Catalyzing Gender Norm Change for Adolescent Sexual and Reproductive Health: Investing in Interventions for Structural Change.

As part of an encouraging trend in the last decade, recent consolidations of existing literature and evidence—including those in this volume—help us to move forward in understanding and addressing social norms in relation to improving adolescent reproductive and sexual health (ASRH). Especially important is the increasing recognition that gender is at the center of social norms that shape ASRH outcomes, and that these norms are underpinned by power inequalities [1], [2], [3], [4]. This understanding and the consolidation of evidence to date compel us to examine the limitations around the scope, range, and effectiveness of social norms interventions. In an environment of shrinking resources with multiple competing demands, it becomes critically important that these emerging insights inform future investments in social norms work, making it more efficient in benefitting the largest possible subpopulations of adolescents as speedily as possible.

In this commentary, we provide some direction for addressing the gender-based structural underpinnings of ASRH-related social norms, with the aim of expanding both the scope and effectiveness of what are currently termed “social norm interventions.” Our first point is that although the emphasis on gender and power inequalities in the evolving conceptualization of social norm change (as articulated also in the commentary on social norms theory in this volume) is highly commendable, this thinking has yet to be mainstreamed in the ASRH social norm change programming and vernacular. Our second point is that effectively addressing gendered power dynamics requires expanding the scope of ASRH-related social norms programming beyond the remit of individual, group, or community interventions, currently driven largely by social and behavior change (SBC) programming; rather, we must enhance investments in interventions that leverage the scale and impact of structural drivers. We provide a preliminary frame for doing so by mapping structural drivers of social norm change at the macro-, meso-, and micro-levels, building on the theoretical framework for understanding social norms laid out by Pulerwitz et al. [4] in this volume.

Why Gendered Power Structures Are Central to ASRH Social Norms Programming?

To translate the concepts of gender and power structures into better funding, research, interventions, and measurement, it is important that these concepts and language become routine in ASRH-related social norms work. For example, based on abstracts alone, we note that although at least six of the eight articles in this volume are addressing gender norms, only one explicitly refers to them as such. Since social norms on ASRH are almost always gender norms, it is better to use that term in referring to them. It is, in fact, impossible to think of ASRH-related social norms that are not fundamentally about gender and power, given that control of women's and girls' bodies, sexuality and reproduction is at the heart of gender inequality [5], [6], and ASRH is by definition about sexuality and reproduction at the critical stage of physical maturation and life transitions where their significance becomes paramount.

This underlying motivation for defining sexual and reproductive control during adolescence is one reason why ASRH-related norms are often pervasive as gendered “meta norms,” such as child marriage, early pregnancy, violence against women, and more restricted mobility, schooling, economic opportunity, and decision-making for girls than boys [7]. This is also why such norms are not just perpetuated through shared social expectations but actively enforced through social sanctions that very clearly emphasize the underlying gendered power dynamics: there are real and sometimes brutal costs for girls and/or their families for violating norms that relate to sexuality and reproduction—ranging from mistreatment, violence, abandonment, social or economic exclusion disfigurement, rape, or even death [1], [8]. Therefore, it is critical to keep a focus on gender and power in ASRH social norm programming, recognize and address the unique complexity of these norms, and challenge the underlying structures that perpetuate them.

Enhancing Investments in Structural Interventions

Despite increased acknowledgement of multiple factors in driving shifts in social norms, the role of structural drivers in shifting the gendered power dynamics underpinning ASRH-related social norms remains underestimated, and investments in structural interventions are scarce. By structural drivers, we refer to the political economy and social systems that delineate the roles and responsibilities for subgroups of individuals, as well as the resources, opportunities, power, and influence they are able to access and exercise. This includes legal and policy frameworks, governance and political institutions, as well as markets, collectives, technologies, health and education services, and marriage and family systems. These and similar structural drivers shape the gender- and age-related dimensions of ASRH norms and behaviors at various levels: at the macro-level as when labor markets shape adolescent girls' childbearing and child-rearing roles; at the meso-level as when technological access in specific geographies shapes information channels on sexuality, relationships, and contraception, often differentially for girls and boys; or at the micro-level as when family finances shape the practice of transactional sex—mostly for girls.

We would argue that a shift in these more structural and institutional drivers is essential for the desired shift in norms and behaviors around ASRH to be both long term and pervasive.

And so, it is important that our approach to “social norms interventions” not be limited to SBC interventions alone, as is the case in most of the articles included in this volume and in a majority of the literature reviews. For example, we have significant and consistent evidence of large-scale and sustainable declines in child marriage rates and shifts in attitudes that are linked to increased schooling levels for girls, especially at the secondary level [9], [10], [11]. Even as we refine our efforts around the mixed results and the issues of scale and sustainability of more “standard” norm change interventions on child marriage such as community mobilization and life skills, we must also consider girls' schooling itself—a structural intervention—as a highly successful “social norm change intervention.” There is a good reason to consider that the “social modeling” depicted by large numbers of adolescent girls dressed in school uniforms, on bicycles going to school, and visible in classrooms is a powerful catalyst for sustainable and large-scale norm change in the perceptions of and aspirations for girls, and in the unacceptability of child marriage [11].

To provide a framework for considering how structural factors can be more systematically addressed to change ASRH-related norms, we build on the conceptual model articulated by Pulerwitz et al. [4] (“the flower diagram”). In Figure 1, we take the four dimensions of the “flower diagram”—institutional, resource, social, and individual—and map structural factors at the macro-, meso-, and micro-levels to demonstrate how structural interventions addressing gender dynamics could be operationalized at each level.

Figure 1

Three levels to operationalize structural interventions for norm change.

The Macro-Level

At the macro-level (for countries, states, or provinces), institutions and resources are the most relevant dimensions for considering structural interventions. As opposed to donor-funded interventions, macro-level shifts in institutions and resources such as the economy, government, laws, policies, technology, employment, are in fact the primary drivers of large-scale norm change. Examples of structural drivers that are shifting ASRH norms—both positively and negatively—include young people's expanded access to the internet and mobile phones, the infiltration of religious fundamentalism in education systems, the shrinkage of extended family sizes with declining birth rates, or the shifts in female economic opportunity with the expansion of manufacturing and service sectors. These structural shifts affect norms related to the timing and control around marriage, sexuality, and reproduction—typically through cumulative shifts in opportunities, options, and ideologies over at least a generation or more, rather than through small punctuated time frames as is often hypothesized in SBC interventions. For example, in South Korea, reforms in labor laws and employment opportunities for women throughout the 1990s were a key driver in eventually shifting norms around son preference [12]. Similarly, in Nicaragua, the prevalence of gender-based violence showed significant declines for the age group 15–24 years over a 20-year period, highlighting a generational shift in acceptability of violence against women resulting from legal reforms, availability of services, and better understanding by women of their rights [13].

Given the overarching influence of the macro-level context, SBC interventions can be best seen as “catalyzing” positive trajectories that are already underway, rather than “driving” social norm change. Demonstrating success and ensuring the sustainability of funded social norm change interventions necessitates that they are undertaken opportunistically, in more favorable macro-level contexts. This requires assessing the “preconditions” that are likely to be most “ripe” to leverage a catalytic and supportive role. An assessment can be done through a review of the political economy of a country or its large subunits by examining the positive or negative status and trends for most of the elements in the institutional and resource dimensions as outlined in the “macro” column in Figure 1 [4]. SBC interventions may not lead to sustained norm shifts unless there is at least a moderately favorable context—for example, in the form of a progressive government, an active and capable civil society, funded legal mandates, and/or a vibrant economy.

The Meso-Level

At the meso-level (usually a district or sub-district), there is significant potential to proactively invest in structural interventions for norm change. This requires mapping of resource and social conditions to identify those structural interventions that can leverage promising opportunities for improving key systems and institutions (health, education, social protection, poverty reduction, and employment) to benefit adolescents and as pathways to shifting gender and power structures. For example, working with the district education system to increase female teachers in upper grades can concurrently improve the quality of learning, expand comprehensive sexuality education, and provide positive role models for girls [14], [15]. Similarly, well-designed performance incentives to community health workers for outreach to young people can improve health system delivery to this age group while also changing norms around contraceptive acceptability and uptake among adolescents [16], [17].

Strengthening social movements is another important avenue for shifting norms. Investments in grassroots movements of women and young people can and have played an important role in fostering and demanding accountability on entitlements, including around safety and security in schools, or the availability of commodities, providers, and services in health facilities [18]. Partnership with private and public sector media, marketing and communication companies to counter sexist, discriminatory, and violent language, images, advertisements, or films is another important area for innovation, as is partnership with public and private sector efforts to economically empower women and girls [19]. These collaborations need to be developed, enhanced, and evaluated for generating evidence for their impact on norm change.

The Micro-Level

At the micro-level, norms are addressed through interventions targeted at individuals, families, and communities, a space where most SBC interventions operate. More concerted efforts can be made to link these interventions to complementary programs aimed at improving local institutions, systems, and services. More can also be invested in the complementary structural programs, especially in taking them to scale. For example, a concerted effort to integrate life skills or parental education programs within the school system or the finetuning of cash transfer programs to maximize access by intended beneficiaries can raise the scale and sustainability of such interventions [15].

In conclusion, the learnings from a decade of programming to drive social norm change show the importance of integrating gender and power structures and for expanding programming focus beyond the individual, group, or community to also address necessary shifts in institutions, systems, and resources. It is time to prioritize investments that explicitly tackle the structural drivers and power dynamics that underpin ASRH-related gender norms to realize sustainable social change at scale.