improves information access and decision-making [7].

Figure 2. Operational pathway of the Contextual Reproductive Harmony Theory (CRHT): From the habitual cycle of inertial resistance to contextualized reproductive harmony.

In this context, it becomes essential to empirically assess the relevance and effectiveness of this theoretical framework in real-world intervention settings. The present study addresses this need and was conducted in the Lonkly and Atomey districts in southern Benin—areas characterized by socio-economic constraints and socio-cultural norms that strongly influence reproductive health behaviors.

The objective of this study is to evaluate the impact and effectiveness of CRHT implementation in improving access to and utilization of reproductive health services, as well as in transforming associated community behaviors and dynamics in marginalized contexts.

The Lonkly and Atomey districts are located within the Aplahoué commune in southwestern Benin, in the Couffo department. This region features a sub-equatorial climate with two rainy and two dry seasons, favoring predominantly subsistence agriculture. Road infrastructure is often rudimentary, limiting access to basic services, including reproductive health care, for the local population. Socio-culturally, the communities of Lonkly and Atomey are primarily composed of ethnic groups such as the Adja and Fon, with deeply rooted traditional social structures. Cultural practices, religious beliefs, and social norms significantly influence reproductive health behaviors.

The intervention based on the Contextual Reproductive Harmony Theory (CRHT) significantly improved multiple reproductive health indicators in the experimental group compared to the control group. Knowledge of modern contraceptive methods (MCM) increased markedly from 1.89% to 67.92%, as did their acceptance (from 11.32% to 32.08%) and utilization of maternal health services (from 6.25% to 75.00%). Furthermore, regular antenatal consultations (69.23%), spousal involvement in reproductive health (50.94%), and youth participation in awareness activities (80.56%) also demonstrated significant increases. These findings underscore the effectiveness of CRHT in enhancing access, uptake, and community engagement in reproductive health services within marginalized areas.

Notably, stakeholder involvement in the control group did not differ significantly from the intervention group at endline (p = 0.4585), which may reflect pre-existing community engagement structures in Atomey village independent of the CRHT program.

The results of this study can be interpreted in light of the Inertial Resistance Cycle (IRC), one of whose major contributions lies in explaining the sociocultural barriers to the adoption of contraceptive methods. The observed shift from very low levels of knowledge and adherence to markedly improved levels suggests that the CRHT intervention was able to partially disrupt the different phases of the IRC, notably initial distrust and passive indifference, thereby initiating a progressive engagement dynamic. These observations confirm that resistance is not solely due to an informational deficit but arises from a complex set of psychosocial and

Table 1. Effect of the Contextual Reproductive Harmony Theory (CRHT) on reproductive health indicators: Pre/post-intervention comparison (phase 1) and intervention vs. control village comparison (phase 2).

community factors.

The literature supports this interpretation. According to Boke et al. [9], barriers to contraceptive adoption in Ethiopia are strongly influenced by social and cultural beliefs, including fears of infertility and pressures from traditional norms. Similarly, Allotey and Bosoka [10] demonstrated that contraceptive acceptance in Ghana largely depends on the influence of community and religious leaders. In this context, the outcomes observed in our study, notably increased spousal involvement and enhanced youth participation, suggest that CRHT effectively mobilized these social levers, consistent with its principles of co-ownership and multi-level mobilization.

Moreover, the simultaneous improvement in knowledge, attitudes, and practices observed in this study reinforces the notion that approaches combining education and community engagement are the most effective. Moucheraud et al. [11] demonstrated that the impact of contraceptive services is maximized when interventions integrate both an educational dimension and active community involvement. Likewise, the work of Osborne et al. [12]-[14] highlights that the absence of sociocultural mediation constitutes a major determinant of inequities in contraceptive use in Sierra Leone. By incorporating tools such as community mediation, engagement of local leaders, and participatory strategies, CRHT appears to directly address these structural gaps.

The results of this study also provide critical insight into the limitations of classical behavior change models. While such models assume that increased access to information is sufficient to alter practices, empirical data suggest otherwise. Silverman et al. [15] notably highlighted the lack of correlation between access to information and effective contraceptive use among married adolescents in Niger. In contrast, the outcomes of our study suggest that the CRHT approach, by integrating the social, cultural, and relational dimensions of behavior, can overcome this limitation by translating information into genuine engagement.

This effectiveness can be attributed to the systemic and adaptive nature of CRHT. By considering local specificities and fostering community ownership, this approach aligns with a logic of sustainable transformation of social norms. The findings of Gebrerufael and Hagos [16], which demonstrated the effectiveness of interventions adapted to nomadic populations in Ethiopia, support the idea that contextualization is a key determinant of intervention success.

However, despite these promising results, several challenges must be considered when contemplating broader implementation of CRHT. Deploying this approach requires substantial financial and technical resources, particularly for training community actors and deploying innovative tools such as the Digital Harmonization Platform [17]-[19]. In contexts characterized by chronic underfunding of health systems, as highlighted by several studies [19], these requirements may pose barriers to scaling up.

Furthermore, institutional acceptability of CRHT represents a major challenge. Policymakers often favor standardized approaches that are easier to integrate into public policy, at the expense of contextualized models requiring continuous adaptation. On the sociocultural level, despite observed progress, resistance linked to religious and patriarchal norms persists, as noted by Allotey and Bosoka [10], and may limit long-term impact if not sustainably addressed.

Finally, the question of sustainability remains central. Although this study demonstrated short-term effectiveness, the durability of behavioral changes will depend on institutionalization of the approach and its integration into existing health systems. Moucheraud et al. [11] emphasize the importance of monitoring mechanisms and sustainable funding to ensure the continuity of family planning interventions.

Overall, the findings of this study empirically validate the relevance and effectiveness of CRHT as an innovative model for promoting reproductive health. By simultaneously addressing cognitive, social, and structural dimensions of behavior, this approach offers a credible alternative to classical models, particularly in contexts with strong sociocultural constraints.

Several limitations of this study must be acknowledged. First, the purposive sampling of 35 households per village limits the statistical power and generalizability of findings; results should be interpreted as exploratory rather than confirmatory. Second, the quasi-experimental design, while appropriate for the field context, does not allow for full control of confounding variables or definitive causal inference. Third, all outcome measures relied on self-reported data, which may be subject to social desirability bias, particularly for stigmatized topics such as contraceptive use. Fourth, the relatively short follow-up period (8 months) does not allow assessment of the durability of behavioral changes beyond the intervention period. Fifth, the Digital Harmonization Platform (DHP) component assumes mobile phone access, which may not be uniformly available across similar communities. These limitations suggest caution in extrapolating findings to other settings and underscore the need for larger, randomized evaluations of the CRHT framework.

This study provides preliminary evidence that the Contextual Reproductive Harmony Theory (CRHT) may represent a meaningful advance in reproductive health promotion by addressing the sociocultural and structural determinants of contraceptive inertia. The observed improvements across multiple indicators including knowledge, acceptance, ANC attendance, and community engagement suggest that context-adapted, community-owned approaches can partially overcome the barriers described by the Inertial Resistance Cycle. However, given the small purposive sample, quasi-experimental design, and short follow-up, these results should be interpreted cautiously. Scaled, randomized evaluations with longer follow-up are needed to confirm effectiveness, assess cost-efficiency, and guide institutionalization. Subject to those confirmations, CRHT offers a credible and replicable framework for reproductive health programming in socio-culturally constrained settings across West Africa and beyond.

Informed consent was obtained from all participants prior to data collection. Confidentiality, anonymity, and the right of participants to withdraw from the study were strictly respected.

All authors contributed to the study conception and design, data collection and analysis, and manuscript drafting. All authors approved the final version submitted for publication.

The data collected during this study are confidential and cannot be publicly shared due to the sensitive nature of the information.

All participants provided informed consent for the publication of anonymized data derived from their interviews.

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and adhered to established standards of good scientific practice in qualitative research.

The authors would like to express their sincere gratitude to the staff of the Research Unit in Epidemiology and Population Health (CaRESaP, https://www.caresap.org/) and the Institute for Research, Mediation and Facilitation for Development (IReMeF, https://www.iremef.com/) for their methodological and technical support. Their expertise, insightful guidance, and continuous assistance throughout this study were instrumental in ensuring the quality and rigor of this work.