Social change is complex. Program designers and implementers need to deal with complexity in ethical ways. Ms Susan Igras and Dr Anjalee Kohli at Georgetown University and their co-authors examine the power dynamics of norms-shifting interventions in fostering health improvement. Their aim is to develop an approach to designing and carrying out interventions which more systematically take into account values, power differentials, and needs of local populations and organizations. They advocate for systematising ethical thinking in partnerships and dialogues between NGOs, communities, and external organizations.
Social norms are everywhere. Norms – what communities believe are desirable and expected behaviours of its members – can influence a range of health behaviours. A seemingly simple program promoting an uptake of the COVID-19 vaccine reveals normative issues requiring ethical decision-making. For example, as a designer of a vaccination program, who do you prioritize for vaccines in the midst of a pandemic – the elderly or school-aged children? People living in urban or in rural communities? At the level of program implementation, how do you convince groups who are hesitating to get the vaccine, and how to you mitigate public opposition that might emerge? Although there is often no ‘right’ answer – decision-making in health promotion projects is complex – ethical thinking can help to clarify decisions in ways that respect community beliefs and achieve public health aims.
One overarching goal of norms-shifting interventions (NSI) is to create a supportive normative environment that enables improved health and well-being (Legros & Cislaghi, 2020; Mackie et al., 2015; Miller & Prentice, 2016). Community-based NSI aim to foster change through community dialogues that support new normative possibilities as part of social and behaviour change strategies.
NSI are often carried out by organizations who are not intimately familiar with the socio-cultural and political context of the communities they affect. Yet, these organizations and individuals may be responsible for or part of teams that design and implement interventions for communities. This distance between organizations external to communities local organizations and communities is a barrier to social change and improved normative environments. All communities have their own complex histories that mould their societies. Communities include a diverse mix of stakeholders, who have different economic, social, gender, and age backgrounds. Power dynamics within and between organizations and community members affect who has voice and choice, how decisions are made and whose values and perspectives are given importance. Even when not explicitly stated, values and assumptions are guiding the process of NSI design and implementation, and perhaps not in the way people think.
In their paper, Ms Susan Igras, Dr Anjalee Kohli and co-authors critically reflect on the ethical considerations that should be taken into account in such interventions.
Ethical considerations in public health and social issues
In order to gain a better understanding into the issues that NSI can cause, Igras, Kohli, and their collaborator Catherine Tier reviewed 125 articles on ethical considerations in public health, social justice, and human rights. They aimed at pointing to the gaps in existing literature and propose ten ethical values to guide engagement with people and communities. The first five values – inclusiveness, openness, reasonableness, responsiveness, and responsibleness – relate to the NSI program design. The process of implementation should involve minimising harm, respect, fairness, solidarity, and reciprocity. Keeping that in mind, all 10 values can be applied at any stage of a project.
NSI seek social change for greater equity, changing norms while trying to place NSI designers and local community on an equal footing.
NSI work at multiple levels, even when they primarily focus on the community strategies. NSI seek social change for greater equity, changing norms while trying to place NSI designers and local community on an equal footing. Yet relationships between Global North implementers and program designers with Global South organizations do not typically play out this way. Instead, unequal power dynamics as seen in organizational funding and decision-making power, for example, have roots in colonialism and other historical forces. Global North organizations, knowingly or not, impose their own way of thinking on the Global South communities. It is important to make sure that unequal power relations are replaced by more equitable relationships.
These issues also arise and are important to the relationships between external organizations seeking to make change in communities, local NGOs and communities. To this end, the researchers highlight the importance of ethical thinking, seen as “the process of analysing and understanding multiple connected variables in a changing context AND applying ethical values to make responsible choices. It requires doing the work to understand issues clearly before making decisions or taking actions that are ethical” (Thornton, 2019). Ethical thinking is concerned with the application of values (Fawcett, 1991), in particular, using values to inform how we make decisions and what decisions we make. In this respect, the authors argue that NSI interact with many actors and groups. NSI aims and strategies can be interpreted through different value systems by communities and outsider organizations, and different social groups within communities.
The hybridity approach
People designing NSI interventions should be aware that there are different sets of values that should be accounted for. There is a danger that Global North NGOs or other financed organizations design interventions through their own cultural lenses, without considering the perspectives, values and needs of local populations and organizations and how these views may inform program focus and strategies. Often, these outsider organizations work within a postcolonial context. Even if they assume they are doing good, outsider decisions may exacerbate rather than improve community inequities.
Dialogue and negotiation with community stakeholders is the foundation of a hybridity approach. The team suggest that “hybridity recognises that there is a diversity in value systems and values held at the individual, community and organizational levels”. Purposefully discussing and stating values and appreciating different value systems can be used to build partnerships and guide discussions and decision-making for NSI design and implementation. Without structured reflection and partnership and programming grounded in values, this leads to situations where Global North NGOs and other financed organizations assume their intention to do good is sufficient to achieve social change, a more enabling normative environment, and prevent harm. The risk is clear; approaches not grounded in hybridity and ethical thinking may widen existing inequities in the short and long term and may sustain uneven power dynamics.
Defining a shared set of values can guide what decisions are made vis-a-vis emerging social changes throughout the NSI implementation cycle.
Ethical thinking during the community assessment and project design phase should involve defining a set of shared values that the intervention designers and the local communities may have. These values can guide discussions on what an NSI seeks to do and how it will do this. Designers should create spaces to engage community members in the design phase, in strategic decision-making during the definition of key project strategies. This is important, as it will lead to a more equal footing between the designers and the local communities and will ensure that the local values are taken into account.
How to mitigate social pushback
In the process of norms-shifting, social pushback often occurs. Vaccine hesitators, for example, may threaten health care workers doing vaccinations or they might refuse other prevention strategies such as mask wearing. On the other hand, communities may take off with an idea and move it forward such as neighbourhood groups organizing transportation for the elderly to go to vaccination sites. These are normal phenomena that occur when social change efforts begin. Health promotion projects need to anticipate, monitor, and be ready to respond to pushback and support community or individual early adopters of change. The inclusion of ethical thinking based on common values should occur more systematically in both project design and implementation phases.
Project staff should conduct regular follow-ups between project staff, frontline workers, and other community stakeholders on how the interventions are progressing, and obtain regular feedback through the meetings organized. As the researchers aptly put it, “defining a shared set of values can guide what decisions are made vis-a-vis emerging social changes throughout the NSI implementation cycle”. As new issues emerge, returning to project values can be helpful during the decision-making process of how to support or mitigate in ethically considered ways the new effects of social change processes. It is important to understand the local context within which specific social values operate; otherwise, actions viewed as positive by outsiders may lead to the generation of new forms of inequalities.
What inspired you to conduct this research?
<>Susan: For me, it was the accumulation of NGO experiences addressing social determinants of health. While NGO projects were aligned with government and donor policies, for example addressing the socially condoned practice of female genital cutting, communities might disagree on project designs and strategies yet had limited voice to suggest changes. How outsider projects subsequently responded was uneven.
Anjalee: For me, it was the years of witnessing unequal and harmful relationships dominated by Global North organizations at the expense of local communities’ well-being. Frequently, community members and local organizations were expressing frustration and suggesting different program strategies or priorities without being taken seriously.