Social Norms and Adolescents’ Sexual Health: An introduction for practitioners working in Low and Mid-income African countries

Abstract

Donors, practitioners and scholars are increasingly interested in harnessing the potential of social norms theory to improve adolescents’ sexual and reproductive health outcomes. However, social norms theory is multifaceted, and its application in field interventions is complex. An introduction to social norms that will be beneficial for those who intend to integrate a social norms perspective in their work to improve adolescents’ sexual health in Africa is presented. First three main schools of thought on social norms, looking at the theoretical standpoint of each, are discussed. Next, the difference between two important types of social norms (descriptive and injunctive) is explained and then the concept of a “reference group” is examined. The difference between social and gender norms are then considered, highlighting how this difference is motivated by existing yet contrasting approaches to norms (in social psychology and gender theory). In the last section, existing evidence on the role that social norms play in influencing adolescents’ sexual and reproductive health are reviewed. Conclusions call for further research and action to understand how norms affecting adolescents’ sexual and reproductive health and rights (SRHR) can be changed in sub-Saharan Africa.

INTRODUCTION

Scholars and practitioners from high-income countries are increasingly integrating social norms strategies to address a variety of health-related behaviours. However, we have found little reference to norms in the platforms available to practitioners from low and mid-income African countries working on adolescents’ health and reproductive rights. In this paper, we aim to provide an introduction to social norms theory for practitioners working to improve adolescents’ reproductive health in Africa. We detail main distinctions across schools of thoughts in the social norms literature, briefly discuss the difference between social norms and gender norms, and then present recent advancement in social norms theory. Before some brief concluding remarks, we review key studies on norms and adolescents’ sexual reproductive health and rights (SRHR) (some of which are from low and mid-income African countries).

Despite the fact that social norms are one of the most widely studied drivers of human behaviour, scholars who study social norms disagree on what they are, how they sustain behaviour, and how they can be changed. Most theoretical studies that look at social norms acknowledge that complexity. Article titles such as: “Norms: the problem of definition and classification”¹; “What is a social norm?”²; “An Explanation of Social Norms”³; “Explaining Norms”⁴; are common within the literature. The great variety of approaches and theoretical standpoints can generate confusion for those who want to apply social norms theory to real-life problems.

An important introductory distinction is that between legal, moral, and social norms. Legal norms are mostly written rules – laws and regulations, for instance – enforced by formal organisms (such as the State) with the authority to prosecute non-compliers ^5–7. Moral norms are instead internally-driven, value-based motivators of behaviour, that push individuals to behave in compliance with ideal states for self and the world⁸. Social norms, finally, are context-dependent, externally-derived rules of obligatory, appropriate, and acceptable behaviour shared by people in the same group or society ^9–11.

Even though these three types of norms are often presented as different theoretical constructs, in practice many connections exist between them. Legal and social norms can influence each other, both positively (when one causes the shift and realignment of the other) and negatively (when one “crowds out” the other). While the law, if enforced, might overtime contribute to a shift in the norm (think of the change in acceptability of smoking in restaurants), laws that are too far from the norm might not be respected¹². That is, people might not follow a specific law because it seems unreasonable or unrealistic to them, and they believe nobody else will. Also, while enforcement of the law requires the institutional capacity to enforce that law, respect of the law requires a social norm of legal obedience. That is, when people believe that nobody in their region or country respects the law (or that everybody follows customary rules but not State law), law compliance requires the strengthening of the belief that State law are respected¹³.

Commentators have argued that moral and social norms are deeply linked, with some suggesting that their distinction is not easily drawn¹⁴. Haidt¹⁵, for instance, suggested that evolution shaped our “moral senses,” so that all human beings share the same moral emotions, but that the trigger-events for those emotions are socially constructed.

Three main theoretical perspectives on social norms

In the literature, there exist three main perspectives on social norms: norms as behavioural regularities, norms as clusters of attitudes, and norms as social beliefs. In this paper, we adopt the last of these approaches, but look briefly at the first two.

Social Norms as behavioural regularities

Early work on social norms (mostly emerging from the fields of sociology and economics) defined them as practices shared across individuals, that emerge through repetition of behaviours¹⁶. However, as several commentators have observed, behavioural regularities might be due to factors other than normative. In certain parts of the world, for instance, most marriages might take place in June not because there is a norm demanding that people should do so, but because that’s when the weather is at its best¹⁷. Similarly, most people drink water, but they don’t do so motivated by the belief that others do as well, just because they are thirsty.

Social Norms as clusters of attitudes

Another school of thought in social norms theory defines social norms as the attitudes that people share in a given group⁴. However, the idea that norms can be understood as clusters of attitudes has limited applicability when people act against their own individual attitude, under the false belief they are aligning their actions with the attitudes of others. This dynamic (in which people falsely believe others have attitudes different from their own) is a well-studied phenomenon in social psychology called pluralistic ignorance^{18, 19}. The norms as attitudes school is not helpful for practitioners dealing with cases of pluralistic ignorance and, for both measurement and programmatic purposes, is less complete than those approaches that explain why people behave against their own and (unwittingly) other people’s individual attitudes.

Social norms as social beliefs

A third school of thought on social norms emerged from empirical findings primarily originating from studies in social psychology. In this school of thought, the work by Cialdini and colleagues has been path-breaking ^20–23. Their theory identifies two types of social norms as beliefs: 1) one’s belief about what others typically do in a situation X; and 2) one’s belief about what actions other people approve and disapprove in a situation X. These scholars called beliefs of the first type descriptive norms, and beliefs of the second type injunctive norms²¹. Some commentators have suggested that social norms only exist when both beliefs are active. Bicchieri²⁴, for instance, spoke of social norms as being the function of both empirical expectations (what I think others do) and normative expectations (what I think others think I should do). Even though these theories vary in the words they use to define social norms, they agree on the basic premise that both individuals’ beliefs about what others do and beliefs about what others approve of influence individuals’ choices and actions. This paper adopts Cialdini’s terminology of descriptive and injunctive norms.

Descriptive and Injunctive norms as behavioural drivers

Descriptive and injunctive norms can be powerful drivers of behaviour. Experts in public advertisement have for many years exploited the power of descriptive norms to influence consumers’ behaviour: when people believe that many others are doing something, they will be more favourably oriented towards, or even compelled to do the same. Much of the empirical evidence on the influence of descriptive norms comes from studies conducted in high-income countries, many of which were carried out by researchers interested in: 1) increasing pro-environmental behaviour^25–28; and 2) reducing consumption of alcohol in university campuses^29–34. Injunctive norms have also been studied as influential drivers of human behaviour, and as with descriptive norms, have been used frequently in advertisements that strive to shape ideas of what consumers should do to be popular, likeable, or accepted by others (“drinking this beer will make a real man of you”, or “using that mascara will make you more popular”). Studies that look exclusively at injunctive norms do exist^{35, 36}, although empirical researchers more commonly integrate analysis of both injunctive and descriptive norms in their studies.

The evidence is mixed about which of the two types of norms has stronger influence; differences in their strength might be due to the behaviour being influenced, as well as the characteristics of the population being influenced by the norm (age, gender, or economic status), the relationship between the influencers and the influenced (perceived social distance or proximity), and the characteristics of the context in which the influenced live (urban or rural, familiar or unfamiliar, for instance)^{27, 37, 38}.

The role of the “reference group”

Scholars from various disciplines have been familiar with the concept of a reference group for more than half a century^39–43. Even before social norms theory had emerged as field of research and practice, some scholars had started to propose a “reference group theory,” arguing that individuals’ behaviours are influenced by the behaviour of the group. In its earlier definition, a reference group was understood as the specific group of people that influence how individuals “think, feel, and see things”⁴⁰.

Studies have shown that group membership can indeed act as a strong motivator for following the groups’ behaviour. A group is likely to exert a stronger influence on behaviour particularly when one identifies with that group^{44, 45}. Some theorists have further argued that one’s normative beliefs are projected onto a given reference group of people that matter to them when carrying out a given action ^{24, 46}. Different reference groups can matter in different situations or for different actions behaviours. However, as Cialdini⁴⁷ observed, the behaviour of others can be normative even when the group is not particularly meaningful, as, for instance, in the street, where we might align our behaviour to what we believe is appropriate in front of complete strangers^{48, 49}.

Mechanisms of norm compliance

There is no widely shared agreement on why people comply with social norms. There are six main mechanisms that provide convincing explanations for people’s tendency to comply with norms. The theories behind each of these mechanisms are varied and sometimes overlapping or contrasting. Attempts at comprehensive reviews exist elsewhere ¹⁰. We offer here a simplified version as an introduction.

Socialisation, Internalisation and Automaticity

Psychological theories of social learning posit that social norms are learnt in the day to day interactions that humans have as children and adolescents⁵⁰. As children learn them throughout their development, norms become connected to feelings of shame and guilt that are triggers of appropriate behaviour⁵¹. In most of these cases, compliance with norms becomes automatic, rather than the result of internal rational deliberation^{52, 53}.

Social Identity

Norms compliance can express group membership. For instance, a group of adolescents might share how they dress, talk, and more generally behave because they connect those actions to their sense of self in the group^54,55.

Power

Norms compliance can be enforced by power holders invested in maintaining the social status quo^{56, 57}. Others less powerful might not have the resources required to challenge the norm (authority, credibility, visibility, money, or relational network, for instance).

Solving Social Dilemmas

Norms can help solve social dilemmas that require coordination or cooperation^{58, 59}. Coordination allows people to achieve individual goals that require synchronising with the behaviour of others. An example can be found in the spread of fax machines in the late 80s: every person wants to communicate, but they will use faxes only if most others do. Cooperation instead allows people to achieve collective goals benefitting them as a group (often when their individual interests would be conflicting). Take, for instance, a group of fishermen who fish in the same lake. It’s in their individual interest to overfish (they earn more money) but if everyone does there will be no more fish in the lake. A norm against overfishing will allow them to carry on their activity sustainably.

Punishments and rewards

Finally, norms compliance can be motivated by the fear of social punishments and rewards for non-compliers and compliers respectively^{60, 61}. Rewards might include praising, promotions, being recognised as a member of an elite group, and punishments might include gossip, disapproval, isolation, and potentially even death.

Recent advancements in the “norms as belief” approach

Norms are on a spectrum of influence

Cislaghi and Heise ⁹ argued that the strength of a norm varies according to four characteristics of a practice: 1) its detectability; 2) its interdependence; 3) it being held in place by proximal norms; and 4) its likelihood of resulting in sanctions. They suggest that there are four possible types of influence that norms can have: 1) they can make a practice obligatory (taking the example of female genital cutting); 2) they can make it appropriate (as in the case of an adolescent smoking to impress a group of friends); 3) they can make it tolerated (as in the case of littering); or 4) by exposing a person to a new attitude or behaviour, they can expand what is possible (as it happens, for instance, in the diffusion of a new technology).

Effective change requires embedding norms within an integrated framework of influence

If norms operate along a spectrum, they do not exert exclusive influence on a given behaviour, but interact with other (material, institutional, social, and individual) factors in affecting the persistence of a practice or a behaviour^62–64.

The influence of social norms is often underestimated by actors

Social Influence in general is underestimated⁶⁵ or unrecognised by actors²⁵. When asked about the reasons they do something, not many might realise or admit that they are under the influence of norms. That has obviously major implications for social norms measurement and diagnosis. Social network analysis, by measuring the similarity between the attitudes and behaviours of socially connected people, can be an important tool for uncovering those underreported dynamics.

Social Norms and Gender Norms

Particularly relevant for adolescents’ SRHR are gender norms. Practitioners working in this area, while perhaps unfamiliar with the theories presented so far, will be familiar with gender norms. There currently exists a gap between these two fields of research and practice; the language, approaches and perspectives used in the “gender theory” approach need more harmonisation with those used in the nascent “social norms approach” to international development. On the one end are practitioners interested in challenging patriarchy, for whom transforming gender norms becomes part of the larger project of achieving gender equity. On the other end, there are donors and practitioners who, while less focused specifically on gender, began to apply the social norms theory to gender-related harmful practices. Even though the two fields of theory and practice are now intersecting, much remains to be done to develop a common vocabulary that would allow greater collaboration.

Social Norms and SRHR

Much evidence exists around the role that social norms play in influencing adolescents’ health-related behaviour^66–69. There also is a body of literature specifically on adolescent sexual behaviour and social norms in high-income countries, including many papers utilizing social network analysis as a way to capture peer effects. One sharp contributions is in the work by Mollborn^{70, 71}, who conducted a large qualitative study with adolescent students in the US, and identified bundles of norms (at times contradictory) that would variably stretch or restrict the space for adolescents’ agency in negotiating sex. The two most comprehensive papers in the available literature are 1) a systematic review and 2) a qualitative synthesis of the norms affecting adolescents’ SRHR^{72, 73}. The review investigated the associations between descriptive and injunctive norms, and sexual activity⁷³. The authors found that adolescent sexual activity was more strongly associated with descriptive norms than with injunctive norms. However, gender, age, and the socio-cultural context had a significant moderating effect. The qualitative synthesis found that adolescents focus more on the social rewards that sex brings to them, and less on health risk. The authors also found that adolescents reproduce dominant gender norms in how they talk about sexual behaviour and sexual decision-making⁷².

Much of the available research on social norms and adolescents’ SRHR focuses on sexual initiation. Even though many of these studies did not specifically measure social norms, results point towards the effect of these norms on adolescents’ sexual behaviour. A series of studies showed that the age of sexual initiation of one’s adolescents’ peers is a strong predictor of one’s age of sexual initiation, controlling for other factors^74–78. Teitler and Weiss⁷⁹, for instance, found that while school level sexual initiation predicts individual adolescent sexual initiation, the school level perceived norms regarding the acceptable age for sexual initiation was a significant predictor of individual age at initiation controlling for students own attitudes. The effect of norms on adolescents’ SRHR is not limited to sexual debut: studies have found similar relations between peers’ contraceptive use and one’s use⁸⁰ and even peers’ experience of sexual violence and one’s experience⁸¹. The effect of social norms on adolescents’ sexuality differs by gender. A recent study conducted in Uganda, for instance, showed that, while boys who have reported a multitude of sexual partners achieve popularity, girls who have reported a multitude of sexual partners are more likely to be ostracized⁸². While research on what works to change social norms to improve adolescent sexual health in sub-Saharan Africa is still growing, evidence exists that norms play an important role in the way adolescents make decisions about sexuality in these contexts. Research in South Africa, for instance, has highlighted the impact of peer opinions on adolescent condom use^{83, 84}. Other work has identified the role of social norms in the perpetration of sexual violence amongst South African youth⁸⁵, transactional sex in sub-Saharan Africa⁸⁶, and multiple partnerships and early sexual initiation amongst adolescents in South Africa⁸⁴.

CONCLUSIONS

The usefulness of theoretical approaches that see social norms as people’s beliefs about what others do and approve of have been highlighted. This is offered as an introduction to researchers and practitioners who intend to integrate a social norms perspective within their work in sub-Saharan Africa. Recent findings suggest that a similar endeavour can bear promising results⁸⁷. In spite of some evidence on the role that social norms play in influencing adolescents’ sexual behaviour, little is available on what works to change social norms to improve adolescents’ SRHR in low and mid-income African countries. Future research and practice should further investigate the dynamics of normative influence and its change in these countries, particularly the ways in which social norms change intersects with change in other institutional, material, social and individual factors that contribute to sustaining harmful practices.