Presentation_Tura - Norms Shifting Interventions
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This document discusses the Care Group approach used in an intervention in Nepal from 2005-2010. It aimed to shift social norms around maternal and child health issues through community groups. Formative research identified key norms and barriers. Community groups engaged women to reflect critically and root issues in community values. Evaluations found sustained impact on behaviors like breastfeeding years later. Challenges included focusing directly on norm drivers and unrealistic community health worker workloads. Further research on accurate norm assessment and evidence-based norm-shifting is still needed.
Presentation_Tura - Norms Shifting Interventions
- 1. Halkeno Tura, MBA, MA, MPH, PhD candidate, University of Iowa May 6-9,2019 Bethesda, Maryland
- 2. Case in point: Care Group approach as a model for norm shifting intervention Why norm-shifting intervention
- 3. Have you ever made a decision in isolation?
- 4. Are we at odds with individual behavior change theorists or interventionists?
- 5. ▪ SBCC+? ▪ SNBCC? ▪ SBCC+NS? Does the world need another acronym?
- 7. October 1, 2005 – September 30, 2010 Interventions: Nutrition, Diarrhea/WASH, integration w/IMCI No food supplementation Funding: $2.5 million from USAID CSHGP, $0.5 million match from FH Scale:Total population reached = 1.1 million people. 148K children 0-59 months of age, 71K WRA = 220K total beneficiaries in seven districts Equity: >90% of mothers had contact with the CGV every two weeks.
- 8. What is it?
- 9. Is Care Group (CG) approach a norm-shifting intervention? Began with accessing norms and barriers to a behavior Equitably reached every women of reproductive age-south community level change Engaged community members at multiple levels Challenged gender norms (power imbalance)
- 10. Is Care Group (CG) approach a norm- shifting intervention? created safe spaces for critical reflection by women in the community Maternal and child health issues were rooted within community’s own value Used organized diffusion
- 11. Guided by and benefited from the following models ▪ Social NetworkTheory, PersuasionTheory, Positive Deviance, Health Belief Model,Theory of Reasoned Action Preceded by formative research ▪ Normative determinants of nutrition, Barrier analysis, Qualitative studies
- 12. Normative beliefs held by the community members ▪ Related to breastfeeding ▪ Most people throw colostrum away, because they say they do not want to poison the babies ▪ My mother and mother-in-law say “ women do not have enough milk after childbirth” ▪ Most people say breast milk will be spoiled if breastfeeding mother s have sex ▪ Everyone says that breastfeeding during new pregnancy is harmful to the baby because pregnancy spoils breast milk ▪ Related to childhood diarrhea ▪ Nyoka, a guardian of bodily purity ▪ Increased fluid intake during diarrheal episodes
- 13. Social norm marketing Effort to reduce some harmful social norm practices and behaviors Personalized behavior and norm change aimed to providing CGV or ML with information about themselves as well as their peers Group based approach focused on risky behaviors, misconceptions and it consequence using facilitators called “promotores”
- 14. • Evaluation research questions • To assess the sustainability of impact of the use of CGV, we replicated the methodology used at the end of the program (see Davis et al., 2013 for full description) • Data was collected from a random sample of ex-beneficiaries (N=506) of which 37 were CGV in one of the areaA
- 18. • 51.5% of CGVs were still active five years after the project ended • 59% received visit from CGVs during labor, delivery and afterward • 57% care givers, other than the mother, received health info from CGVs • 60.7% received visit from CGVs in the last two weeks • 65 % have come in contact with CGVs at least one time and at most 4 times in the last one month • 66.6% got health and nutrition advice from CGVs • 63.6% considered CVG as their sources for health information
- 19. Variables Mean 95% CI % Autonomy 3.06 2.63 to 3.48 82.4 Recognition 3.29 2.79 to 3.80 88.2 Community participation 3.29 2.99 to 3.59 94.1 Intrinsic job satisfaction 3.06 2.53 to 3.59 76.5 Self-motivation 3.18 2.62 to 3.73 76.5 Self-efficacy 3.18 2.72 to 3.63 82.4 Social responsibility and altruism 3.06 2.53 to 3.59 76.5 Social capital 3.47 3.10 to 3.84 76.5
- 20. “ After I gave birth to my first child, my mother and my mother-in-law pressured me to give the baby to them and get a rest.They said “you just gave a birth you have to get a rest and eat to produce milk for the baby” and they took the baby and gave it xima. I lost my baby in the first week of age. The same thing used to happen to many women in our community before the program, now we know how important it is to give the first milk to a newborn baby. I will never do to my grandchildren. I have three daughters and I will teach them to have the first skin contact with their babies and also feed them the first milk” (FGD 1, a 45 years old women)
- 21. Increasing community’s diversity/heterogeneity, especially when clustering mothers which has different background Distinguishing norm from attitude Difficulty to focus on drivers of norm (e.g. why people think colostrum is bad or harmful?) making norm-shifting effort harder The theories used to design the program, although they have norm as a construct, were not social norm theories Unrealistic workload-over 80% of work was done by CGV Massive time commitment for the formative research
- 22. Readiness to develop the infrastructure needed to support change in social norm Message believability Evaluation Replicability Tool to measure social norms
- 23. Developing appropriate tools to accurately assess social norm prior to intervention Focusing on both shifting (harmful ones) and using (protective ones) social norm in intervention design Advocacy for resource and visibility Research to increase the pool of evidence-based norm- shifting interventions
Editor's Notes
- #3: Here is the outline for my talk today. I am going to talk a little bit about the thinking behind norm-shifting intervention to set a ground for my case study presentation.
- #4: I believe we cannot make a decision, whether it is decision about certain behavior or anything for hat matter, in isolation. What is generally true is that humans use reason to retrospectively justify the decision, and largely rely on unquestioned instincts to make choices. Even if a decision seems to bring a benefit, if it is ill-judged by others, then there’s a cost to pay. Relying on our community of knowledge is absolutely critical to functioning. We could not do anything alone. After all, refusing to rely on others’ reasoning and failing to consider how our responses would be socially received would likely leave us isolated and unable to get much done. It is logical to assume that this is also true for the community we serve. That’s where individual behavior health theories fail. They portray humans as naturally rational and autonomous in their decision making.
- #5: The whole we have been talking about the need to shift social norm, but this no means is at odd with the effort to change individual behavior. The effort to change behavior at an individual level is still valid and very important, but we could go a little bit far if we clearly identified social norms that shapes societies day-to-day lives and effectively work to shift them or use them. Individuals' behavior is shaped by what people around them consider appropriate, correct or desirable. Therefore, it is logical to investigating how human behavioral norms are established in groups and how they evolve over time or how we can change them to the benefit of the society.
- #6: For several years, SBCC has played a major role in designing behavior change interventions. SBCC practice recognizes that many of the major individual and social determinants of behavior – like knowledge, attitudes and norms – are shaped by human interaction. Both the concept and practice of SBCC is so crucial, but it puts more emphasis on the form of communication between individuals and within communities and the social norm often gets lot in the weed. social norm is define as unspoken rules prevalent in our society and often reflect in how people are expected to behave. Social norms are constantly defining appropriate or inappropriate way of acting or thinking for an individual or a group. social norms are constantly influencing our thoughts and shaping our behavior which is why it is important to call them out as a problem and work to shift them o to use them. As we push to revive this old science, it is good to brand it in a way it can be visible(e.g. case studies like this, strong advocacy for a design and intervention that help shift the norm and of course research and funding)
- #9: Care Groups are peer-based health promotion programs that can quickly and effectively improve health behaviors and outcomes in low-resource communities. In empowering mothers and local leaders, the Care Group model demonstrates that high-impact solutions to childhood malnutrition and illness can be simple, low-cost, and community-derived. This is one of the behavior change strategies, which has consistently outperformed other approaches in reducing malnutrition and maternal and child deaths in LMIC, and is now being adapted to – and tested in – other contexts.
- #10: While no consensus exists on what defines a norms-shifting approaches or interventions, a review of the literature reveals a set of key attributes that are commonly associated with effective norms-focused interventions, including those designed to promote maternal and child health and well-being (Miller & Prentice, 2016, Yaker, R. 2017.) I believe, based on my own experience with the intervention, CG approach include some of these attributes, but not all! It is also worth to mention that the attributes we see in the literature (about nine they are ) also unweighted: we do not know if some attributes among the nine absolutely must be in place for norms-shifting to occur. Let us dive into what the norm-shifting attributes that CG approach exhibits: Starts with assessing norms and barriers to a behavior: CG identifies which norms shape a given behavior and which groups uphold the norm. this is because social norms exist within reference groups – the group of people that are important to an individual when they are making a decision. Engaging the proper reference group is critical for effectively changing a social norm. Seeks community level change: The program works to shifts social expectations, not just individual attitudes and behaviors, and clearly articulates social change outcomes at the community-level. 3. Engages people at multiple levels: Uses multiple strategies to engage people at different levels: individual, family, community, and policy. The program from Mozambique is a good example for this. It involved individuals in the community (women, men), community leaders called CDC, district health department, Zonal health department, national MOH 4. Challenges power imbalance(gender related marinization): Within patriarchal society such Mozambique, this is usually an important attribute of norms-change programming.
- #11: Creates safe space : CG deliberately creates critical reflection that goes beyond trainings, often in small group settings or 10-12 women also called beneficiary group Roots issues within community’s own value: CG identifies how a norm serves or contradicts a community’s own values, rather than labeling a practice within a given community as bad. A good example is how the program assessed worldview of the participants around child value using their religious value…God wants children to be provided and grow in stature, emotionally etc. Uses organized diffusion: CG sparks critical reflection to change norms first within a core group AKA Care group volunteers(mother leaders) who then engage their neighbors to have community-level impact.
- #12: Based on what I have listed above, it is clear that CG is a norm-shifting intervention. Now, I will talk about how this norm-shifting intervention is designed, implemented and evaluated Program design was guided by an integrated model that is benefited from: Social Network Theory Persuasion Theory Positive Deviance Health Belief Model Theory of Reasoned Action Preceded by formative research Normative determinants of nutrition Barrier analysis Qualitative studies
- #13: Several behavior barriers were identified through the formative research, people in the central region, where the program was implemented, link diarrhea symptoms to the concept of nyoka, a guardian of bodily purity thought to dwell in all people and to cause diarrhea and other symptoms in reaction to the entry of contaminants into the body.
- #14: This project is one of the most effective child survival project across the glob and its approach strictly followed some of the evidence-based practices. Social Norms Marketing: This is related to activities related to the effort to reduce some harmful social norm practices and behaviors including infant feeding (milking colostrum to the ground, feeding babies with solid food) , Provision of “capulana” with healthy social norm practices or behavior messages, In some occasions the use of community radio Personalized behavior and norm change Activities aimed to providing CGV or ML with information about themselves as well as their peers Group based approach Group discussion focused on risky behaviors using facilitators called “promotores” Group discussion involved both the misperceptions that exist about the risky practices and its consequences
- #15: Now, I am going to talk about evaluation of this norm shifting intervention. Around may 2014, Care group Technical advisory group(TAG) authored a report/guideline on care group and one of the potential areas for research put forward by the advisory group was sustainability the study. At that time, I was a first year Master student and I thought to my self I actually could do this. This study investigated sustainability of the impact of Care Group approach and possible motivation for the CGV to continue working five years after the program ended by answering three interrelated questions: Does the tested intervention and health impact continue after the end of the program? To what extent have the community volunteers continued cascading the healthy behavior knowledge, skills and practices among their community? What motivated CGV to continue working after the end of the program? What magnitude of effects can be expected from a community-based health promotion programs like this one five years after the program?
- #20: Autonomy: freedom to move in the community, express opinion and execute responsibilities Recognition: acceptance of CGVs’ performance and its value by family(husband), Community and leaders Community participation: level of women’s interest, acceptance and participation in activities Intrinsic job satisfaction: chance for better use of abilities and time, knowledge and overall happiness being on job Self-motivation: working with a sense that the job is important and is not for avoiding blame from others and gaining money Self-efficacy: able to handle tough situations, solve problems, feel emotionally and physically perfect on work Self-efficacy: able to handle tough situations, solve problems, feel emotionally and physically perfect on work Social capital: group membership, support from group, support from individual, collective action, cognitive social capital
- #22: Like any norm-shifting intervention, this intervention also had some challenges. Most of the time, if norm-shifting intervention that rely on individual theories of behavior change conflate social norms with personal attitude. Social norm massage work best in a relatively homogenous community
- #23: The theory of social norms makes intuitive sense to many prevention specialists in contrast to other approaches which may have failed to produce results. Yet while the theory is elegant, implementation is difficult and requires a significant amount of “readiness” or preparation to ensure that an infrastructure is available that can deliver a quality intervention. Johannessen and Dude (2003) reviewed elements of readiness that include: 1) training key stakeholders and staff in the model, 2) creating support and discussion in the larger community, 3) revising policies that may foster misperceptions, 4) collecting and analyzing data, and 5) training and supporting project staff to implement the model properly. Social norms messages contradict widely held beliefs and introduce cognitive dissonance by suggesting that the truth is different from what is popularly thought. Ideally, these messages will stimulate a process of self-reflection and re-examination of what is normative. However, when a message is not believed and easily rejected, a campaign is compromised. Kilmer and Cronce (2003) have suggested that inadequate evaluation of social norms campaigns may lead to the incorrect conclusion that they have not been successful when in fact positive changes have been overlooked Social norms interventions are context specific. Thus, a particular message or style of media presentation may be appealing in one community and not in another. In addition, the best means of disseminating information may differ among groups or communities. Lack of clear measure or tools to measure prevalence of social norms