Table 4.

Factors identified as facilitators or challenges to scale-up efforts of normative strategies of each of the 13 included interventions

	Resource needs		Intervention design		Partnerships for sustainability		Monitoring and evaluation systems and data
	Financial resources	Human resources	Content and structure	Adaptability of programming	Community support and engagement	Government support and ownership
No. interventions that cited a facilitating factor	7	4	7	3	10	9	7
No. interventions that cited a challenging factor	5	5	4	1	3	3	2
1. AYAa[9], [10], [11]
Facilitators	Advocacy and partnerships with Uganda Kingdoms led to select Kingdoms securing financial resources to take on project initiatives				Communities (including religious institutions) participated in all stages of programming, building capacity to analyze and address AYRH issues	Policymakers involved in all stages of programming, and partnerships with Uganda Kingdoms created supportive AYRH policies
Challenges	No challenges to scale-up documented
GREAT [12], [13], [14], [15]
Facilitators	Used a “low-investment approach” design and user organizations could leverage financial resources to integrate GREAT components into existing programming	Building capacity of staff to understand own gender norms supported community-level work, building sustainability of activities. Resource organization prepared for transition as implementer to capacity builder, provided mentoring to user organizations to lead activities	Conceptualized with “scale in mind”; developed a toolkit with guides that can be easily used by user organizations; worked through existing community mechanisms		Received positive support from community members; active and early engagement with potential user organizations helped build local ownership and sustainability of GREAT components	Assigned scale-up coordination responsibilities to MOH and district stakeholders, thus ensuring ownership of scale-up	Partnered with user organizations and stakeholders to develop monitoring, evaluation, and learning system and indicators in line with district databases and M&E systems
Challenges	The Community Action Cycle component was difficult for user organizations to understand and required repeated trainings and capacity-building initiatives	Existing village health teams were overworked and resource organizations experienced high staff turnover			Not enough community participation necessary to achieve wide diffusion and reach the tipping point for social normative change		User organizations needed capacity building from the resource organization to support M&E system
2. Geração Biz [16], [17]
Facilitators	User organizations could continue activities through integrating program costs into operating budgets				Local user organizations expressed interest and could integrate program costs into operating budgets	Government showed commitment and ministries were involved in development and implementation of intervention	Availability of M&E data helped adapt activities and developed M&E system to be adaptable for user organizations
Challenges	Costs to implement across sectors and at various administrative levels were substantial	High staff turnover, requiring follow-up and additional technical assistance from the resource organization. Gender inequity among peer educators and inadequate gender sensitivity training may have affected program effect on social normative change					M&E systems were inconsistent across provinces, requiring significant time and support from resource organization
3. Ishraq Program [18]
Facilitators			Created steps to integrate graduates into formal schooling and existing systems	Activities easily fit into government systems and initiatives	Local communities maintained support and demand for project to continue and were very involved in community activities	Government ministries involved in design and implementation; increased attention to improving AYRH	Rigorous M&E system allowed for effective learning and implementation of adjustments to streamline activities
Challenges	Cost of providing continued support to graduates needed to be raised from local funds		Graduates aged out of formal program and required additional support			Lack of government legal records and documentation for graduated girls made it difficult to access public services
4. Kenya ARH Project [19], [20], [21]
Facilitators	Costing activities helped to identify essential program components for replication and MOH could leverage resources to integrate activities in existing initiatives		Availability of implementation tools and guidance documents facilitated transition to user organizations		Local community expressed high demand and was very engaged with community activities	Supportive government policies brought attention to project and integration of various intervention components into MOH initiatives	Strong pilot data and dissemination showcased evidence and generated buy-in to adapt and refine for scale-up
Challenges	Lack of sufficient resources for all components	High turnover of relevant staff required high level of continued external technical assistance and additional retraining				Integrating activities into ministries was difficult due to the complex government systems
5. MEMA kwa Vijana [22], [23], [24]	Scale-up of normative components not documented
6. PRACHAR [19], [25], [26]
Facilitators		Building capacity of local NGO staff and community members who led activities to understand own norms and internalize their role as change agents enhanced performance		Adaptable activities and systems to respond to the needs of community and user organizations	Communities were engaged in activities; consistent partnerships with local user organizations from the start fostered commitment		Rigorous M&E data showed evidence of project impact, which generated local support and demand
Challenges			Multiple components were too large for public sector, requiring refinement/adaptation
7. Program H & Program M [27], [28]
Facilitators	Resource organization budgeted for capacity building of user organizations as part of scale-up efforts and made materials available at no cost		Developed materials for user organizations to adopt and made them readily available		Communities showed strong interest and engagement and built capacity of user organizations as part of activities and program costs	Initiated early engagement with government stakeholders and supported government to integrate project activities into ongoing initiatives	Rigorous data and results from adaptations in multiple countries demonstrated programs' effectiveness
Challenges					Recruitment and commitment of participants due to competing priorities was difficult
8. SASA! Raising Voices [29], [30], [31]
Facilitators	Discussion leaders were unpaid volunteers but still showed commitment and engagement; the resource organization made online trainings and program materials available to user organizations at no cost	Program addressed social norms of staff and volunteers first, empowering them to take action and building their commitment to community mobilization activities	Intervention focused on empowerment rather than negative behaviors	Developed an open-source toolkit that is publicly available and freely distributes supplementary materials and online trainings	Messages diffused outside of target population showing strong interest among participants; community advocacy activities built support among user organizations	Fostering relationships with and support from local government leaders built interest and support of activities	M&E tools developed are easy to use and strong impact demonstrated
Challenges	Short-term donor cycles cited as a barrier to achieving the long-term normative change necessary to replicate impact at scale	Difficult to monitor use of freely available materials to ensure fidelity to core components	Community mobilization process can be difficult and costly
9. Sexto Sentido [32], [33], [34], [35]
Facilitators			Availability of telenovela episodes and group discussion materials for user organizations		Strong partnership and support from civil society organizations that became user organizations; target populations generated demand for program	Supportive policy environment with government ownership
Challenges	No challenges to scale-up documented
10. South Africa Regional SBC Communication Program [36], [37]	Facilitators and challenges noted were related to pilot implementation and not specifically to scale-up efforts.
11. Tostan [38], [39], [40]
Facilitators	Resource organization accounted for costs related to capacity building and mentoring of user organization staff	Resource organization mentored and built capacity of user organizations to manage program and understand underlying norms	Content avoided focus of negative behavior; focus on noncombative manner reinforced women's empowerment messages		Community showed enthusiasm for activities; inclusion of capacity-building activities with local user organizations built local ownership	Eventually gained support from government bodies that made public declarations to end female genital cutting
Challenges		Difficult to find local residents to serve as facilitators, increasing program costs	Some content was too difficult for facilitators to discuss, leading to changes in core program components and messages	The complexity of female genital mutilation norms in countries where practice is universal made it difficult to initiate behavior change	Opposition from some community and religious leaders; lack of community participation without tangible incentives	Some countries faced challenges gaining support from government stakeholders at start
12. YEAH [41], [42]	Facilitators and challenges noted were related to pilot implementation and not specifically to scale-up efforts.

Blank = available program documentation did not mention the category as a facilitator of their scale-up effort.

ARH = adolescent reproductive health; AYA = African Youth Alliance; AYRH = adolescent and youth reproductive health; GREAT = Gender Roles, Equality and Transformation; M&E = monitoring and evaluation; MOH = Ministry of Health; SBC = social and behavior change; YEAH = Young Empowered and Healthy Initiative.

^aAvailable documentation specific to project scale-up experience in Uganda.