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

Abstract

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 because 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.

Full text

Debate
Using social norms theory for health promotion
in low-income countries
Beniamino Cislaghi
1,
* and Lori Heise
2
1
Department of Global Health and Development, London School of Hygiene and Tropical Medicine,
London, UK and
2
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-
nues for health promotion in low- and mid-income
countries (LMIC) (Chung and Rimal, 2016;Miller and
Prentice, 2016;Tankard and Paluck, 2016). As practi-
tioners have begun to deploy social norm strategies to
improve health, however, there has been a tendency to
focus on norms to the exclusion of other factors that in-
form people’s actions. Using social norms theory with-
out appreciating the place that norms occupy among
other drivers of behaviour, might position interventions
for failure, ultimately discrediting promising strategies
simply because, in isolation, they are inadequate to im-
prove health. The aim of this paper is to provide a
framework that practitioners can use to embed a social
norm perspective within integrated health interventions
that address the multiple factors that sustain harmful
behaviours.
SOCIAL NORMS AND HEALTH
INTERVENTIONS IN LMIC
Researchers have been aware of the influence of social
norms—informal rules of behaviour that dictate what is
acceptable within a given social context—for a long
time (Young, 2007;Mackie et al., 2015;Chung and
Rimal, 2016). However, in recent years, there has been
V
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Health Promotion International, 2018, 1–8
doi: 10.1093/heapro/day017
Debate
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a surge of interest among both scholars and practitioners
in transforming norms as a tool to achieve change in
people’s behaviour and improve people’s health and
well-being (Mollen et al., 2010).
Although all disciplines agree that social norms influ-
ence health-related behaviours, they offer different theo-
retical perspectives on what social norms are, how they
form and how they shape behaviour (see reviews by
Brennan et al.,2013;Elsenbroich and Gilbert, 2014;
Mackie et al.,2015;Young, 2015). Loosely speaking,
there are three main schools of thought on social norms
that respectively defined them as: (i) behavioural patterns,
(ii) collective attitudes and (iii) individuals’ beliefs about
others’ behaviours and attitudes (Morris et al.,2015;
Young, 2015). Contemporary research in health science
has empirically demonstrated the usefulness of the third,
‘norms as beliefs’, school of thought, which emerged
mostly from social psychology (e.g. Cialdini et al.,1990),
as a means to explain and also to influence people’s
health-related choices (Borsari and Carey, 2003;
Eisenberg et al.,2005;Rimal and Real, 2005;McAlaney
and Jenkins, 2015;Ahmed et al.,2016). Contemporary
scholars in this tradition argue that social norms are one’s
beliefs about (i) what others do and (ii) of what others ap-
prove and disapprove of (Gibbs, 1965;Cialdini et al.,
1991;Cialdini and Trost, 1998;Lapinski and Rimal,
2005;Bicchieri, 2006; for a full review see Mackie et al.,
2015). Among the work of various thinkers in this tradi-
tion, Cialdini’s has been the most influential (Cialdini and
Trost, 1998). In this paper, we adopt theory and termi-
nology developed by him and his colleagues, who identi-
fied two distinct types of social norms: (i) beliefs about
what others do (descriptive norms) and (ii) beliefs about
what others approve and disapprove (injunctive norms)
(Cialdini et al.,1990;Cialdini and Trost, 1998;Cialdini
et al.,2006). People tend to comply with descriptive and
injunctive norms for a variety of reasons (Bell and Cox,
2015), the most well studied being the anticipation of so-
cial rewards and punishments for compliance and non-
compliance, respectively (Bicchieri, 2006;Elster, 2007).
Even though empirical findings in the health sciences
have offered ground-breaking contributions to our under-
standing of the influence of social norms on a wide range
of health outcomes (e.g. Piliavin and Libby, 1986;
Peterson et al.,2009;Gidycz et al.,2011;McAlaney and
Jenkins, 2015;Berger and Caravita, 2016;Prestwich
et al.,2016;Templeton et al.,2016), most of these empir-
ical findings emerge from studies conducted in high-
income countries; the most famous case being the use of
social norms theory to reduce use of alcohol and recrea-
tional drugs in US college campuses (Borsari and Carey,
2003;Lewis and Neighbors, 2006;Prestwich et al.,
2016). This narrow evidence base is particularly problem-
atic given donors’ and practitioners’ recent interest in in-
tegrating social norms theory into health interventions in
LMIC. Each LMIC obviously presents characteristics that
are unique to its context; yet, commonalities exist in the
political and social features of most LMIC. These com-
monalities include, for instance: traditional forms of
power often compensating for weaker state control and
enforcement of the law (Englebert, 2009); relatively weak
infrastructures (including reduced access to information
and communication technology) (Abiad et al.,2017); and
persistent economic deprivation impacting on the effec-
tiveness of the formal health systems (Mills, 2011).
The literature on the effectiveness of social norms in-
terventions for increasing health and well-being in
LMIC is sparse but growing. The most promising
examples are emerging from the field of sexual and re-
productive health and rights (Haylock et al., 2016;
Read-Hamilton and Marsh, 2016). For instance, social
norms theory has been used extensively to understand
the persistence of female genital cutting (FGC), a non-
medically justified modification of women’s genitalia
that poses a global threat to the health of 140 million of
women and girls globally (Wagner, 2015). Existing pro-
gramme implementations that targeted social norms
around FGC offered important insights into the poten-
tial of addressing social norms for social change, sug-
gesting that community-based interventions can be
effective in achieving behavioural change when they suc-
cessfully integrate an approach that considers the social
environment (Diop et al., 2008;Cislaghi et al., 2016;
Miller and Prentice, 2016;Tankard and Paluck, 2016).
Take, for instance, 3-year, community-led social change
programme implemented by the Non-governmental
Organisation (NGO) Tostan, which was widely studied
as an effective model to change social norms sustaining
FGC in Senegal (Johnson, 2003;Diop et al., 2004;
Mbaye, 2007;Diop et al., 2008;Easton et al., 2009;
CRDH, 2010;Gillespie and Melching, 2010;
Mcchesney, 2015;Cislaghi, 2017,2018). The multi-
pronged programme implemented by Tostan offers
some important lessons. It was found effective in chang-
ing people’s health-related practices because it inte-
grated a social norms component within an intervention
that also addressed people’s individual attitudes and
knowledge, local institutional policies and political ac-
countability, and community members’ economic condi-
tions (Cislaghi et al., 2016). Similar integrated
interventions seem particularly promising exactly be-
cause they address social norms in their interplay with
other factors affecting people’s health and well-being.
Yet, practitioners working to increase people’s health in
2B. Cislaghi and L. Heise
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LMIC lack a practical framework they can easily use to
plan and deliver effective social norms programmes that
also address other behavioural drivers. We offer a first
attempt at such a framework in the next section.
A DYNAMIC FRAMEWORK TO EMBED
SOCIAL NORMS
Human action almost never originates from a single cause.
Relying exclusively on norms-based approaches for im-
proving health outcomes oversimplifies the true complex-
ity of human behaviour. We concur with Brennan and
colleagues that ‘we doubt that many if any norms provide
reasons that literally exclude from consideration any inter-
estingly wide range of other reasons for action’ (Brennan
et al., 2013, p. 251). Most of the social norms interven-
tions used with students in high-income countries have fo-
cused on changing descriptive norms; that is: they aimed
to correct students’ misperceptions about the number of
other students who drink or use recreational drugs. In
their approach, they lacked an integrated framework that
would help address other factors contributing to the harm-
ful behaviour of interest, this possibly being one of the rea-
sons for their mixed effectiveness (Borsari and Carey,
2003;Lewis and Neighbors, 2006;Prestwich et al., 2016).
What then should accompany social norms in a
framework of factors influencing health-related behav-
iours? A plethora of models of what influences behaviour
exist and reviews can be found across many disciplines
(see, for instance, Darnton, 2008). One of the most fre-
quently cited is the ‘ecological framework’. Originally
created by Bronfenbrenner (1992,2009), the ecological
framework helps understand the influence of the micro,
meso and macro environments on human behaviour. The
ecological framework has been adapted by many scholars
(Tudge et al.,2009) to study social influence on various
health-related issues. These issues include, to cite a few
examples: pollution (Underwood and Peterson, 1988),
nutrition (Smaling, 1993), adolescent self-esteem (DuBois
et al.,1996), elder abuse (Schiamberg and Gans, 2000)
and school bullying (Swearer and Espelage, 2004). One
of the most well-known adaptations of the ecological
framework among practitioners working on social norms
in LMIC is Heise’s (Heise, 1998). Heise’s adaption is the
starting point for many practitioners working to change
social norms in LMIC, particularly those working on
harmful gender-related social norms and related practices
(e.g. FGC, child marriage or intimate partner violence).
This framework (as Bronfenbrenner’s before) integrates
social norms as a factor contributing to making up cul-
tural influences in the macrosystem. Heise’s ecological
framework, however, was never meant as a tool to plan
interventions; its initial aim was to offer a model for un-
derstanding the interaction of factors that increase or de-
crease the likelihood of intimate partner violence at an
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
evolve in two ways. First, it needs to offer practitioners
an easy way to adapt it to the contexts in which they im-
plement their programmes. The existing version provides
a useful way to organize factors that have emerged as pre-
dictive of Intimate Partner Violence (IPV) across multiple
settings. It intends to conceptualize the phenomenon of
IPV rather than equip practitioners with a tool to diag-
nose the specific factors driving IPV in a specific setting.
Second, the framework needs to spell out key factors that
are currently hidden within the framework (as, for in-
stance, power), as well as the interactions between the
various factors that fall on the framework.
THE DYNAMIC FRAMEWORK FOR SOCIAL
CHANGE
We suggest here a possible adaptation of the ecological
framework, where four domains of influence (institutional,
material, social and individual) overlap (see Figure 1).
The individual domain includes all factors related to
the person: factual beliefs, aspirations, skills, attitudes
and self-efficacy, to cite a few. The social domain in-
cludes factors such as the availability of different types
of social support, the configuration of social networks
both proximal and distal and exposure to positive devi-
ants in a group, for instance. Factors in the material do-
main include physical objects and resources—money,
land or services, for example. Finally, the institutional
domain includes the formal system of rules and regula-
tions (laws, policies or religious rules).
Importantly, these domains overlap generating cross-
cutting factors that also contribute to influencing peo-
ple’s actions. For example, ‘access to services’ would fall
at the intersection between individual (I), social (S) and
material (M) domains. As Bersamin et al. (2017) re-
cently found in their study of young female students’ ac-
cess to the health services, people access health services
when (i) those services physically exist (M); (ii) they
know what those services offer and when they should
visit them (I); and (iii) they believe that they won’t incur
social disapproval if they visit the health service, i.e. that
there are no social norms against accessing the service
(S). What is unique about this framework, thus, is that it
both highlights the importance of addressing change at
those intersections—where social norms operate and
programmatic action can be the most effective—and
Social norms and health promotion: a dynamic framework 3
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offers a tool to design intervention strategies that ad-
dress interactions between factors.
USING THE FRAMEWORK
The use of the framework to plan a health intervention has
two steps. In the first, the factors hypothesized to generate
or sustain the behaviour of interest are identified, using
available research, practice-based evidence and formative
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-
ory of change to inform intervention development.
Table 1 can help organize this work. The table includes
(i) an indication of the domain of analysis (first column),(ii)
the factors falling in that domain that affect the health out-
come of interest (second column), (iii) the dynamics
through which those factors influence the health outcome
(third column) and (iv) the level of influence that the par-
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
between domains. There is no single way in which this
framework could or should be populated. Contextual
socio-cultural circumstances and the characteristics of
the phenomenon on which practitioners want to inter-
vene will change what factors fall into each domain.
USING THE FRAMEWORK: A PRACTICAL
EXAMPLE FROM AN INTERVENTION
DESIGN WORKSHOP
Let us give an example. Recently, this framework was
used to facilitate the design of an intervention on social
norms and transactional sex in an East African country.
Fig. 1: Dynamic framework for social change.
4B. Cislaghi and L. Heise
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During the design workshop, participants split into two
groups. Each group included local researchers, NGO
practitioners and other key stakeholders. Participants
identified, by group, the factors contributing to transac-
tional sex in the region where the intervention was to be
run. They did so by discussing the existing evidence (as
well as their own understandings as cultural insiders) of
how the factors in each section of the diagram contrib-
uted to sustaining transactional sex in that particular
area. The two groups then regathered and compared/
contrasted their findings. The final list that emerged as a
result of the plenary discussion included 40 factors sus-
taining or potentially preventing transactional sex in the
intervention area. They offer the following three exam-
ples: (i) parents’ beliefs that adolescent girls are old
enough to take care of themselves and that if they didn’t
the community would reprimand them as bad parents
(intersection between individual and social domains);
(ii) inheritance laws favouring men (intersection between
institutional, material and social domains) that resulted
in women being economically disadvantaged; and (iii) a
formal education system that doesn’t include sexual
knowledge girls need to understand the risk of having
multiple unprotected sexual relationships (institutional
domain). As participants identified these factors, they
specifically looked at the role that social norms played in
sustaining them. They discussed, for instance, how laws,
religious duties and distribution of resources intersected
with social norms in sustaining transactional sex.
Workshop participants then proceeded to the second
step. The second step is action-oriented: programme de-
signers identify the key factors that their intervention can
and should address and seek collaborating partners to ad-
dress factors that fall outside the reach or realm of
expertise. Participants in the workshop first grouped simi-
lar factors into themes and then discussed the dynamic re-
lation between these themes. Several questions emerged
in this discussion; for instance: which themes are more
important to address in the intervention? what would be
the cascading effect of changing social norms on the dif-
ferent themes? which social protective social norms can
we leverage? which themes required the collaboration of
other stakeholders? From this conversation, participants
drew a diagram showing the dynamic relation between
themes and their influence on transactional sex. This dia-
gram eventually informed the following conversations on
what entry points existed for the intervention and on
what collaborations were required to achieve effective
sustainable change on transactional sex.
The purpose of the dynamic framework is not to de-
termine precisely in which domain a particular factor
should fall. Rather, it is to generate discussion and re-
flection among practitioners about the factors that influ-
ence a particular health outcome in a given context and
the role that social norms may play in strengthening or
weakening those factors. Such discussions help plan an
intervention and assess the need to coordinate with
other actors to ensure effective and sustainable change.
SOCIAL NORMS IN THE DYNAMIC
FRAMEWORK
A socio-psychological approach to social norms (specific to
one’s beliefs about the behaviours and attitudes of others)
would place them at the intersection between the individ-
ual and the social domain. While we think that intersection
can be an appropriate place for social norms, we also think
it’s important to stress the fact that social norms play a
Table 1: A practical tool to diagnose factors influencing a behaviour of interest on the dynamic framework
Domain Factors Contribution to
health outcome
Level of influence
(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
... ... ... ...
Social norms and health promotion: a dynamic framework 5
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role in all intersections. Embedded within local institutions
and practices, social norms influence distribution of mate-
rial resources, as well individual aspirations, and institu-
tional laws and policies (see Figure 2).
Integrating a social norms perspective within health
interventions, thus, contributes valuable potential be-
cause it can generate results across many intersections; it
can widen existing positive cracks in hegemonic collec-
tive beliefs and generate space where change can hap-
pen. As such, the dynamic framework is not only a
practical tool for diagnosing and planning effective inte-
grated interventions, it becomes an ideational tool in
which to plan ways that social norms change can be di-
rected at both individuals and institutions.
CONCLUSION
Today’s considerable interest in using social norms the-
ory to achieve positive health outcomes must be
accompanied by an understanding of how a norms per-
spective can be integrated into a wider approach to so-
cial change. In this paper, we presented a framework
that can help practitioners diagnose and plan effective
interventions by embedding a social norms perspective
into their programming. We refer to this framework as
the 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
the dynamic interactions between different domains of
influence and how those interactions contribute to
harmful practices. The dynamic framework helps recog-
nize, in particular, the combined influence of various
factors in each domain, suggesting that interventions
should aim to achieve cooperation with other actors
working at different points of influence. It also encour-
ages practitioners to recognize the multi-faceted poten-
tial of working with norms at both the individual,
collective, and institutional levels. This framework has
Fig. 2: The influence of social norms visualized on the dynamic framework.
6B. Cislaghi and L. Heise
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been used by several NGO practitioners who found it
both intuitive and useful for programme design.
We offer it to the larger community of practitioners
working to improve health in LMIC, hoping that
others will join those who have already adopted it in
their work.
FUNDING
The study was supported by UKaid from the
Department for International Development through
STRIVE, a research consortium based at the LSHTM.
However, the views expressed do not necessarily reflect
the department’s official policies.
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