Changing Social Norms: The Importance of "Organized Diffusion" for Scaling Up Community Health Promotion and Women Empowerment Interventions

"The three sets of results suggest that facilitating a process through which participants share their knowledge with others can help achieve change in existing social norms, ultimately contributing to change in their practices."

Scholars and practitioners working to improve global health and promote equitable development have been investigating how social norms theory can inform the design of prevention interventions in low- and mid-income countries (LMICs). The aim of this paper is to examine how "organised diffusion" - the sharing of knowledge encouraged by practitioners and led by programme participants - can increase the reach of community discussions, ultimately helping interventions achieve effective social norms change. The paper provides quantitative evidence from 3 case studies - Community Empowerment Program (CEP) in Mali, Change Starts at Home (Change) in Nepal, and Voices for Change (V4C) in Nigeria - to illustrate the potential and power of organised diffusion.

Some harmful practices are sustained by social norms, which are collective beliefs about what people expect from each other. Much of the literature identifies 2 types of normative beliefs: (i) one's belief about what others in one's group do ("descriptive norms") and (ii)one's belief about what others in the group approve and disapprove of ("injunctive norms"). In LMICs, 2 (sometimes intersecting) main intervention strategies are commonly found: (i) wide-reaching media campaigns that often incorporate social marketing strategies, and (ii) participatory discussions between members of the same "reference group". Both approaches have possible shortcomings. For example, community-based discussions might have limited reach due to the relatively elaborate and resource-intense nature of the intervention.

To overcome such challenges, some practitioners have used the method of organised diffusion, in which participants take the lead in sharing information with non-participating members of their group. Researchers Mackie and Lejeune have identified 6 phases in the process: (i) Discussions happen before the programme, as rumours about the intervention generate curiosity; (ii) New knowledge is created with a selected group of participants; (iii) Participants share their knowledge with one "adopted" member in their community (usually a family member); (iv - vi) Information spreads out from the intervention community to new communities, eventually reaching people across the entire larger group (ethnic group, region, or country). Community mobilisation is the final piece of organised diffusion, where participants raise awareness and generate community action in theirs and other communities.

The 3 case studies in the paper illustrate how this process works. In brief (see also Related Summaries, below):

1. CEP: Implemented since the 1990s in thousands of villages in rural West and East Africa by the non-governmental organisation (NGO) Tostan, CEP has 3 components: (i) an informal education programme for men and women making use of participatory paedagogical strategies and involving a 30-month curriculum on democracy, human rights, problem solving, hygiene and health, literacy, and numeracy; (ii) Community Management Committee, a 17-person community group whose task is to implement the vision emerging from the classes in collaboration with the whole community; and (iii) community mobilisation activities organised by participants and members of the committee in their villages and, eventually, in neighbouring villages, motivating people to join in the process to change local harmful norms, such as around female genital cutting (FGC). Selected findings of the evaluation:
   • At baseline, 84% of respondents anticipated positive reactions in their families for cutting their daughters. At midline, this percentage had, on average, decreased to 35%. When disaggregated by type of participation in the programme, the data show that, respectively, injunctive norms decreased more across participants and adoptees (21% and 23%, respectively) than across other members in intervention communities (43%) and members of control communities (where there is no significant change).
   • At midline, 69% of participants reported having actively talked to their family about FGC, while 35% of adoptees did so, which speaks to the fact that at midline adoptees were mostly recipients of information, rather than diffusors. This percentage decreases to 27% for other members in CEP communities and 12% in control communities. At endline, the percentages of participants and members in control communities who talked to their families about FGC remained similar; however, it increased for adoptees (up to 48%) and other members in CEP communities (up to 33%). This increase suggests that, after midline, information recipients became active diffusors too, contributing to the change in social norms described earlier.
2. Change: Designed and implemented by Equal Access International (EAI) in an effort to prevent male-perpetrated intimate partner violence (IPV) against women in Nepal, Change has 4 core components: (i) a 39-week edutainment radio programme involving drama and discussion elements; (ii) a 40-week curriculum delivered to 360 married couples via facilitated Listening and Discussion Groups (LDGs); (iii) wider community engagement largely through LDG-organised activities; and (iv) trainings for religious and community leaders. Selected findings of the evaluation:
   • Among those who heard a message directly, 76.57% (N=549) spoke to someone about it, most often a neighbour, followed in frequency by a friend and then spouse. Ward-level average diffusion scores ranged from 1.57 to 11.07 persons spoken to, demonstrating rather significant differences in degree of diffusion.
   • Living in a high-diffusion community was associated with greater odds of assisting a survivor of IPV only among individuals who were not directly exposed to an anti-violence against women and girls (VAWG) message (odds ratio (OR), 5.24; 95% confidence interval (CI), 1.93, 14.19). There was no additional benefit of residence in a high diffusion community among people who had heard a message directly (OR, 0.90; 95% CI, 0.61, 1.34). They were already more likely to support a survivor regardless of the level of organised diffusion. However, among those who were not directly exposed to an anti-VAWG message, living in a community with more extensive organised diffusion was associated with assisting a survivor.
3. V4C: Implemented from 2012-2017 in 4 of Nigeria's states, V4C focused on changing young people's attitudes and practices in 3 main behavioural areas (VAWG, support for women's role in household decision-making, and support for women's political leadership) at 3 levels: (i) among individuals, through "Safe Space" gender courses offered to young women and men online and in person; (ii) in wider society, through a branded campaign reaching young people through radio discussions and dramas, TV, social media, and billboards; and (iii) within formal institutions, through the passage of legislation enhancing women's rights and supporting women's participation in political structures. Selected findings of the evaluation:
   • Attitude and behaviour change among peers of Safe Space participants was generally a half to a third as large as that for Safe Space participants themselves. The former's attitude and behaviour change was also at least 2-3 times larger and consistently more significant than changes among those reached through V4C's branded communications only.
   • Diffusion of Safe Spaces awareness corresponded with an increase in how much influence young people say they have on the people around them, a key component to catalysing community change. By programme completion, peers of Safe Spaces participants showed an increase in perceived influence nearly a full point larger (on the 9-point scale) than young adults with no programme exposure and 0.66 points larger than young adults with exposure through the branded communications only.

Existing theory can assist in interpretation of these studies' findings. Neo-diffusionism (Kashima 2009, 2014) suggests that through communication, ideas are passed from one cultural agent to others, especially when the speaker tailors an appropriate message. As the 3 case studies show, intracultural processes of diffusion can be facilitated when the listener and the speaker know each other well. Neo-diffusionism also purports that the more frequent the communication, the more the new information will spread across the social network, evolving into a new reality.

The literature on social movements can be of further assistance in interpreting the case study findings. For example, Christiansen (2009) argued that social movements have 4 key stages: (i) emergence (widespread discontent); (ii) coalescence (population collective aware of widespread discontent); (iii) bureaucratisation (the formalisation of the movement into an organisation); and (iv) decline (the end of the movement either because it succeeded or was repressed). The case studies show that a core group of motivated activists is necessary for, and effective at, increasing individual and collective awareness of a widespread discontent with the current status quo. Then, as those motivated activists reach out to others in their community, a general sense of individual unease becomes more concrete: It gets discussed in conversations that generate new visions, strengthening people's collective intentions to address what is causing it.

The key message emerging from the findings is that integrating organised diffusion strategies within social norms interventions has the potential to achieve greater and more diffuse impact - reaching others than those who were immediately and more intensively exposed to the intervention. It is suggested here that future community-based interventions seeking to achieve social norms change should equip participants with knowledge and skills to engage others in their network in transformative conversations. Intervention strategies that request participants to "adopt" other participants (as in the case of the CEP) can be of assistance.

In conclusion: "Future research and practice shall increase our understanding of the most effective and ethical ways in which organized diffusion can help achieve greater social norms change to improve global health, well-being, and empowerment. Doing so has the potential to generate additional impact with little additional investment."