Assessing Social Norms, Health Behavior, and Change Using Visually Informed Participatory Research Tools: Social Network Mapping and 2x2 Tables

"Each tool has been field tested in various global health contexts throughout the world and may be useful in a variety of research contexts where adding a qualitative, participatory component can enhance formative research and intervention programs as well as for M & E [monitoring and evaluation]."

Participatory approaches such as community-based participatory research (CPBR) and participatory action research (PAR) are increasingly used in global health work. This paper explores two visual tools - social network mapping (SNM) and 2x2 tables - used for participatory data collection in interventions that seek to shift social norms to facilitate change for women's health. It begins with an introduction to social norms as the context in which participatory approaches and tools can be used to effect change. It then shares two examples of how these two visual tools were used as part of social norms interventions to impact social and behaviour change around female genital mutilation (FGM) and menstrual hygiene management (MHM). The paper concludes by identifying these tools' limitations and challenges, as well as their potential for application to research on various public health issues.

As outlined here, social norms are the unwritten rules that guide human behaviour that are determined by a "reference group" that imposes sanctions for non-adherence and rewards for adherence to norms. Change of social norms requires cognitive shifts in deeply embedded scripts formed within dynamic interpersonal relationships with people who serve as primary reference groups. For purposes of this discussion, social norms are the construct that public health interventions intended to change by using participatory methods such as SNM and 2x2 tables. By including audience participation, these tools can be effective for applying to social norms change with deeply embedded cultural practices, where the potential social consequences for engaging or not engaging in the practice seem dire, and structural barriers seem great.

Specifically:

• SNM is a visual technique that illustrates how community members are connected and how information flows through social networks. Participants draw or fill in graphics or "maps" that show and list who is in their social network in relation to themselves and others. Doing so helps identify participants' key sources of information, as well as barriers to communication. As a transformative activity, SNM can have a therapeutic effect on participants, where they visualise themselves as part of a social network and within the context of the health issue being discussed. For the researcher, reviewing the data and relevant themes provides insight into the importance of engaging different reference groups in the community. In later research stages, diagrams might be re-examined to monitor the impact of community interventions, including quantification of changes in patterns of interpersonal communication among programme participants.
• 2x2 tables measure an individual's behaviours (what we do), descriptive norms (what we think others do), and injunctive norms (what we think others expect or believe we should do). Though they can be simple visual depictions with limited text and four boxes, conceptually they are complex. They can aid researchers, participants, and communities in assessing the existence, persistence, and change in social norms over time. This tool provides mixed-methods data for analysis that can be used to design programmes, measure norms and behaviours at baseline and end-line, and measure change as part of monitoring and evaluating a programme for efficacy.

Small focus group discussions were part of the framework for participant involvement in both the FGM and MHM programmes described in the paper. Consultation with global and local experts and discussion with programme implementers, followed by rigorous pretesting of each of the tools, were used to ensure that these methods were acceptable. In brief, the programmes include:

• FGM: The ACT ("A": assessing for affective and normative data about the practice; "C": the context in which these practices occur; and "T": tracking or monitoring of behavior change) framework was designed to provide adaptable yet standardised participatory measures of social and behavior change for FGM in Ethiopia and Guinea. (See Related Summaries, below.) As part of ACT, SNMs and 2x2 tables are used to allow participants to reflect on and discuss behaviours and norms and explore the reasons why these norms exist, especially when follow-up dialogue is facilitated as part of the activity. For example, in Ethiopia, the use of the 2x2 tables helped researchers and frontline community programme workers to parse participants' understanding of where their beliefs and practices regarding FGM come from in order to loosen the grip of such beliefs.
• MHM: The Girls' Adolescent and Reproductive Rights (GARIMA) programme addressed MHM in India, where a culture of silence leaves young girls with poor knowledge and myths related to the care of their bodies during menstruation. For example, the SNM map was used to help young girls express who influences them and their decision-making, attitudes, and practices. An endline evaluation found that, in comparison to non-intervention village adolescent girls, girls who have participated in GARIMA were better able to discuss a wider variety of aspects of MHM, had more knowledge about puberty and reproductive body parts, and had more positive attitudes about gender.

The researchers explain that using a visual tool can allow participants to envision the complexities of who is in their social network and the importance they place on their opinions or beliefs in ways that other standard qualitative and ranking methods, such as a verbal interview, may not. Similarly, asking about attitudes and perceptions within a standard focus group or interview may be less effective at parsing out the fullness of attitudes and behavior practices compared to using the 2x2 tables.

Additional global health concerns that may introduce visual participatory research methods might include: violence against children; issues around water, sanitation, and hygiene (WASH); positive parenting; gender socialisation; or other health and human-rights issues, such as child marriage.

As the researchers stress, when engaging in such endeavours: "It is imperative that the research team consider how they engage the community as fully as possible when social norms are deeply embedded in a community...and where social change is dependent on shifting such deeply held beliefs. These tools may leverage research and program development to be integrated into larger community change. The activities can also catalyze change as part of participatory programs that can help community members to feel that they are part of the process of change. These visual tools are also a more inclusive means of promoting dialogue and discussion across knowledge and literacy levels, allowing for reciprocal interaction to better design, change, and adapt programs while also allowing room for innovation at the community level. Participatory methods can be used to support equity in research designed to consider the agency and leadership of participant communities, culture-centeredness, de-colonial approaches, and other perspectives..."

In conclusion: "The use of participatory tools engages the intended audience in safely exploring sensitive, embedded notions that raise their awareness and create openings toward social behavior communication change. Community involvement may also serve to increase community accountability and support the tracking of change over time....The research values and methods outlined in the paper provide strong encouragement to use visual participatory methods for data collection, analysis, and interpretation."