14 May

Social norms transformation: what works in the context of SRHR?


Social norms transformation: what works in the context of SRHR?

What are social norms?

Put simply, social norms are social rules, created by people, that allow us to live and cooperate with each other. We need social norms. They help us to create societies and collaborate, predict each other’s behaviour, and be accepted in society.

People conform to social norms on the condition that they believe (a) most people in their reference network conform to a specific behaviour (empirical expectation), and (b) that most people in their reference network believe they ought to conform to the behaviour (normative expectation) (Bicchieri, 2006). Similarly, Cialdini et al (1991) distinguish between descriptive norms (beliefs about what others would do in a given situation), and injunctive norms (beliefs about what others would approve or disapprove of).

Social norms can be positive or negative. For example, in the context of sexual and reproductive health and rights (SRHR), they can be positive when communities promote autonomy over reproductive choices. They can be negative when there is acceptance of child marriage. SRHR organisations want to change negative social norms to allow communities to adopt new norms that produce positive SRHR outcomes.

Within SRHR interventions, social norms often come up as one of the main behavioural drivers for anything from youth access to contraception, condom use, child spacing and access to safe abortion.  They are often also the behavioural determinant that, if successfully changed, can lead to highly impactful SRHR outcomes, because of the potential for diffusion of adoption of new healthy behaviours.

While this article focuses on how projects have succeeded in transforming social norms, it is important to remember that it is still necessary to conduct thorough research on the full range of behavioural drivers of the SRHR topic one is addressing, to ensure that an evidence-based intervention is designed. Another important aspect to consider is that a behaviour can be driven by multiple social norms, and so working on only one may not be enough to effect change. Cislaghi & Heise (2018a) offer excellent guidance on how to avoid common pitfalls with regards to social norms intervention design.

Approach to transforming social norms

For organisations to work on social norms, it is important to understand that social norms change is a dynamic process and requires working at multiple levels. According to The Dynamic Framework For Social Change (DFSC), work needs to be done at the institutional, individual, social and material levels, while also taking into consideration the effects of gender dynamics and power structures, as well as forces at the global level. Cislaghi & Heise (2018b) offer good starting points on how to design a social norms focused intervention using the DFSC.

The Dynamic Framework For Social Change (Cislaghi & Heise (2018b)

Examples of successful social norms transformation interventions

 

Growing up GREAT! (Institute for Reproductive Health, Georgetown University, 2021)

 

Format & target audience

Growing Up GREAT! adapts and scales existing social norm shifting interventions implemented over nine months, which aims to shift priority norms through activities that engage very young adolescents (VYAs, 10-14) and their families, communities, and health systems.

Strategy

The intervention includes: weekly small group discussions and activities using an interactive, gender-transformational toolkit; community facilitators working with local organisations; caregiver sessions; video testimonials featuring parents and VYAs from local communities; facilitated discussions; and linkages to the formal health system by inviting facility-based health workers trained in adolescent-friendly health services.

Outcome

The Growing Up GREAT! quantitative evaluation compared baseline and follow-up surveys among intervention and control groups. Growing Up GREAT! improved gender-equal sharing of household chores, communication about sexual relationships and contraception, as well as out-of-school adolescent girls’ perceptions of their ability to participate in daily life decisions, make their voices heard, and freedom of movement. The quantitative evaluation did not show any intervention effect on three measures that assessed VYAs’ agreement with specific unequal gender norms related to stereotypical male and female characteristics and roles and romantic relationships.

Safe Homes And Respect for Everyone (SHARE) (Kerr-Wilson et al, 2020)

 

Format & target audience

SHARE is an intimate partner violence (IPV) prevention intervention. It targeted men and women in Rakai, Uganda. SHARE used five community level strategies: advocacy, capacity building, community activism, learning materials and special events.

Strategy

SHARE integrated IPV prevention into Rakai Health Sciences Program (RHSP), an organisation that conducts HIV prevention trials, laboratory/clinical research and qualitative studies, and provides health education, HIV counselling and testing and HIV medical care. SHARE was modelled on a community mobilization approach developed for IPV prevention in East Africa, based on the Transtheoretical Model, borrowed methods from Stepping Stones, and provided enhanced HIV post-test counselling services to address violence against women.

Outcome

The SHARE study showed a 20% reduction in women’s reports of past year physical and sexual IPV three years after baseline; however, men’s reports of perpetration were unchanged. The reduction in the experience of IPV is very positive and the programme merits further exploration into its strategy of transforming social norms on IPV and other forms of violence against women.

Values clarification workshops on  abortion (VCAT) (Turner et al, 2018)

 

Format & target audience

A workshop format that can be held with various types of stakeholders who are reference groups or who control access to abortion services (e.g. healthcare providers, policy-makers, traditional leaders).

Strategy

The focus is on the real consequences of abortion stigma: unsafe abortion, which can result in women’s injury or death. The VCAT intervention consists of participatory presentations and activities (14 total activities in the Toolkit) that engage participants with accurate abortion information, realistic scenarios, critical self-reflection, empathy-evoking experiences and meaningful dialogue on abortion beliefs, values and professional ethics and responsibilities.

Outcome

The workshops: deepen policymakers’ understanding of existing or new knowledge on abortion; help policymakers experience empathy for people who seek, provide or are affected by abortion; enable policymakers to clarify current values on abortion and explore alternative values; help policymakers recognise barriers to change and become open to change; and get policymakers to advocate for high quality, comprehensive abortion care for all women.

The Kalyani Campaign: Community-level behaviour change campaign in India (Banerjee et al, 2013)

 

Format & target audience

The campaign was composed of three communication tools: interpersonal communication (household visits and community group meetings), street dramas with interactive quizzes and wall signs or posters in public areas, along with distribution of take-home material. It targeted women 15-49 with low literacy levels.

Strategy

The intervention was designed to dismantle social norms around abortion and to promote self-efficacy. It provided information on the legality of abortion, the locations of the nearest public-sector facilities offering safe abortion and contraceptive services, and the health consequences of unsafe abortion using a fictitious young woman named Kalyani as the protagonist.

Outcome

Women who had been exposed to any intervention communication event had significantly higher odds than those who had not of knowing the legal status of abortion. The women who were exposed to all three message formats showed the greatest increases in knowledge, particularly in knowledge about more complex concepts such as the legal gestational age limit. There was also improvement in women’s self-efficacy with regards to family planning and abortion. Importantly, the women in the intervention districts at follow-up reported higher perceived levels of social support for abortion within their families.

“Roving” Auxiliary Nurse Midwives (RANMs) in Nepal (FACT, 2018)

 

Format & target audience

RANMs collaborated with Female Community Health Volunteers, provided group education sessions  and engaged with community members. Target group was women 15-49.

Strategy

Addressing deep-seated social, structural, and geographic barriers to enhance the reach of formal health services.

Outcome

RANMs effectively reached marginalized communities. Women in the RANM communities experienced improvements in social norms and pressures over time. Women in the RANM sites were 2.7 times more likely to have a high fertility awareness score than women in the non-RANM sites.

 

Key considerations when addressing social norms in SRHR

Promising practices for addressing social norms in SRH programming. Adapted from the Social Norms Learning Collaborative (2021).

Overall, SRHR projects that are successful in transforming harmful social norms share a few common characteristics.

  1. They are well designed, well planned and grounded in behaviour change theory.
  2. They have a full understanding of the drivers of the behaviour and the context.
  3. They are pretested and refined.
  4. They have a wide range of intervention tactics, including interpersonal communication, community level communication and mass-media.
  5. They are long-term and are implemented with high fidelity and optimal intensity.
  6. Staff and volunteers are carefully recruited, thoroughly trained and well supervised.

For more information, please see the references below, and there are fantastic initiatives that share knowledge and learning in the field of social norms such as the ALiGN Learning Collaborative.

Banerjee S.K., Andersen K.L. & Warvadekar, J.  (2013). Effectiveness of a behaviour change communication intervention to improve knowledge and perceptions about abortion in Bihar and Jharkhand, India.  International Perspectives on Sexual and    Reproductive Health. 39:142–51.

Bicchieri, C. (2006). The Grammar of Society: The Nature and Dynamics of Social Norms. New York: Cambridge University Press.

Bicchieri, C & Funcke, A. (2018).  Norm Change: Trendsetters and Social Structure , Social Research: An International Quarterly, 85(1), 1-21.

Cialdini R.B., Kallgren C.A. & Reno R.R. (1991). A focus theory of normative conduct: A theoretical refinement and reevaluation of the role of norms in human behavior. Advances in experimental social psychology, 24(20):1–243. 

Cislaghi, B. & Heise, L. (2018a). Theory and practice of social norms interventions: eight common pitfalls. Global Health 14 (83). https://doi.org/10.1186/s12992-018-0398-x

Cislaghi, B. & Heise, L. (2018b). Using social norms theory for health promotion in low-income countries. Health promotion international.

FACT (2018). “Roving” Auxiliary Nurse Midwives (RANMs)

Institute for Reproductive Health (2021). Insights from two norm-shifting interventions to support very young adolescents.  Washington, D.C. Georgetown University for the U.S. Agency for International Development (USAID).

Kerr-Wilson, A., Gibbs, A., McAslan Fraser E., Ramsoomar, L., Parke, A., Khuwaja, H.M.A. & Jewkes, R. (2020). A rigorous global evidence review of interventions to prevent violence against women and girls, What Works to prevent violence among women and girls global Programme, Pretoria, South Africa.

Social Norms Learning Collaborative (2021). Social Norms Atlas: Understanding Global Social Norms and Related Concept. Washington, DC: Institute for Reproductive Health, Georgetown University.

Turner, K.L., Pearson, E. & George, A.. (2018). Values clarification workshops to improve abortion knowledge, attitudes and intentions: a pre-post assessment in 12 countries. Reproductive Health  15: 40