ArticlePDF Available
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
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
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
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 violence against children (VAC). During the
Fig. 1: Dynamic framework for social change.
4B. Cislaghi and L. Heise
design workshop, participants split into three groups.
Participants identified, by group, the factors contribut-
ing to VAC 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 con-
tributed to sustaining VAC in that particular area. The
groups then regathered and compared/contrasted their
findings. The final list that emerged as a result of the ple-
nary discussion included several factors sustaining or po-
tentially preventing VAC in the intervention area. As
participants identified these factors, they specifically
looked at the role that social norms played in sustaining
them.
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 exper-
tise. Participants in the workshop first grouped similar
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
different themes? which social protective social norms
can we leverage? which themes required the collabora-
tion of other stakeholders? From this conversation,
participants drew a diagram showing the dynamic rela-
tion between themes and their influence on VAC. This
diagram eventually informed the following conversa-
tions on what entry points existed for the intervention
and on what collaborations were required to achieve
effective sustainable change.
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
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.
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
CONCLUSION
Today’s considerable interest in using social norms the-
ory to achieve positive health outcomes must be accom-
panied by an understanding of how a norms perspective
can be integrated into a wider approach to social
change. In this paper, we presented a framework that
can help practitioners diagnose and plan effective inter-
ventions 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
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.
Fig. 2: The influence of social norms visualized on the dynamic framework.
6B. Cislaghi and L. Heise
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8B. Cislaghi and L. Heise
... To take this into account, we used a framework influenced by Cislaghi et. al. to situate gender norms within wider levels of influence including overlapping domains (e.g. between the individual, their household, and their community) that are relevant when considering gender norms [20]. ...
... Code refinement was conducted following consultation with research investigators. We developed a framework guided by SNT and Cislaghi et al. (19,20) to organize and summarize the data by several factors across levels of influence. Relevant quotes illustrating the findings were identified. ...
... These experiences were further influenced by societal and community-level factors depending on the settlement type and perceptions of common practices in their community unities. We summarized our findings using an ecological framework consisting of four levels (institutional, community, household/interpersonal, and individual) with contextual, psychological, and material/technological domains guided by SNT and Cislaghi et al. [19,20] (Table 2). This qualitative summary aimed to describe the various channels through which norms exert their influence on women's ability to make sanitation decisions. ...
Article
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In low- and middle-income countries, poor autonomy prevents women from making financial decisions, which may impact their access to improved sanitation facilities. Inadequate access to improved sanitation disproportionately affects women’s and children’s health and wellbeing. Although socio-cultural factors are known contributors to gender inequity, social beliefs that potentially motivate or dissuade women from making sanitation-related household decisions are not well understood. These beliefs may vary across settlement types. To empower more women to make sanitation-related decisions, the relevant socio-cultural norms and underlying social beliefs need to be addressed. In this mixed methods study, we explored women’s role in sanitation-related decision making in three settlement types, urban slums, peri-urban, and rural communities in Bihar. Trained qualitative researchers conducted six focus group discussions with women of two age groups: 18–30 years old, and 45–65 years old to understand the norm-focused factors around women’s role in getting a toilet for their household. Using insights generated from these group discussions, we developed and conducted a theory-driven survey in 2528 randomly selected participants, to assess the social beliefs regarding women making toilet construction decisions in these communities. Overall, 45% of the respondents reported making joint decisions to build toilets that involved both men and women household members. More women exclusively led this decision-making process in peri-urban (26%) and rural areas (35%) compared to urban slums (12%). Social beliefs that men commonly led household decisions to build toilets were negatively associated with women’s participation in decision making in urban slums (adjusted prevalence ratio, aPR: 0.53, 95% CI: 0.42, 0.68). Qualitative insights highlighted normative expectations to take joint decisions with elders, especially in joint family settings. Surrounding norms that limited women’s physical mobility and access to peers undermined their confidence in making large financial decisions involved in toilet construction. Women were more likely to be involved in sanitation decisions in peri-urban and rural contexts. Women’s involvement in such decisions was perceived as widely acceptable. This highlights the opportunity to increase women’s participation in sanitation decision making, particularly in urban contexts. As more women get involved in decisions to build toilets, highlighting this norm may encourage gender-equitable engagement in sanitation-related decisions in low-resource settings.
... While its conceptualization varies within and across disciplines, social norms are commonly defined as the social and cultural unwritten expectations or rules that influence behaviour by prescribing what is expected, allowed, or sanctioned in specific circumstances [62,63]. Similarly, gender norms can be defined as the "widely accepted social rules about roles, traits, behaviours status and power associated with masculinity and femininity in a given culture" [64]. ...
... Despite this, social norms do change. Understanding and changing beliefs of reference groups towards more SRHR and gender equality supportive norms and values is therefore a central part of social norms interventions [62,63]. ...
... Drawing on theories related to social norms and values, gender, power and sexuality, the current study is guided by two central frameworks. First, we use an adapted version of the conceptual framework by Cislaghi and Heise [63] to explain how (individual) values and beliefs affect different institutional, material, social and individual factors to shape norms, thereby guiding which factors need to be addressed by developmental assistance and interventions. Displayed in Figure 3, the framework points to how social norms and values are embedded within institutions at different levels (local, regional, national, international),-and are shaped by -laws, policies, distribution of resources (e.g., health services, education, livelihood), social relationships (e.g., social capital and support), as well as individual's knowledge, personal values, self-efficacy, skills opportunities, and aspirations. ...
Technical Report
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This EBA report aims to increase the understanding of values and norms related to SRHR and gender in Sub-Saharan Africa. In addition, it maps Swedish aid to SRHR and identifies gaps and opportunities for Swedish development cooperation supporting SRHR. In the first part of the study, data on values and norms related to gender and SRHR are collected through a newly developed module in the World Values Survey in three countries, namely, Ethiopia, Nigeria and Zimbabwe. This data will be publicly available for download from the World Values Survey website. The generation of a public good in the form of data was an important aspect for EBA when deciding to undertake this study. The second part of the study provides a descriptive mapping of Swedish development assistance for SRHR
... Cislaghi and Heise's Dynamic Framework for Social Change (2019), draws on Bronfenbrenner's (1979) ecological framework by stressing the overlapping and dynamic interaction of global, institutional, material, social and individual factors influencing health-related choices and actions. Social norms operate at intersection points of each ecological domain, where they exert their greatest influence (Cislaghi & Heise, 2019). We draw from the Dynamic Framework as a conceptual scaffolding to explore how public health initiatives can create and reinforce social norms supporting facility-based delivery, but also result in negative consequences for women delivering at home. ...
... First, we add to an existing body of literature documenting shifting social norms in favour of facilitybased delivery across Africa (Montagu et al., 2017;Shifraw et al., 2016). Changes in social norms can be subtle and progressive, inculcated through socialization, or more overt and sudden, imposed by more powerful authorities (Cislaghi & Heise, 2019). The potential of norms-based interventions for affecting widespread and lasting community-based health promotion and reducing harmful genderrelated practices is being increasingly recognized (Cislaghi & Heise, 2019). ...
... Changes in social norms can be subtle and progressive, inculcated through socialization, or more overt and sudden, imposed by more powerful authorities (Cislaghi & Heise, 2019). The potential of norms-based interventions for affecting widespread and lasting community-based health promotion and reducing harmful genderrelated practices is being increasingly recognized (Cislaghi & Heise, 2019). ...
Article
Increasing facility-based delivery rates is pivotal to reach Sustainable Development Goals to improve skilled attendance at birth and reduce maternal and neonatal mortality in low- and middle-income countries (LMICs). The translation of global health initiatives into national policy and programmes has increased facility-based deliveries in LMICs, but little is known about the impact of such policies on social norms from the perspective of women who continue to deliver at home. This qualitative study explores the reasons for and experiences of home delivery among women living in rural Zimbabwe. We analysed qualitative data from 30 semi-structured interviews and 5 focus group discussions with women who had delivered at home in the previous 6 months in Mashonaland Central Province. We found evidence of strong community-level social norms in favour of facility-based delivery. However, despite their expressed intention to deliver at a facility, women described how multiple, interacting vulnerabilities resulted in delivery outside of a health facility. While identified as having delivered ‘at home’, narratives of birth experiences revealed the majority of women in our study delivered ‘on the road’, en route to the health facility. Strong norms for facility-based delivery created punishments and stigmatization for home delivery, which introduced additional risk to women at the time of delivery and in the postnatal period. These consequences for breaking social norms promoting facility-based delivery for all further increased the vulnerability of women who delivered at home or on the road. Our findings highlight that equitable public health policy and programme designs should include efforts to actively identify, mitigate and evaluate unintended consequences of social change created as a by-product of promoting positive health behaviours among those most vulnerable who are unable to comply.
... Social norms are an important concept in the theory of hegemonic masculinity. This has led to a rise in norms theory (Cislaghi 2018c) and a re-emphasising of diffusion of innovation and social marketing theory, which target change in norms rather than change in reflexivity (Cislaghi 2020). Thus, health promotion theory has almost come full circle and once again approaches the truism of the Theory of Planned Behaviour (Fig. 8): that is, beliefs, norms, and perception of control determine behavioural intention. ...
Thesis
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This extended case study explores the process of social change in two Gambian Jola communities, whose participation in the Stepping Stones HIV prevention programme in 1998, caused them to end intimate partner violence (IPV). Research Question: How did the Stepping Stones programme prevent intimate partner violence in two West African communities: what was the mechanism of change, was there any evidence of change in the social reproduction of the patriarchal marital system before or after the intervention, and how does this contribute to the theory of empowerment? Starting from the theoretical origins of Stepping Stones in the philosophy of Paulo Freire, this study aims to develop a theory of change for Stepping Stones, which could be used to understand and evaluate cultural action and empowerment in general. The study includes a review of the history of the region, and analysis of interviews and focus groups with intervention and control communities. Data collection focussed on gender identity, the marital system and the social control of marital disharmony, past and present. Findings Production and social activity were divided by gender. Most IPV occurred in the context of the polygynous marital system, which used arranged marriage and daughter exchange to maintain the extended family. Young women were often married to much older men and love marriages were unusual. Emotional satisfaction could be derived from extramarital relationships, which had their own cultural forms predating conversion to Islam in the 1930s. The jealousy of older husbands towards their younger wives was a significant driver for IPV. When husbands gave inadequate financial support to their wives, there was increased participation in extra-marital relationships as wives tried to secure the money needed to look after their children. Cash cropping had been promoted from the 1920s by the colonial powers, which caused a change in the gendered relations of agricultural production and a move away from collective labour and responsibility. Men’s domination of cash cropping allowed them to sequester financial resources. Stepping Stones utilised a gendered analysis, working simultaneously with groups of husbands and wives; together and apart, ‘privately’ and ‘publicly’, using a ‘fission and fusion’ strategy. This led to a democratisation of social space, in which women were afforded the opportunity to strengthen their corporate identity in private discussion amongst themselves and their voices were given equal weight to the men in public discussion. The programme ended with proposals for change from each group which were accepted by consensus. The community agreed to try to end extramarital relationships, and in return husbands would financially support their wives and include them in household decision-making. This represented a role change for women from ‘wife’ to ‘partner’. The cessation of violence had the support of men and women because they shared the goals of happy relationships, families, and communities. It was successful because the quality of marital relationships improved, and because of the imposition of ‘bylaws’ against violence. Women acted individually, together, and with community members to ensure the ban was successful. Following the programme, marital relationships continued to improve. In the early days some of the changes were contested, but by the time of the study there seemed to be a comfortable acceptance of the wives’ new role, and many husbands and wives described their relationships as becoming increasingly loving. The cumulative involvement of wives in household decisions appeared to induce a change in social norms against the continuation of arranged marriages for their daughters. Freire’s theory of pedagogy was inadequate for explaining the Stepping Stones process of change until it was elaborated with the critical perspectives of both Margaret Archer and Pierre Bourdieu.
... Local governments often also have the capacity through law to enlist local institutions to reinforce behavioral rules and norms, whether the primary rules are in national, provincial or local law. Schools and universities, health care facilities and workplaces can be required by local law to create their own internal policies that limit unhealthy behavior like smoking and encourage healthy behavior like regular exercise or breast-feeding (Cislaghi and Heise, 2019). ...
Article
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Governance is an important factor in urban health, and law is an important element of healthy governance. Law can be an intervention local government wields to influence behavior and shape environments. Law can also be an important target of health promotion efforts: Law and the enforcement and implementation behaviors it fosters can promote unhealthy behaviors and environmental conditions, and can act as a barrier to healthy interventions or practices. Finally, law is a design and construction tool for the organization of governance. Law is the means through which cities are formally established. Their powers and duties, organizational structure, boundaries and decision-making procedures are all set by law. Regardless of the form of government, cities have legal levers they can manipulate for health promotion. Cities can use tax authority to influence the price of unhealthy products, or to encourage consumption of healthy foods. Cities can use their legal powers to address incidental legal effects of policies that they themselves cannot control. Cities may also have the authority to use law to address deeper determinants of health. The overall level of income or wealth inequality in a country reflects factors well-beyond a local government's control, but city government nonetheless has levers to directly and indirectly reduce economic and social inequality and their effects. A renewed focus on law and urban governance is the key to assuring health and well-being and closing the health equity gap.
... While the gender system operates through a set of socially accepted rules (gender norms) that establish societal ideas for how men and women should behave, the system is produced and reproduced through social interactions. These dynamics determine and reinforce gender [14] and simultaneously reinforce and legitimize the social and institutional arrangements that are based on sex differences [15]. These broader institutional systems sustain gendered divisions by rewarding masculine traits and behaviors with increased power. ...
Article
Full-text available
Purpose: To examine how perceptions of gender norms and expressions of empowerment are related among disadvantaged young adolescent boys and girls in Kinshasa, DRC. Methods: We included data from 2,610 adolescent boys and girls between 10 and 14 years old. We examined correlations between three dimensions of perceived gender norms (a sexual double standard, gender stereotypical roles, and gender stereotypical traits) and two domains of agency (voice and decision-making), overall and by sex. We conducted sex-stratified simple and multivariable linear regression models to assess these associations, adjusting for sociodemographic factors. We also tested for differences in the association between gender norm perceptions and agency by sex. Results: Correlations between gender norm perceptions and agency scores were low (under 0.15). Among boys, greater perception of a sexual double standard was related to more voice (p=0.001) and more decision-making power (p=0.008). Similar patterns were observed among girls for the relationship between sexual double standard and voice (p≤.001), but not for decision-making. Increased perceptions of gender stereotypical traits were related to more voice among girls (p≤.001), while conversely girls who perceived greater gender stereotypical roles had less decision-making power (p=0.010). Conclusions: This study demonstrated that gender norm perceptions and agency are distinct but related constructs. Interventions aimed to promote gender equality must consider gender unequal norms and gender-unequal divisions of power as important but different dynamics.
Article
Public health scholars and practitioners have increasingly distanced themselves from the term “culture,” which has been used to essentialize and blame marginalized “others.” However, leading health theories inevitably entail the study of culture; omitting the term may sever vital connections to useful social theory. Instead, we propose the Intersectional Theory of Cultural Repertoires in Health (RiH), integrating social norms and intersectionality with repertoire theory, which has been highly influential in cultural sociology. We outline an approach to investigating relationships between cultural resources and health behaviors and illustrate the theory's application with two qualitative case studies. The cases demonstrate how RiH theory can elucidate the roles of cultural resources in influencing health outcomes, such as gender-equitable behavior in Nigeria and coping strategies in Haiti. Building on conventional normative explanations of health, we theorize how schemas, narratives, boundaries, and other cultural resources shape behavior and demonstrate how norms constrain the use of repertoires. We detail how this theory can deepen our understanding of health phenomena and identify future research priorities.
Article
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There exist significant inequities in access to family planning (FP) in Kenya, particularly for nomadic and semi-nomadic pastoralists. Health care providers (HCP), are key in delivering FP services. Community leaders and religious leaders are also key influencers in women’s decisions to use FP. We found limited research exploring the perspectives of both HCPs and these local leaders in this context. We conducted semi-structured interviews with HCPs (n=4) working in facilities in Wajir and Mandera, and community leaders (n=4) and religious leaders (n=4) from the nomadic and semi-nomadic populations the facilities serve. We conducted deductive and inductive thematic analysis. Three overarching themes emerged: perception of FP as a health priority, explanations for low FP use, and recommendations to improve access. Four overlapping sub-themes explained low FP use: desire for large families, tension in FP decision-making, religion and culture, and fears about FP. Providers were from different socio-demographic backgrounds to the communities they served, who faced structural marginalisation from health and other services. Programmes to improve FP access should be delivered alongside interventions targeting the immediate health concerns of pastoralist communities, incorporating structural changes. HCPs that are aware of religious and cultural reasons for non-use, play a key role in improving access.
Article
Participatory research was conducted with adolescent girls and women in three isolated rural communities of Bangladesh to assess their perspectives and the role of social and gender norms on the construction of knowledge regarding menstruation, pregnancy and abortion. Norms of privacy and silence, local beliefs and a culture of shame held that the human body is ‘natural’ and does not require formal sexual and reproductive health care. Instead, participants sought out traditional healers and used herbal plants as natural remedies. Participants reported being restricted in performing religious activities, cooking and food consumption during menstruation. Because sanitary protection was expensive, women used old cloths to soak up menstrual blood and used them repeatedly without washing with soap or drying in the open air, due to shame and the fear of evil spirits. The local incidence of child marriage was high, which also limited women’s agency and voice. Contraceptive use was irregular and inappropriate; none of participants or their husbands used contraceptives, resulting in unwanted pregnancy often followed by unsafe abortion. Programmes and interventions are needed that engage with women’s experiences within the sociocultural context of studied communities.
Article
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This research investigated whether people change their food preferences and eating behavior in response to health-based social norms. One hundred twenty participants rated a series of healthy and unhealthy food images. After each rating, participants sometimes viewed a rating that ostensibly represented the average rating of previous participants. In fact, these average ratings were manipulated to convey a particular social norm. Participants either saw average ratings that favored healthy foods, favored unhealthy foods, or did not see any average ratings. Participants then re-rated those same food images after approximately ten minutes and again three days later. After the norm manipulation, participants were given the chance to take as many M&Ms as they wanted. Participants exposed to a healthy social norm consistently reported lower preferences for unhealthy foods as compared to participants in the other two conditions. This preference difference persisted three days after the social norm manipulation. However, health-based social norm manipulations did not influence the amount of M&Ms participants took. Although health-based social norm manipulations can influence stated food preferences, in this case they did not influence subsequent eating behavior.
Article
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The objective of the current study was to explore demographic, financial, and psychosocial barriers associated with the use/non-use of reproductive health (RH) services. The sample included 212 college students (60 % female) aged 18–19 from a Northern California public university. In October, 2014, students took an on-line survey with questions on knowledge, access, barriers, and use of different RH services and settings. Findings indicated that college students were more likely to visit a primary care setting and/or school-based setting for their RH care. Sexual intercourse was the strongest correlate of having received RH care in the past year, followed by gender, social disapproval, and knowledge of available services. Analyses stratified by gender found a similar pattern among females. However, the only significant predictor among males was knowledge of available services. These finding highlight universities as uniquely positioned to reduce perceived barriers to accessing RH services by making use of technology, promoting health and wellness centers, and providing/adding sexual and reproductive information to general education classes.
Article
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While significant progress has been made in recent years in responding to violence against women and girls in humanitarian contexts, timely and quality care and support to survivors still remains a challenge. Little is known about effective prevention. Few interventions have targeted underlying drivers of violence against women and girls (VAWG), which include social norms. In response to the urgent need to increase access to services for survivors, as well as the imperative to develop and test effective strategies to actually prevent VAWG in conflict-affected communities, UNICEF has developed the Communities Care: Transforming Lives and Preventing Violence programme. An innovative and holistic initiative currently being piloted in internally displaced camps and communities in Somalia and South Sudan, the Communities Care programme is premised on the idea that while armed conflict causes horrendous suffering, the changes created to community structure, economic roles, and social dynamics offer an opportunity to promote social norms that uphold women and girls’ equality, safety, and dignity. While the pilot phase is ongoing throughout 2016, indications to date are positive. The preliminary analyses of data suggest promising trends, with the intervention communities having significantly greater improvement than the control communities on some of the dimensions of social norms measured. Communities Care programme is also promoting community actions against violence in pilot sites. Evidence and lessons from Communities Care will contribute to the refinement of efforts to prevent and respond to VAWG in conflict-affected settings around the world.
Article
We examine the evolution of infrastructure, and the impact of infrastructure investment, in middle-income countries (MICs). We document how different types of infrastructure stocks, as well as infrastructure investment, vary with the level of development and growth performance. We then use the two-stage approach of Corsetti, Meier, and Müller (2012) to identify exogenous public investment shocks and investigate the macroeconomic impact of these shocks. We find that the provision of infrastructure varies across development stages; there is a focus on basic infrastructure, such as transport, water, and sanitation, during early stages, and an emphasis on “advanced” infrastructure, such as power and especially information and communication technology, in later stages. Better-performing MICs tend to invest more on infrastructure. They also have more information and communication technology infrastructure. Finally, we find a more significant and sustained impact of exogenous public investment shocks on output in MICs than in low-income countries.
Article
This article offers a qualitative investigation of how human rights education sessions, embedded in a multi-faceted intervention, helped members of a rural community in West Africa challenge inequitable gender norms that hindered women’s political participation. Results show a change in women’s political participation and community members’ descriptions of women’s potential. Three features of the intervention contributed to this change: (1) its pedagogical approach; (2) its substantive content; and (3) the engagement of men and women together. The article calls for interventions that facilitate sustained dialogue between men and women to achieve greater gender equity.
Article
The book focusses on questions of individual and collective action, the emergence and dynamics of social norms and the feedback between individual behaviour and social phenomena. It discusses traditional modelling approaches to social norms and shows the usefulness of agent-based modelling for the study of these micro-macro interactions. Existing agent-based models of social norms are discussed and it is shown that so far too much priority has been given to parsimonious models and questions of the emergence of norms, with many aspects of social norms, such as norm-change, not being modelled. Juvenile delinquency, group radicalisation and moral decision making are used as case studies for agent-based models of collective action extending existing models by providing an embedding into social networks, social influence via argumentation and a causal action theory of moral decision making. The major contribution of the book is to highlight the multifaceted nature of the dynamics of social norms, consisting not only of emergence, and the importance of embedding of agent-based models into existing theory.
Article
Background: 'Chemsex' refers to the combining of sex and illicit drugs, typically mephedrone, GHB/GBL, and crystal methamphetamine. While numerous studies have examined the role of illicit drugs in sexual risk taking, less attention has been paid to the broader social context and structures of their use among gay men. Given their established role in influencing health related behaviour, this study sought to examine the nature and operation of social norms relating to chemsex among gay men residing in South London. Methods: In-depth interviews were conducted with thirty self-identifying gay men (age range 21-53) who lived in three South London boroughs, and who had used either crystal methamphetamine, mephedrone or GHB/GBL either immediately before or during sex with another man during the previous 12 months. Data were subjected to a thematic analysis. In addition, two focus groups (n=12) were conducted with gay men from the community to explore group-level perceptions of drug use and chemsex. Results: Chemsex was perceived as ubiquitous amongst gay men by a majority of participants, who additionally described a variety of ways it is arranged (including mobile apps) and a variety of settings in which it occurs (including commercial and private settings). Chemsex was associated with unique sexual permissions and expectations, although participants also described having personal boundaries with respect to certain drug and sex practices, suggesting within-group stigmatisation. Conclusion: This study clearly documents exaggerated beliefs about the ubiquity of chemsex, shifts in the perceived normativity of certain settings and means to facilitate chemsex, and attitudes revealing stigma against certain types of chemsex and men who engage in it. There is a need for health promotion interventions to challenge social norms relating to drug use generally, and chemsex specifically, and for such interventions to make use of the online settings in which chemsex is often facilitated.
Book
This book describes how a program of values deliberations-sustained group reflections on local values, aspirations, beliefs and experiences, blending with discussions of how to understand and to realize human rights-led to individual and collective empowerment in communities in rural Senegal. The study explains what happens during the deliberations and shows how they bring about a larger process that results in improved capabilities in areas such as education, health, child protection, and gender equality. It shows how participants, particularly women, enhance their agency, including their individual and collective capacities to play public roles and kindle community action. It thus provides important insights on how values deliberations help to revise adverse gender norms.
Article
This article explores an ongoing knowledge initiative, co-ordinated by Oxfam’s new Knowledge Hub on violence against women and girls/gender-based violence (VAWG/GBV), which aims to help deepen Oxfam’s effectiveness in work to change attitudes, social norms, and modes of behaviour which cause and perpetuate VAWG. Here, we share some of what we have learned so far, in terms of useful concepts and programme elements, including two case studies from Malawi and South Africa that illustrate these.