- Open Access
Theory and practice of social norms interventions: eight common pitfalls
© The Author(s). 2019
- Received: 18 January 2018
- Accepted: 17 July 2018
- Published: 17 August 2018
Recently, Global Health practitioners, scholars, and donors have expressed increased interest in “changing social norms” as a strategy to promote health and well-being in low and mid-income countries (LMIC). Despite this burgeoning interest, the ability of practitioners to use social norm theory to inform health interventions varies widely.
Here, we identify eight pitfalls that practitioners must avoid as they plan to integrate a social norms perspective in their interventions, as well as eight learnings. These learnings are: 1) Social norms and attitudes are different; 2) Social norms and attitudes can coincide; 3) Protective norms can offer important resources for achieving effective social improvement in people’s health-related practices; 4) Harmful practices are sustained by a matrix of factors that need to be understood in their interactions; 5) The prevalence of a norm is not necessarily a sign of its strength; 6) Social norms can exert both direct and indirect influence; 7) Publicising the prevalence of a harmful practice can make things worse; 8) People-led social norm change is both the right and the smart thing to do.
As the understanding of how norms evolve in LMIC advances, practitioners will develop greater understanding of what works to help people lead change in harmful norms within their contexts. Awareness of these pitfalls has helped several of them increase the effectiveness of their interventions addressing social norms in the field. We are confident that others will benefit from these reflections as well.
- Social norms
- Health promotion
Practitioners and scholars working for global health have long been interested in understanding how socio-cultural context influences people’s health-related behaviour.
Most of the field’s conceptual models acknowledge both the importance of context in shaping behaviour, and the role of social norms. Brofenbenner’s socio-ecological model, for instance, emphasizes how individual, social, institutional, and macro level factors combine to influence people’s actions [1, 2]. The framework invites users to examine how the micro, meso, and macro-level environments interact to affect human behaviour. It has been used to examine a wide range of health practices “e.g. [3–8]” and more recently adapted specifically to help design social norms interventions . In addition to the ecological model, several other theories and frameworks exist to study how social factors influence people’s health and health-related behaviours . The fields of medical sociology and social epidemiology, for instance, have offered several paradigms of how “social determinants” combine with an individual’s genetic endowment, and social world to make people either healthy or ill . Approaches that analyse social determinants traditionally evoke factors such as income and income distribution, physical environment, employment and job security, education as well as social networks .
When these and other behavioural science models have been used to design health-promotion programmes, the relational dimension of social norms has sometimes been lost; rather interventions have focussed instead on improving knowledge and changing attitudes [13–16]. Today, we are witnessing an increased interest in using social norms frameworks to inform health promotion interventions in low and mid-income countries (LMIC) [15, 17–23]. The first “social norms interventions” were originally used to reduce alcohol consumption in a few US universities in the early 1980s by correcting students’ overestimates of how much other students drink . Later, more campuses (mostly in the US, Canada, and the UK) used similar interventions to address tobacco use , sexual violence [26, 27], and use of recreational drugs .
In the late 90s, several health practitioners working in LMIC began to explore the potential of changing social norms to achieve a wider range of health outcomes, especially around harmful traditional practices. This interest followed the discovery that people in West Africa were abandoning female genital cutting – a non-medically-justified modification of women’s genitalia – in response to interventions that integrated a norms component [29, 30]. Today, many interventions in LMIC aim to change social norms that sustain harmful practices, including, to cite a few examples, child marriage [18, 31, 32], female genital cutting [33, 34] and intimate partner violence . Gelfand and Jackson  spoke of this interest as the “emerging science” of social norms, and Miller and Prentice  attributed it to a “growing disillusionment with the capacity of factual information and economic inducements to reduce [harmful] behaviour” (p. 340).
Despite this burgeoning interest, the ability of practitioners to use social norm theory to inform health-related interventions varies widely. In practice, we have noticed that when practitioners first apply a social norms frame to behaviour change, they make similar mistakes. To help avoid these early missteps, we outline here, eight common pitfalls that practitioners may encounter in their early efforts to apply social norms theory. We begin my reviewing some of the extensive and multi-disciplinary literature on social norms; we conclude by describing each pitfall in greater depth.
Theoretical and empirical literature on social norms exists in sociology, anthropology, social and moral psychology, economics, law, political science, and health sciences. Definitions across these disciplines vary and sometimes contradict each other. The full range of these definitions includes a constellation of social rules ranging from mere etiquette to the most fundamental moral duties [13, 14, 37, 38]. In their simplest definition, social norms are the informal, mostly unwritten, rules that define acceptable, appropriate, and obligatory actions in a given group or society. Current practitioners’ interest in social norms theory mostly draws from the work by Cialdini and colleagues, who defined social norms as one’s beliefs about: 1) what others in one’s group do (descriptive norms); and 2) what they approve and disapprove of (injunctive norms) [39–44]. Influence of norms has been demonstrated empirically. Drawing on Cialdini’s definitions, researchers have demonstrated the influence of social norms on several health-related practices, including: alcohol consumption [45, 46], food intake , use of recreational drugs [48, 49], smoking , water purification , and hand washing .
Many theories exist on why people comply with social norms, including when doing so is harmful to self and others. In a recent review, Young  identified four main compliance mechanisms: 1) Coordination: people want to achieve a goal that requires coordinated action among group members; to that purpose, they follow what they believe to be common rules for that action; 2) Social pressure: people anticipate social rewards or social punishment for their compliance and non-compliance with a norm; trying to achieve the former and avoid the latter, they follow social norms even when they may prefer not to; 3) Signalling and Symbolism: people want to signal their membership in a given group to self and/or others; to do so, they follow what they think to be the rules specific to that group; 4) Benchmark and Reference points: people internalise rules of what action is considered normal in a given situation, to the point that they follow those rules automatically — what Morris and colleagues called social autopilot in .
Social norms are not written in stone; they naturally evolve through time, and sometimes can change very quickly [13, 54–58]. The literature on what works to spark sustainable social norms change in LMIC is still emergent, but growing . In their recent review, Miller and Prentice  identified three recurring approaches to change social norms. The first is social norms marketing: this strategy was used in the 80s to address college students’ drinking. To change group behaviour, social norms marketing campaigns aim to correct people’s misperceptions of what others in their group do and approve of. In college drinking interventions, for instance, social marketing strategies sent messages like: “85% of students in this university only drink one beer on Saturday and approve of those who do the same”. The second strategy is personalized normative feedback, where people receive information on how they are performing against others around them. This strategy, which exploits the influence of (descriptive) norms, has been used, for instance, to reduce energy consumption. By telling people whether they were doing better or worse at saving energy than their neighbours, the intervention achieved on average a considerable reduction in energy consumption [59, 60]. The third strategy is facilitator-led group conversations, where participants look critically at existing norms and practices within their group and renegotiate those norms among themselves. A few models exist of how group reflection processes can help achieve change in harmful social norms [18, 20, 61–64]. Studying effective facilitator-led programmes, Cislaghi [65, 66] identified three steps for social norms change: 1) motivation (where participants learn about the detrimental consequences for themselves and others of their compliance with the harmful norm); 2) deliberation (where participants create a new positive norm within their reference group and identify strategies to motivate others in their surroundings); and 3) action (where participants publicly enact their strategies and motivate others to join the group, eventually reaching the critical mass needed for normative change). This final step is often formalized through a public commitment to change.
The current literature, however, does not adequately elucidate the challenges and potential pitfalls of designing change strategies using social norms theory. Here, we list the most critical factors to be taken into account when designing such interventions.
This paper offers some practical reflections for those designing interventions addressing social norms. At this particular moment of research and practice, eight pitfalls seem to be particularly critical for achieving effective normative change. The corresponding learnings for practitioners are: 1) Social norms and attitudes are different; 2) Social norms and attitudes can coincide; 3) Protective norms can offer important avenues for effective social change; 4) Harmful practices are sustained by a matrix of interacting factors; 5) The prevalence of a norm is not necessarily a sign of its strength; 6) Social norms can exert both direct and indirect influence; 7) Publicising the prevalence of a harmful practice can recruit more people to the practice; 8) People-led social norm change is both the right and the smart thing to do. As the understanding of how norms evolve in LMIC advances, practitioners will develop greater understanding of what works to help people lead change in harmful norms within their contexts. Awareness of these pitfalls has helped several programmes in the past increase the effectiveness of their interventions. Hopefully, others will benefit from these reflections as well.
We wish to thank Giulia Ferrari (LSHTM), Erin Stern (LSHTM), and Rebecca Liron (Columbia University) who provided feedback on an earlier version of this manuscript.
Cislaghi’s time was funded by an anonymous donor. The study was supported the STRIVE research programme consortium, funded by UKaid from the Department for International Development. However, the views expressed do not necessarily reflect the department’s official policies.The funding body did not have any role in the ideation and writing of the manuscript.
BC Drafted and reviewed the manuscript and was the main contributor to conception and design. LH Reviewed and commented on the manuscript and made substantial contributions to conception and design. All authors read and approved the final manuscript.
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