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Using social norms theory for health promotion in low-income countries

Using social norms theory for health promotion in low-income countries Health Promotion International, 2019;34:616–623 doi: 10.1093/heapro/day017 Advance Access Publication Date: 22 March 2018 Debate Debate Using social norms theory for health promotion in low-income countries 1, 2 Beniamino Cislaghi * and Lori Heise Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK and Johns Hopkins Bloomberg School of Public Health and Johns Hopkins School of Nursing, Baltimore, MD, USA *Corresponding author. E-mail: ben.cislaghi@lshtm.ac.uk Summary Social norms can greatly influence people’s health-related choices and behaviours. In the last few years, scholars and practitioners working in low- and mid-income countries (LMIC) have increasingly been trying to harness the influence of social norms to improve people’s health globally. However, the literature informing social norm interventions in LMIC lacks a framework to understand how norms interact with other factors that sustain harmful practices and behaviours. This gap has led to short-sighted interventions that target social norms exclusively without a wider awareness of how other institutional, material, individual and social factors affect the harmful practice. Emphasizing norms to the exclusion of other factors might ultimately discredit norms-based strategies, not be- cause they are flawed but because they alone are not sufficient to shift behaviour. In this paper, we share a framework (already adopted by some practitioners) that locates norm-based strategies within the wider array of factors that must be considered when designing prevention programmes in LMIC. Key words: social norms, harmful practices, intervention, community health promotion, low-income countries Social norms theory is opening new programmatic ave- framework that practitioners can use to embed a social nues for health promotion in low- and mid-income norm perspective within integrated health interventions countries (LMIC) (Chung and Rimal, 2016; Miller and that address the multiple factors that sustain harmful Prentice, 2016; Tankard and Paluck, 2016). As practi- behaviours. tioners have begun to deploy social norm strategies to improve health, however, there has been a tendency to SOCIAL NORMS AND HEALTH focus on norms to the exclusion of other factors that in- INTERVENTIONS IN LMIC form people’s actions. Using social norms theory with- Researchers have been aware of the influence of social out appreciating the place that norms occupy among norms—informal rules of behaviour that dictate what is other drivers of behaviour, might position interventions acceptable within a given social context—for a long for failure, ultimately discrediting promising strategies time (Young, 2007; Mackie et al., 2015; Chung and simply because, in isolation, they are inadequate to im- Rimal, 2016). However, in recent years, there has been prove health. The aim of this paper is to provide a V C The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Social norms and health promotion: a dynamic framework 617 a surge of interest among both scholars and practitioners 2016). This narrow evidence base is particularly problem- in transforming norms as a tool to achieve change in atic given donors’ and practitioners’ recent interest in in- people’s behaviour and improve people’s health and tegrating social norms theory into health interventions in well-being (Mollen et al., 2010). LMIC. Each LMIC obviously presents characteristics that Although all disciplines agree that social norms influ- are unique to its context; yet, commonalities exist in the ence health-related behaviours, they offer different theo- political and social features of most LMIC. These com- retical perspectives on what social norms are, how they monalities include, for instance: traditional forms of form and how they shape behaviour (see reviews by power often compensating for weaker state control and Brennan et al.,2013; Elsenbroich and Gilbert, 2014; enforcement of the law (Englebert, 2009); relatively weak Mackie et al.,2015; Young, 2015). Loosely speaking, infrastructures (including reduced access to information there are three main schools of thought on social norms and communication technology) (Abiad et al.,2017); and that respectively defined them as: (i) behavioural patterns, persistent economic deprivation impacting on the effec- (ii) collective attitudes and (iii) individuals’ beliefs about tiveness of the formal health systems (Mills, 2011). others’ behaviours and attitudes (Morris et al.,2015; The literature on the effectiveness of social norms in- Young, 2015). Contemporary research in health science terventions for increasing health and well-being in has empirically demonstrated the usefulness of the third, LMIC is sparse but growing. The most promising ‘norms as beliefs’, school of thought, which emerged examples are emerging from the field of sexual and re- mostly from social psychology (e.g. Cialdini et al.,1990), productive health and rights (Haylock et al., 2016; as a means to explain and also to influence people’s Read-Hamilton and Marsh, 2016). For instance, social health-related choices (Borsari and Carey, 2003; norms theory has been used extensively to understand Eisenberg et al.,2005; Rimal and Real, 2005; McAlaney the persistence of female genital cutting (FGC), a non- and Jenkins, 2015; Ahmed et al.,2016). Contemporary medically justified modification of women’s genitalia scholars in this tradition argue that social norms are one’s that poses a global threat to the health of 140 million of beliefs about (i) what others do and (ii) of what others ap- women and girls globally (Wagner, 2015). Existing pro- prove and disapprove of (Gibbs, 1965; Cialdini et al., gramme implementations that targeted social norms 1991; Cialdini and Trost, 1998; Lapinski and Rimal, around FGC offered important insights into the poten- 2005; Bicchieri, 2006; for a full review see Mackie et al., tial of addressing social norms for social change, sug- 2015). Among the work of various thinkers in this tradi- gesting that community-based interventions can be tion, Cialdini’s has been the most influential (Cialdini and effective in achieving behavioural change when they suc- Trost, 1998). In this paper, we adopt theory and termi- cessfully integrate an approach that considers the social nology developed by him and his colleagues, who identi- environment (Diop et al., 2008; Cislaghi et al., 2016; fied two distinct types of social norms: (i) beliefs about Miller and Prentice, 2016; Tankard and Paluck, 2016). what others do (descriptive norms) and (ii) beliefs about Take, for instance, 3-year, community-led social change what others approve and disapprove (injunctive norms) programme implemented by the Non-governmental (Cialdini et al.,1990; Cialdini and Trost, 1998; Cialdini Organisation (NGO) Tostan, which was widely studied et al.,2006). People tend to comply with descriptive and as an effective model to change social norms sustaining injunctive norms for a variety of reasons (Bell and Cox, FGC in Senegal (Johnson, 2003; Diop et al., 2004; 2015), the most well studied being the anticipation of so- Mbaye, 2007; Diop et al., 2008; Easton et al., 2009; cial rewards and punishments for compliance and non- CRDH, 2010; Gillespie and Melching, 2010; compliance, respectively (Bicchieri, 2006; Elster, 2007). Mcchesney, 2015; Cislaghi, 2017, 2018). The multi- Even though empirical findings in the health sciences pronged programme implemented by Tostan offers have offered ground-breaking contributions to our under- some important lessons. It was found effective in chang- standing of the influence of social norms on a wide range ing people’s health-related practices because it inte- of health outcomes (e.g. Piliavin and Libby, 1986; grated a social norms component within an intervention Peterson et al.,2009; Gidycz et al.,2011; McAlaney and that also addressed people’s individual attitudes and Jenkins, 2015; Berger and Caravita, 2016; Prestwich knowledge, local institutional policies and political ac- et al.,2016; Templeton et al.,2016), most of these empir- countability, and community members’ economic condi- ical findings emerge from studies conducted in high- tions (Cislaghi et al., 2016). Similar integrated income countries; the most famous case being the use of interventions seem particularly promising exactly be- social norms theory to reduce use of alcohol and recrea- cause they address social norms in their interplay with tional drugs in US college campuses (Borsari and Carey, other factors affecting people’s health and well-being. 2003; Lewis and Neighbors, 2006; Prestwich et al., Yet, practitioners working to increase people’s health in 618 B. Cislaghi and L. Heise LMIC lack a practical framework they can easily use to interventions; its initial aim was to offer a model for un- plan and deliver effective social norms programmes that derstanding the interaction of factors that increase or de- also address other behavioural drivers. We offer a first crease the likelihood of intimate partner violence at an attempt at such a framework in the next section. individual or population level. For it to become a practi- cal tool that NGO practitioners can use when planning social norm interventions, Heise’s framework needs to A DYNAMIC FRAMEWORK TO EMBED evolve in two ways. First, it needs to offer practitioners SOCIAL NORMS an easy way to adapt it to the contexts in which they im- Human action almost never originates from a single cause. plement their programmes. The existing version provides Relying exclusively on norms-based approaches for im- a useful way to organize factors that have emerged as pre- proving health outcomes oversimplifies the true complex- dictive of Intimate Partner Violence (IPV) across multiple ity of human behaviour. We concur with Brennan and settings. It intends to conceptualize the phenomenon of colleagues that ‘we doubt that many if any norms provide IPV rather than equip practitioners with a tool to diag- reasons that literally exclude from consideration any inter- nose the specific factors driving IPV in a specific setting. estingly wide range of other reasons for action’ (Brennan Second, the framework needs to spell out key factors that et al., 2013, p. 251). Most of the social norms interven- are currently hidden within the framework (as, for in- tions used with students in high-income countries have fo- stance, power), as well as the interactions between the cused on changing descriptive norms; that is: they aimed various factors that fall on the framework. to correct students’ misperceptions about the number of other students who drink or use recreational drugs. In THE DYNAMIC FRAMEWORK FOR SOCIAL their approach, they lacked an integrated framework that CHANGE would help address other factors contributing to the harm- ful behaviour of interest, this possibly being one of the rea- We suggest here a possible adaptation of the ecological sons for their mixed effectiveness (Borsari and Carey, framework, where four domains of influence (institutional, 2003; Lewis and Neighbors, 2006; Prestwich et al., 2016). material, social and individual) overlap (see Figure 1). What then should accompany social norms in a The individual domain includes all factors related to framework of factors influencing health-related behav- the person: factual beliefs, aspirations, skills, attitudes iours? A plethora of models of what influences behaviour and self-efficacy, to cite a few. The social domain in- exist and reviews can be found across many disciplines cludes factors such as the availability of different types (see, for instance, Darnton, 2008). One of the most fre- of social support, the configuration of social networks quently cited is the ‘ecological framework’. Originally both proximal and distal and exposure to positive devi- created by Bronfenbrenner (1992, 2009), the ecological ants in a group, for instance. Factors in the material do- framework helps understand the influence of the micro, main include physical objects and resources—money, meso and macro environments on human behaviour. The land or services, for example. Finally, the institutional ecological framework has been adapted by many scholars domain includes the formal system of rules and regula- (Tudge et al.,2009) to study social influence on various tions (laws, policies or religious rules). health-related issues. These issues include, to cite a few Importantly, these domains overlap generating cross- examples: pollution (Underwood and Peterson, 1988), cutting factors that also contribute to influencing peo- nutrition (Smaling, 1993), adolescent self-esteem (DuBois ple’s actions. For example, ‘access to services’ would fall et al.,1996), elder abuse (Schiamberg and Gans, 2000) at the intersection between individual (I), social (S) and and school bullying (Swearer and Espelage, 2004). One material (M) domains. As Bersamin et al. (2017) re- of the most well-known adaptations of the ecological cently found in their study of young female students’ ac- framework among practitioners working on social norms cess to the health services, people access health services in LMIC is Heise’s (Heise, 1998). Heise’s adaption is the when (i) those services physically exist (M); (ii) they starting point for many practitioners working to change know what those services offer and when they should social norms in LMIC, particularly those working on visit them (I); and (iii) they believe that they won’t incur harmful gender-related social norms and related practices social disapproval if they visit the health service, i.e. that (e.g. FGC, child marriage or intimate partner violence). there are no social norms against accessing the service This framework (as Bronfenbrenner’s before) integrates (S). What is unique about this framework, thus, is that it social norms as a factor contributing to making up cul- both highlights the importance of addressing change at tural influences in the macrosystem. Heise’s ecological those intersections—where social norms operate and framework, however, was never meant as a tool to plan programmatic action can be the most effective—and Social norms and health promotion: a dynamic framework 619 Fig. 1: Dynamic framework for social change. offers a tool to design intervention strategies that ad- (third column) and (iv) the level of influence that the par- dress interactions between factors. ticular factor has over a behaviour (fourth column). Through a collective process of reflection, this pro- cess generates hypotheses and prompts collective discus- sion, particularly around what falls in the intersections USING THE FRAMEWORK between domains. There is no single way in which this The use of the framework to plan a health intervention has framework could or should be populated. Contextual two steps. In the first, the factors hypothesized to generate socio-cultural circumstances and the characteristics of or sustain the behaviour of interest are identified, using the phenomenon on which practitioners want to inter- available research, practice-based evidence and formative vene will change what factors fall into each domain. research. Next, collaborating partners distribute these fac- tors across the various domains and intersections of the framework, perhaps during a workshop to develop a the- USING THE FRAMEWORK: A PRACTICAL ory of change to inform intervention development. EXAMPLE FROM AN INTERVENTION Table 1 can help organize this work. The table includes DESIGN WORKSHOP (i) an indication of the domain of analysis (first column),(ii) the factors falling in that domain that affect the health out- Let us give an example. Recently, this framework was come of interest (second column), (iii) the dynamics used to facilitate the design of an intervention on social through which those factors influence the health outcome norms and violence against children (VAC). During the 620 B. Cislaghi and L. Heise Table 1: A practical tool to diagnose factors influencing a behaviour of interest on the dynamic framework Domain Factors Contribution to Level of influence health outcome (high, mid, low) Individual Knowledge Values Skills Self-efficacy Aspirations Social/material Inheritance traditions (intersection) Social Mobility Material Services Laws Individual/social/material Access to services (Intersection) Individual/social/material/structural Power relations (intersection) Gender roles ... ... ... ... design workshop, participants split into three groups. The purpose of the dynamic framework is not to de- Participants identified, by group, the factors contribut- termine precisely in which domain a particular factor ing to VAC in the region where the intervention was to should fall. Rather, it is to generate discussion and re- be run. They did so by discussing the existing evidence flection among practitioners about the factors that influ- (as well as their own understandings as cultural insiders) ence a particular health outcome in a given context and of how the factors in each section of the diagram con- the role that social norms may play in strengthening or tributed to sustaining VAC in that particular area. The weakening those factors. Such discussions help plan an groups then regathered and compared/contrasted their intervention and assess the need to coordinate with findings. The final list that emerged as a result of the ple- other actors to ensure effective and sustainable change. nary discussion included several factors sustaining or po- tentially preventing VAC in the intervention area. As participants identified these factors, they specifically SOCIAL NORMS IN THE DYNAMIC looked at the role that social norms played in sustaining FRAMEWORK them. Workshop participants then proceeded to the second A socio-psychological approach to social norms (specific to step. The second step is action-oriented: programme de- one’s beliefs about the behaviours and attitudes of others) signers identify the key factors that their intervention can would place them at the intersection between the individ- and should address and seek collaborating partners to ad- ual and the social domain. While we think that intersection dress factors that fall outside the reach or realm of exper- can be an appropriate place for social norms, we also think tise. Participants in the workshop first grouped similar it’s important to stress the fact that social norms play a factors into themes and then discussed the dynamic re- role in all intersections. Embedded within local institutions lation between these themes. Several questions emerged and practices, social norms influence distribution of mate- in this discussion; for instance: which themes are more rial resources, as well individual aspirations, and institu- important to address in the intervention? what would tional laws and policies (see Figure 2). be the cascading effect of changing social norms on the Integrating a social norms perspective within health different themes? which social protective social norms interventions, thus, contributes valuable potential be- can we leverage? which themes required the collabora- cause it can generate results across many intersections; it tion of other stakeholders? From this conversation, can widen existing positive cracks in hegemonic collec- participants drew a diagram showing the dynamic rela- tive beliefs and generate space where change can hap- tion between themes and their influence on VAC. This pen. As such, the dynamic framework is not only a diagram eventually informed the following conversa- practical tool for diagnosing and planning effective inte- tions on what entry points existed for the intervention grated interventions, it becomes an ideational tool in and on what collaborations were required to achieve which to plan ways that social norms change can be di- effective sustainable change. rected at both individuals and institutions. Social norms and health promotion: a dynamic framework 621 Fig. 2: The influence of social norms visualized on the dynamic framework. working at different points of influence. It also encour- CONCLUSION ages practitioners to recognize the multi-faceted poten- Today’s considerable interest in using social norms the- tial of working with norms at both the individual, ory to achieve positive health outcomes must be accom- collective, and institutional levels. This framework has panied by an understanding of how a norms perspective been used by several NGO practitioners who found it can be integrated into a wider approach to social both intuitive and useful for programme design. change. In this paper, we presented a framework that We offer it to the larger community of practitioners can help practitioners diagnose and plan effective inter- working to improve health in LMIC, hoping that ventions by embedding a social norms perspective into others will join those who have already adopted it in their programming. We refer to this framework as the their work. dynamic framework for social change (but note that some practitioners who are using it refer it as ‘the flower’) because it encourages practitioners to look at FUNDING the dynamic interactions between different domains of influence and how those interactions contribute to The study was supported by UKaid from the harmful practices. The dynamic framework helps recog- Department for International Development through nize, in particular, the combined influence of various STRIVE, a research consortium based at the LSHTM. factors in each domain, suggesting that interventions However, the views expressed do not necessarily reflect should aim to achieve cooperation with other actors the department’s official policies. 622 B. Cislaghi and L. Heise CRDH. (2010) Evaluation De L’Impact Du Programme De REFERENCES Renforcement Des Capacite ´ s Des Communaute ´s Mis En Abiad, A., Debuque-Gonzales, M. and Sy, A. L. 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Using social norms theory for health promotion in low-income countries

Health Promotion International , Volume 34 (3) – Mar 22, 2018

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Abstract

Health Promotion International, 2019;34:616–623 doi: 10.1093/heapro/day017 Advance Access Publication Date: 22 March 2018 Debate Debate Using social norms theory for health promotion in low-income countries 1, 2 Beniamino Cislaghi * and Lori Heise Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK and Johns Hopkins Bloomberg School of Public Health and Johns Hopkins School of Nursing, Baltimore, MD, USA *Corresponding author. E-mail: ben.cislaghi@lshtm.ac.uk Summary Social norms can greatly influence people’s health-related choices and behaviours. In the last few years, scholars and practitioners working in low- and mid-income countries (LMIC) have increasingly been trying to harness the influence of social norms to improve people’s health globally. However, the literature informing social norm interventions in LMIC lacks a framework to understand how norms interact with other factors that sustain harmful practices and behaviours. This gap has led to short-sighted interventions that target social norms exclusively without a wider awareness of how other institutional, material, individual and social factors affect the harmful practice. Emphasizing norms to the exclusion of other factors might ultimately discredit norms-based strategies, not be- cause they are flawed but because they alone are not sufficient to shift behaviour. In this paper, we share a framework (already adopted by some practitioners) that locates norm-based strategies within the wider array of factors that must be considered when designing prevention programmes in LMIC. Key words: social norms, harmful practices, intervention, community health promotion, low-income countries Social norms theory is opening new programmatic ave- framework that practitioners can use to embed a social nues for health promotion in low- and mid-income norm perspective within integrated health interventions countries (LMIC) (Chung and Rimal, 2016; Miller and that address the multiple factors that sustain harmful Prentice, 2016; Tankard and Paluck, 2016). As practi- behaviours. tioners have begun to deploy social norm strategies to improve health, however, there has been a tendency to SOCIAL NORMS AND HEALTH focus on norms to the exclusion of other factors that in- INTERVENTIONS IN LMIC form people’s actions. Using social norms theory with- Researchers have been aware of the influence of social out appreciating the place that norms occupy among norms—informal rules of behaviour that dictate what is other drivers of behaviour, might position interventions acceptable within a given social context—for a long for failure, ultimately discrediting promising strategies time (Young, 2007; Mackie et al., 2015; Chung and simply because, in isolation, they are inadequate to im- Rimal, 2016). However, in recent years, there has been prove health. The aim of this paper is to provide a V C The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Social norms and health promotion: a dynamic framework 617 a surge of interest among both scholars and practitioners 2016). This narrow evidence base is particularly problem- in transforming norms as a tool to achieve change in atic given donors’ and practitioners’ recent interest in in- people’s behaviour and improve people’s health and tegrating social norms theory into health interventions in well-being (Mollen et al., 2010). LMIC. Each LMIC obviously presents characteristics that Although all disciplines agree that social norms influ- are unique to its context; yet, commonalities exist in the ence health-related behaviours, they offer different theo- political and social features of most LMIC. These com- retical perspectives on what social norms are, how they monalities include, for instance: traditional forms of form and how they shape behaviour (see reviews by power often compensating for weaker state control and Brennan et al.,2013; Elsenbroich and Gilbert, 2014; enforcement of the law (Englebert, 2009); relatively weak Mackie et al.,2015; Young, 2015). Loosely speaking, infrastructures (including reduced access to information there are three main schools of thought on social norms and communication technology) (Abiad et al.,2017); and that respectively defined them as: (i) behavioural patterns, persistent economic deprivation impacting on the effec- (ii) collective attitudes and (iii) individuals’ beliefs about tiveness of the formal health systems (Mills, 2011). others’ behaviours and attitudes (Morris et al.,2015; The literature on the effectiveness of social norms in- Young, 2015). Contemporary research in health science terventions for increasing health and well-being in has empirically demonstrated the usefulness of the third, LMIC is sparse but growing. The most promising ‘norms as beliefs’, school of thought, which emerged examples are emerging from the field of sexual and re- mostly from social psychology (e.g. Cialdini et al.,1990), productive health and rights (Haylock et al., 2016; as a means to explain and also to influence people’s Read-Hamilton and Marsh, 2016). For instance, social health-related choices (Borsari and Carey, 2003; norms theory has been used extensively to understand Eisenberg et al.,2005; Rimal and Real, 2005; McAlaney the persistence of female genital cutting (FGC), a non- and Jenkins, 2015; Ahmed et al.,2016). Contemporary medically justified modification of women’s genitalia scholars in this tradition argue that social norms are one’s that poses a global threat to the health of 140 million of beliefs about (i) what others do and (ii) of what others ap- women and girls globally (Wagner, 2015). Existing pro- prove and disapprove of (Gibbs, 1965; Cialdini et al., gramme implementations that targeted social norms 1991; Cialdini and Trost, 1998; Lapinski and Rimal, around FGC offered important insights into the poten- 2005; Bicchieri, 2006; for a full review see Mackie et al., tial of addressing social norms for social change, sug- 2015). Among the work of various thinkers in this tradi- gesting that community-based interventions can be tion, Cialdini’s has been the most influential (Cialdini and effective in achieving behavioural change when they suc- Trost, 1998). In this paper, we adopt theory and termi- cessfully integrate an approach that considers the social nology developed by him and his colleagues, who identi- environment (Diop et al., 2008; Cislaghi et al., 2016; fied two distinct types of social norms: (i) beliefs about Miller and Prentice, 2016; Tankard and Paluck, 2016). what others do (descriptive norms) and (ii) beliefs about Take, for instance, 3-year, community-led social change what others approve and disapprove (injunctive norms) programme implemented by the Non-governmental (Cialdini et al.,1990; Cialdini and Trost, 1998; Cialdini Organisation (NGO) Tostan, which was widely studied et al.,2006). People tend to comply with descriptive and as an effective model to change social norms sustaining injunctive norms for a variety of reasons (Bell and Cox, FGC in Senegal (Johnson, 2003; Diop et al., 2004; 2015), the most well studied being the anticipation of so- Mbaye, 2007; Diop et al., 2008; Easton et al., 2009; cial rewards and punishments for compliance and non- CRDH, 2010; Gillespie and Melching, 2010; compliance, respectively (Bicchieri, 2006; Elster, 2007). Mcchesney, 2015; Cislaghi, 2017, 2018). The multi- Even though empirical findings in the health sciences pronged programme implemented by Tostan offers have offered ground-breaking contributions to our under- some important lessons. It was found effective in chang- standing of the influence of social norms on a wide range ing people’s health-related practices because it inte- of health outcomes (e.g. Piliavin and Libby, 1986; grated a social norms component within an intervention Peterson et al.,2009; Gidycz et al.,2011; McAlaney and that also addressed people’s individual attitudes and Jenkins, 2015; Berger and Caravita, 2016; Prestwich knowledge, local institutional policies and political ac- et al.,2016; Templeton et al.,2016), most of these empir- countability, and community members’ economic condi- ical findings emerge from studies conducted in high- tions (Cislaghi et al., 2016). Similar integrated income countries; the most famous case being the use of interventions seem particularly promising exactly be- social norms theory to reduce use of alcohol and recrea- cause they address social norms in their interplay with tional drugs in US college campuses (Borsari and Carey, other factors affecting people’s health and well-being. 2003; Lewis and Neighbors, 2006; Prestwich et al., Yet, practitioners working to increase people’s health in 618 B. Cislaghi and L. Heise LMIC lack a practical framework they can easily use to interventions; its initial aim was to offer a model for un- plan and deliver effective social norms programmes that derstanding the interaction of factors that increase or de- also address other behavioural drivers. We offer a first crease the likelihood of intimate partner violence at an attempt at such a framework in the next section. individual or population level. For it to become a practi- cal tool that NGO practitioners can use when planning social norm interventions, Heise’s framework needs to A DYNAMIC FRAMEWORK TO EMBED evolve in two ways. First, it needs to offer practitioners SOCIAL NORMS an easy way to adapt it to the contexts in which they im- Human action almost never originates from a single cause. plement their programmes. The existing version provides Relying exclusively on norms-based approaches for im- a useful way to organize factors that have emerged as pre- proving health outcomes oversimplifies the true complex- dictive of Intimate Partner Violence (IPV) across multiple ity of human behaviour. We concur with Brennan and settings. It intends to conceptualize the phenomenon of colleagues that ‘we doubt that many if any norms provide IPV rather than equip practitioners with a tool to diag- reasons that literally exclude from consideration any inter- nose the specific factors driving IPV in a specific setting. estingly wide range of other reasons for action’ (Brennan Second, the framework needs to spell out key factors that et al., 2013, p. 251). Most of the social norms interven- are currently hidden within the framework (as, for in- tions used with students in high-income countries have fo- stance, power), as well as the interactions between the cused on changing descriptive norms; that is: they aimed various factors that fall on the framework. to correct students’ misperceptions about the number of other students who drink or use recreational drugs. In THE DYNAMIC FRAMEWORK FOR SOCIAL their approach, they lacked an integrated framework that CHANGE would help address other factors contributing to the harm- ful behaviour of interest, this possibly being one of the rea- We suggest here a possible adaptation of the ecological sons for their mixed effectiveness (Borsari and Carey, framework, where four domains of influence (institutional, 2003; Lewis and Neighbors, 2006; Prestwich et al., 2016). material, social and individual) overlap (see Figure 1). What then should accompany social norms in a The individual domain includes all factors related to framework of factors influencing health-related behav- the person: factual beliefs, aspirations, skills, attitudes iours? A plethora of models of what influences behaviour and self-efficacy, to cite a few. The social domain in- exist and reviews can be found across many disciplines cludes factors such as the availability of different types (see, for instance, Darnton, 2008). One of the most fre- of social support, the configuration of social networks quently cited is the ‘ecological framework’. Originally both proximal and distal and exposure to positive devi- created by Bronfenbrenner (1992, 2009), the ecological ants in a group, for instance. Factors in the material do- framework helps understand the influence of the micro, main include physical objects and resources—money, meso and macro environments on human behaviour. The land or services, for example. Finally, the institutional ecological framework has been adapted by many scholars domain includes the formal system of rules and regula- (Tudge et al.,2009) to study social influence on various tions (laws, policies or religious rules). health-related issues. These issues include, to cite a few Importantly, these domains overlap generating cross- examples: pollution (Underwood and Peterson, 1988), cutting factors that also contribute to influencing peo- nutrition (Smaling, 1993), adolescent self-esteem (DuBois ple’s actions. For example, ‘access to services’ would fall et al.,1996), elder abuse (Schiamberg and Gans, 2000) at the intersection between individual (I), social (S) and and school bullying (Swearer and Espelage, 2004). One material (M) domains. As Bersamin et al. (2017) re- of the most well-known adaptations of the ecological cently found in their study of young female students’ ac- framework among practitioners working on social norms cess to the health services, people access health services in LMIC is Heise’s (Heise, 1998). Heise’s adaption is the when (i) those services physically exist (M); (ii) they starting point for many practitioners working to change know what those services offer and when they should social norms in LMIC, particularly those working on visit them (I); and (iii) they believe that they won’t incur harmful gender-related social norms and related practices social disapproval if they visit the health service, i.e. that (e.g. FGC, child marriage or intimate partner violence). there are no social norms against accessing the service This framework (as Bronfenbrenner’s before) integrates (S). What is unique about this framework, thus, is that it social norms as a factor contributing to making up cul- both highlights the importance of addressing change at tural influences in the macrosystem. Heise’s ecological those intersections—where social norms operate and framework, however, was never meant as a tool to plan programmatic action can be the most effective—and Social norms and health promotion: a dynamic framework 619 Fig. 1: Dynamic framework for social change. offers a tool to design intervention strategies that ad- (third column) and (iv) the level of influence that the par- dress interactions between factors. ticular factor has over a behaviour (fourth column). Through a collective process of reflection, this pro- cess generates hypotheses and prompts collective discus- sion, particularly around what falls in the intersections USING THE FRAMEWORK between domains. There is no single way in which this The use of the framework to plan a health intervention has framework could or should be populated. Contextual two steps. In the first, the factors hypothesized to generate socio-cultural circumstances and the characteristics of or sustain the behaviour of interest are identified, using the phenomenon on which practitioners want to inter- available research, practice-based evidence and formative vene will change what factors fall into each domain. research. Next, collaborating partners distribute these fac- tors across the various domains and intersections of the framework, perhaps during a workshop to develop a the- USING THE FRAMEWORK: A PRACTICAL ory of change to inform intervention development. EXAMPLE FROM AN INTERVENTION Table 1 can help organize this work. The table includes DESIGN WORKSHOP (i) an indication of the domain of analysis (first column),(ii) the factors falling in that domain that affect the health out- Let us give an example. Recently, this framework was come of interest (second column), (iii) the dynamics used to facilitate the design of an intervention on social through which those factors influence the health outcome norms and violence against children (VAC). During the 620 B. Cislaghi and L. Heise Table 1: A practical tool to diagnose factors influencing a behaviour of interest on the dynamic framework Domain Factors Contribution to Level of influence health outcome (high, mid, low) Individual Knowledge Values Skills Self-efficacy Aspirations Social/material Inheritance traditions (intersection) Social Mobility Material Services Laws Individual/social/material Access to services (Intersection) Individual/social/material/structural Power relations (intersection) Gender roles ... ... ... ... design workshop, participants split into three groups. The purpose of the dynamic framework is not to de- Participants identified, by group, the factors contribut- termine precisely in which domain a particular factor ing to VAC in the region where the intervention was to should fall. Rather, it is to generate discussion and re- be run. They did so by discussing the existing evidence flection among practitioners about the factors that influ- (as well as their own understandings as cultural insiders) ence a particular health outcome in a given context and of how the factors in each section of the diagram con- the role that social norms may play in strengthening or tributed to sustaining VAC in that particular area. The weakening those factors. Such discussions help plan an groups then regathered and compared/contrasted their intervention and assess the need to coordinate with findings. The final list that emerged as a result of the ple- other actors to ensure effective and sustainable change. nary discussion included several factors sustaining or po- tentially preventing VAC in the intervention area. As participants identified these factors, they specifically SOCIAL NORMS IN THE DYNAMIC looked at the role that social norms played in sustaining FRAMEWORK them. Workshop participants then proceeded to the second A socio-psychological approach to social norms (specific to step. The second step is action-oriented: programme de- one’s beliefs about the behaviours and attitudes of others) signers identify the key factors that their intervention can would place them at the intersection between the individ- and should address and seek collaborating partners to ad- ual and the social domain. While we think that intersection dress factors that fall outside the reach or realm of exper- can be an appropriate place for social norms, we also think tise. Participants in the workshop first grouped similar it’s important to stress the fact that social norms play a factors into themes and then discussed the dynamic re- role in all intersections. Embedded within local institutions lation between these themes. Several questions emerged and practices, social norms influence distribution of mate- in this discussion; for instance: which themes are more rial resources, as well individual aspirations, and institu- important to address in the intervention? what would tional laws and policies (see Figure 2). be the cascading effect of changing social norms on the Integrating a social norms perspective within health different themes? which social protective social norms interventions, thus, contributes valuable potential be- can we leverage? which themes required the collabora- cause it can generate results across many intersections; it tion of other stakeholders? From this conversation, can widen existing positive cracks in hegemonic collec- participants drew a diagram showing the dynamic rela- tive beliefs and generate space where change can hap- tion between themes and their influence on VAC. This pen. As such, the dynamic framework is not only a diagram eventually informed the following conversa- practical tool for diagnosing and planning effective inte- tions on what entry points existed for the intervention grated interventions, it becomes an ideational tool in and on what collaborations were required to achieve which to plan ways that social norms change can be di- effective sustainable change. rected at both individuals and institutions. Social norms and health promotion: a dynamic framework 621 Fig. 2: The influence of social norms visualized on the dynamic framework. working at different points of influence. It also encour- CONCLUSION ages practitioners to recognize the multi-faceted poten- Today’s considerable interest in using social norms the- tial of working with norms at both the individual, ory to achieve positive health outcomes must be accom- collective, and institutional levels. This framework has panied by an understanding of how a norms perspective been used by several NGO practitioners who found it can be integrated into a wider approach to social both intuitive and useful for programme design. change. In this paper, we presented a framework that We offer it to the larger community of practitioners can help practitioners diagnose and plan effective inter- working to improve health in LMIC, hoping that ventions by embedding a social norms perspective into others will join those who have already adopted it in their programming. We refer to this framework as the their work. dynamic framework for social change (but note that some practitioners who are using it refer it as ‘the flower’) because it encourages practitioners to look at FUNDING the dynamic interactions between different domains of influence and how those interactions contribute to The study was supported by UKaid from the harmful practices. The dynamic framework helps recog- Department for International Development through nize, in particular, the combined influence of various STRIVE, a research consortium based at the LSHTM. factors in each domain, suggesting that interventions However, the views expressed do not necessarily reflect should aim to achieve cooperation with other actors the department’s official policies. 622 B. Cislaghi and L. Heise CRDH. (2010) Evaluation De L’Impact Du Programme De REFERENCES Renforcement Des Capacite ´ s Des Communaute ´s Mis En Abiad, A., Debuque-Gonzales, M. and Sy, A. L. 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Published: Mar 22, 2018

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