Social Norms: A Missing Ingredient of Programs Seeking to Foster Women's Agency in Nutrition

"Actively engaging the social context that influences women's nutrition agencies holds the promise of achieving long-lasting, widespread behavior change, a goal that has often proven elusive when programs focus singularly on the knowledge and attitudes of individual women."

The social and gender norms upheld by families, communities, and leaders not only directly impact food choice and allocation but also impact women's agency to improve nutrition practices. However, as this perspective piece argues, social and behaviour change research and programming for nutrition often overlook social norms due not only to challenges with identifying and measuring relevant norms but also to the tendency to prioritise individual attitudes and skills without understanding community rules and shared expectations and beliefs. It advocates for a paradigm shift by outlining a "norms-aware" approach that focuses on recognising, measuring, and addressing the societal constraints and barriers that women and children encounter in their journey to improved nutrition.

As noted here, social norms exist within a web of culture, can be positive or negative, and often shift over time. Social norms are pivotal in shaping an individual's agency, which stands at the centre of the empowerment process. For example, in many contexts, there is variation in decision-making power; however, even when women have some say in decisions, the final decision often ultimately rests with the man. In these instances, efforts to improve women's dietary diversity are unlikely to gain traction without first understanding and addressing unquestioned norms about food distribution and allocation that disadvantage women, including norms that women eat last, are restricted from nutritious food during pregnancy and while breastfeeding, and have limited access to foods with high prestige and nutritional value.

The authors suggest that a crucial initial step in understanding social norms related to nutrition practices is to conduct a "norms diagnosis" to identify what norms are at play, who enforces them, and what rewards and sanctions are associated with adherence. For instance, tools such as the Social Norms Exploration Tool (SNET - see Related Summaries, below) provide rapid, participatory, and practical approaches for collecting and analysing information, aiding in the design of interventions, policies, and programmes and adaptation to local contexts. It is equally vital, the authors contend, to consult women about the social norms that enable or restrict their agency. 

To explore these concepts in practice, the perspective piece goes on to describe the United States Agency for International Development (USAID)-funded Kulawa project in Niger. USAID Kulawa, part of the USAID Resilience in the Sahel Enhanced II Health Services Delivery activity in Niger, aims to improve access to and use of quality health services while strengthening ownership and management by communities, local government, and service providers. USAID Kulawa engages in a community-led development process using the Community Action Cycle (see Related Summaries, below) to increase demand for and use of quality health services and adoption of recommended health and nutrition behaviours at the community level. This approach empowers communities to identify and then analyse their health problems, prioritise action, develop community action plans, and monitor and evaluate progress over time.

The USAID Kulawa team applied the SNET to better understand whether and how social norms influence exclusive breastfeeding in programme communities and to respond as relevant. After project staff were trained to use the SNET, they pretested and refined the data collection instruments based on community feedback and validation, interviewed 216 married and unmarried women aged 15-24 years who were first-time parents from a total of 6 villages, and conducted 6 group discussions in each village. The project staff also used participatory learning exercises.

Participants shared that the mother-in-law upholds nutrition norms and determines what and when the child is fed. Furthermore, social expectations related to power and the division of labour limit what mothers can do, even if the family were to approve of exclusive breastfeeding. These and other findings reveal how strongly social norms can influence women's agency to breastfeed exclusively. It is not enough to simply promote exclusive breastfeeding during antenatal care counseling with pregnant women or via group education sessions with pregnant women and mothers; the importance of other social actors needs to be central.

Based on the findings, USAID Kulawa is working with imams to organise sermons on inequalities related to norms, behaviours, and practices that hinder access to services, for example. Imams leverage verses from the Koran that support family health and well-being to encourage the adoption of priority nutrition behaviours such as exclusive breastfeeding. Also, USAID Kulawa, in collaboration with community leaders, facilitates nutrition dialog sessions for young mothers and their mothers-in-law on maternal nutrition, exclusive breastfeeding, infant and young child nutrition, consumption of micronutrient-rich foods, growth monitoring, and hygiene. These dialog sessions, led by community health workers, are designed to equip mothers-in-law with the skills necessary to support young breastfeeding mothers in their households. Thus, a "norms-aware" programme in Niger could engage both husbands and mothers-in-law, recognising their influence on both their daughters-in-law and sons.

Inspired by the USAID Kulawa example, the perspective piece delves into the role of the socio-ecologic system, underscores the importance of addressing power imbalances related to gender and social hierarchy, and emphasises that programmes targeting norms should aim for community- rather than individual-level change. The authors note that "Social norms shift when it becomes apparent that old norms are no longer relevant or are harmful, or when enough people see others who matter to them changing their behavior. Thus, nutrition programs can consider strategies that facilitate modeling and reflection of desired behaviors, public testimony about the value of a new norm and behavior, and activities to diffuse these new ideas beyond direct program recipients." Diffusion strategies could involve including family members in some of the home visits to mothers or community education sessions or creating tailored media content for family members and their influencers.

The perspective piece offers the following suggestions for nutrition programmes when integrating a norms perspective into behaviour change initiatives:
 

• Programmes should be designed and implemented in collaboration with communities; they should not be top-down. Effective interventions typically involve communities in programme design, implementation, monitoring, and evaluation, drawing on existing resources such as the Community Action Cycle.
• Focusing on the negative consequences of a behaviour can unintentionally reinforce that behaviour by making it seem widespread. Instead, the authors advise finding and amplifying protective norms that build on existing positive values. In Niger, USAID Kulawa reinforced protective norms by using social and behaviour change tools that leverage religious texts and that speak to the importance of family and harmony.
• It is important to remember that social norms may influence nutrition behaviours directly or indirectly. Social norms related to women's productive role in the family, for example, may influence breastfeeding indirectly by limiting the time they have available to breastfeed, as was the case in Niger. Expectations about what children should be fed, on the other hand, may influence infant feeding directly, with clear sanctions, such as emotional or physical abuse or blaming mothers if the child falls ill. It is imperative that research or programme strategies do not inflame harmful norms or put women in danger.
• Qualitative approaches, such as reflection meetings, observation, and interviews with implementers, are well suited to identify signs of whether perceptions of the norms relevant to programme outcomes are weakening, strengthening, or not changing at all, and whether new norms are emerging. Applying a lens of collaborating, learning, and adapting will help programmes anticipate, plan for, monitor, and mitigate pushback and any unanticipated harmful effects of their work to shift norms. It is particularly important to monitor the skills and attitudes of facilitators, as they are critical catalysts in the norms-shifting process. 
   

In conclusion: "it is time to recognize, acknowledge, and seek to support communities in addressing the normative constraints and barriers that women face on their journey to better nutrition....Integrating a 'norms aware' approach into research and programs, with small but significant adjustments to program models as offered in the guidelines above, holds the promise of better adaptation to local contexts and lasting impacts on nutrition and health, as well as agency and other aspects of well-being."