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.
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
15.
16.
17.
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
Notas del editor
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.
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.
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.
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)
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.
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.
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.
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
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.
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
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?
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
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
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