Dynamic Norms and Vaping: A Test of Four Mediators.

Background: The prevalence of vaping among young people is a public health crisis. Social norms can contribute to the problem, but also to the solution. Objective: The current study examined young adults' responses to anti-vaping messages that varied on two features: social norms and behavioral framing. Methods: College students (N = 270) were randomly assigned to one of five conditions in a 2 (social norm: dynamic norm, static norm) X 2 (behavioral framing: vaping, not vaping) between-subjects factorial design with a no message control condition (n range = 49-58 in each condition). Results: Independent samples t-test, univariate analysis of variance, and structural equation modeling were used to test hypotheses and answer research questions. Results showed main effects of social norm, such that the dynamic (vs. static) norm message led to higher preconformity (p <.001) and self-efficacy (p = .012), and lower freedom threat (p = .040) and reactance (p < .001). There was also an indirect effect of dynamic norm on attitude as mediated by self-efficacy (p = .040). No main effect of behavioral framing was observed. Few interactions between social norm and behavioral framing were observed on preconformity (p < .001), anger (p < .001), and negative cognitions (p = .003). Conclusion: Overall, findings suggest a persuasive advantage for a dynamic norm relative to a static norm. Theoretically, these findings add to the literature suggesting the persuasiveness of dynamic norms. Practically, these results imply anti-vaping campaigns targeting young populations should communicate the changing (dynamic) norms in regard to (not) vaping.

Persuasive communication, financial incentives, and social norms: Interactions and effects on behaviors.

Social norms and financial incentives are both known to shape the decisions people make about prosocial actions. This paper reviews the financial incentives in normative systems (FINS) model, which integrates theories of social norms from communication, social psychology, and behavioral economics to predict relationships among incentives, norms, and behaviors. It addresses how incentives can affect norms and how they change the effects of norms on behaviors. The model shows how strategic communication (framing) of social norms and incentives can shape the way people respond to incentives, minimizing unwanted outcomes and even enhancing the effectiveness of behavioral incentive payments. These insights can guide hypothesis testing and application to real-world use of incentives for behavior change.

The dynamics of intercultural clinical encounters in times of pandemic crisis. Swedish healthcare providers' reflections on social norms in relation to sexual and reproductive healthcare.

BACKGROUND: Experiences from the COVID-19 pandemic may help to better understand resilience, competences and skills for healthcare providers and the healthcare system. Within sexual and reproductive health inequalities for migrants exist and it is an area where promoting both cultural competency and healthcare equity in the clinical encounter is expected of healthcare providers yet can create tension. The aim is to explore healthcare providers experiences of encounters with migrants in the context of the pandemic and the subsequent changes in routines and norms. METHODS: A qualitative study based on semi-structured interviews with 31 healthcare providers working in sexual and reproductive healthcare in southern Sweden. Interviews were conducted during the COVID-19 pandemic influencing how healthcare providers reflected on their experiences. Analysis was done using reflexive thematic data analysis. FINDINGS: Healthcare providers reflected on how changes in routines increased the understanding of challenges and enablers in the intercultural encounter including the impact on communication and role of relatives and male partners. They emphasized the dynamics of culture in the clinical encounter and healthcare system through highlighting the importance of structural awareness, self-reflection and the flexibility of conducts and norms, often given a cultural connotation. CONCLUSION: The COVID-19 pandemic resulted in changes of previously established routines directly affecting clinical encounters, which provided a unique opportunity for healthcare providers to reflect, with communication and self-reflection being discussed as central in complex encounters. It highlighted the dynamics of presumed deeply rooted cultural norms and the interplay with social factors affecting healthcare providers and patients alike.

Anticonformists catalyze societal transitions and facilitate the expression of evolving preferences.

The world is grappling with emerging, urgent, large-scale problems, such as climate change, pollution, biodiversity loss, and pandemics, which demand immediate and coordinated action. Social processes like conformity and social norms can either help maintain behaviors (e.g. cooperation in groups) or drive rapid societal change (e.g. rapid rooftop solar uptake), even without comprehensive policy measures. While the role of individual heterogeneity in such processes is well studied, there is limited work on the expression of individuals' preferences and the role of anticonformists-individuals who value acting differently from others-especially in dynamic environments. We introduce anticonformists into a game-theoretical collective decision-making framework that includes a complex network of agents with heterogeneous preferences about two alternative options. We study how anticonformists' presence changes the population's ability to express evolving personal preferences. We find that anticonformists facilitate the expression of preferences, even when they diverge from prevailing norms, breaking the "spiral of silence" whereby individuals do not act on their preferences when they believe others disapprove. Centrally placed anticonformists reduce by five-fold the number of anticonformists needed for a population to express its preferences. In dynamic environments where a previously unpopular choice becomes preferred, anticonformists catalyze social tipping and reduce the "cultural lag," even beyond the role of committed minorities-that is, individuals with a commitment to a specific cause. This research highlights the role of dissenting voices in shaping collective behavior, including their potential to catalyze the adoption of new technologies as they become favorable and to enrich democracy by facilitating the expression of views.

Social sanctions in response to injunctive norm violations.

Injunctive social norms are societal standards for how people are expected to behave. When individuals transgress these norms, they face social sanctions for their behavior. These sanctions can take many forms ranging from verbal or non-verbal reactions and from disapproval to ostracism. We review the stable characteristics and situational variables that affect a bystander's tendency to enact social sanctions against someone who violates an injunctive social norm. Stable characteristics include the bystander's extraversion, altruism, the belief that others can change their behavior, and their cultural background. Situational factors include the extent to which the violated norm implicates the bystander, the social hierarchies among the bystander and transgressor, the presence of additional bystanders, and (when applicable) the bystander's relationship to the victim of the norm violation. We also discuss the costs that a bystander can incur by attempting to enact social sanctions. We conclude with a discussion of the application of social sanctions to enforce pro-social social norms.

Influence of cultural values and hierarchical social norms on buying counterfeits online: a 17-country study.

Introduction: As a globally prevalent phenomenon, buying counterfeit products harms consumers, economies, societies, governments, and the environment. The study examined the hierarchy of injunctive normative influence (personal vs. societal) on counterfeit purchase intentions and trends in non-deceptive (known) counterfeit purchase behavior. The current research expands the hierarchical norms approach by examining how the cultural values of power distance and individualism-collectivism predict injunctive normative perceptions and counterfeit buying intention and behavior. Methods: A cross-sectional survey (N = 13,053) of consumers from 17 nations, administered in seven languages, explored cross-country differences in perceived social norms about buying counterfeits. Results: The findings of multilevel moderated mediation analyses showed that personal injunctive norms (perceived acceptance of buying counterfeits by close friends) mediated the relationship between societal injunctive norms (perceived acceptance for buying counterfeits by peers in the same country) and the outcome variables. Selected paths of the mediation model were moderated by the two cultural dimensions. Discussion: Theoretical implications are discussed within the context of cultural orientations' and social norms' roles in informing risky behavior, and practically, within the context of awareness-raising and behavior-change interventions.

Computational evolution of social norms in well-mixed and group-structured populations.

Models of indirect reciprocity study how social norms promote cooperation. In these models, cooperative individuals build up a positive reputation, which in turn helps them in their future interactions. The exact reputational benefits of cooperation depend on the norm in place, which may change over time. Previous research focused on the stability of social norms. Much less is known about how social norms initially evolve when competing with many others. A comprehensive evolutionary analysis, however, has been difficult. Even among the comparably simple space of so-called third-order norms, there are thousands of possibilities, each one inducing its own reputation dynamics. To address this challenge, we use large-scale computer simulations. We study the reputation dynamics of each third-order norm and all evolutionary transitions between them. In contrast to established work with only a handful of norms, we find that cooperation is hard to maintain in well-mixed populations. However, within group-structured populations, cooperation can emerge. The most successful norm in our simulations is particularly simple. It regards cooperation as universally positive, and defection as usually negative-unless defection takes the form of justified punishment. This research sheds light on the complex interplay of social norms, their induced reputation dynamics, and population structure.

Institutional Change Affects Perceived and Personal Intergroup Attitudes.

This research tested whether institutional change impacts policy support and attitudes toward the social groups impacted by policy change. Study 1 demonstrated across a variety of topics that, when a hypothetical state legislature banned (vs. affirmed) a practice (e.g., allowing companies to implement mandatory anti-racism training), participants perceived less support for the policy and more negative attitudes toward the group impacted (e.g., Black Americans). Study 2, a longitudinal study, investigated the short- and long-term impact of real-world policy change-the U.S. Supreme Court's Dobbs v. Jackson Women's Health Organization ruling that gave states the right to restrict access to abortion. Although the ruling did not produce lasting change in personal support for abortion restriction, it did lead participants to perceive more support for traditional gender roles and to personally endorse traditional gender attitudes more strongly. These results demonstrate the power of institutional policies to influence individually held intergroup attitudes.

Compliance with social norms in the face of risks: Delineating the roles of uncertainty about risk perceptions versus risk perceptions.

Social norms are often considered as behavioral guidelines to mitigate health and environmental risks. However, our understanding of the magnitude of their impact on risk-mitigating behaviors and how perceptions of risks affect the magnitude remains limited. Given the increasing importance of understanding factors influencing behavioral responses to health and environmental risks, this research examines whether the relationship between social norms and behavioral intention to mitigate health and environmental risks is a function of (1) risk perceptions and (2) uncertainty about risk perceptions. A cross-sectional survey involving a national sample (N = 803) across three health and environmental risks (i.e., infectious diseases, climate change, and water shortage) is conducted. The results reveal a three-way interaction between descriptive norms, uncertainty about susceptibility, and uncertainty about severity on behavioral intention to mitigate the risk. Individuals exhibit the strongest intention to engage in risk-mitigating behaviors when they perceive prevailing social norms and are uncertain about their susceptibility to the risk and the severity of the risk. Moreover, injunctive norms interact with uncertainty about susceptibility to influence behavioral intention, such that the more uncertain individuals feel about their vulnerability to a risk, the stronger the impact of injunctive norms is on behavioral intention. Neither descriptive nor injunctive norms interact with perceived risks to influence behavioral intention. This study contributes valuable insights into the interplay between social norms, uncertainty about perceived risk, and behavioral intention, and offers valuable theoretical and practical implications.

Comparison of FGM prevalence among Nigerian women aged 15-49 years using two household surveys conducted before and after the COVID-19 pandemic.

BACKGROUND: Due to its economic burden and change of focus, there is no gainsaying of the potential impacts of the COVID-19 pandemic on the progress of several female genital mutilation (FGM) interventions across the various countries. However, the magnitude of the potential changes in likelihood and prevalence should be more accurately explored and quantified using a statistically robust comparative study. In this study, we examined the differences in the likelihood and prevalence of FGM among 15-49 years old women before and after the pandemic in Nigeria. METHODS: We used advanced Bayesian hierarchical models to analyse post-COVID-19 datasets provided by the Multiple Indicator Cluster Surveys (MICS 2021) and pre-COVID-19 data from the Demographic and Health Surveys (DHS 2018). RESULTS: Results indicated that although there was an overall decline in FGM prevalence nationally, heterogeneities exist at state level and at individual-/community-level characteristics. There was a 6.9% increase in prevalence among women who would like FGM to continue within the community. FGM prevalence increased by 18.9% in Nasarawa, while in Kaduna there was nearly 40% decrease. CONCLUSIONS: Results show that FGM is still a social norm issue in Nigeria and that it may have been exacerbated by the COVID-19 pandemic. The methods, data and outputs from this study would serve to provide accurate statistical evidence required by policymakers for complete eradication of FGM.

Psychological and psychosocial determinants of COVID-related handwashing behaviours: A systematic review.

Background: The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has resulted in illness, deaths and societal disruption on a global scale. Societies have implemented various control measures to reduce transmission of the virus and mitigate its impact. Individual behavioural changes are crucial to the successful implementation of these measures. One commonly recommended measure to limit risk of infection is frequent handwashing. It is important to identify those factors that can predict the uptake and maintenance of handwashing. Objectives: We aimed to identify and synthesise the evidence on malleable psychological and psychosocial factors that determine uptake and adherence to handwashing aimed at reducing the risk of infection or transmission of COVID-19. Search Methods: We searched various literature sources including electronic databases (Medline ALL, Child Development & Adolescent Studies, ERIC, PsycInfo, CINAHL and Web of Science), web searches, conference proceedings, government reports, other repositories of literature and grey literature. The search strategy was built around three concepts of interest including (1) context (terms relating to COVID-19), (2) behaviour of interest and (3) terms related to psychological and psychosocial determinants of COVID Health-Related Behaviours and adherence or compliance with handwashing, to capture malleable determines. Searches capture studies up until October 2021. Selection Criteria: Eligibility criteria included observational studies (both retrospective and prospective) and experimental studies that measure and report malleable psychological and psychosocial determinants and handwashing at an individual level, amongst the general public. Screening was supported by the Cochrane Crowd. Titles and abstracts were screened against the eligibility criteria by three independent screeners. Following this, all potentially relevant studies were screened at full-text level by the research team. All conflicts between screeners were resolved by discussion between the core research team. Data Collection and Analysis: All data extraction was managed in EPPI-Reviewer software. All eligible studies, identified through full-text screening were extracted by one author. We extracted data on study information, population, determinant, behaviour and effects. A second author checked data extraction on 20% of all included papers. All conflicts were discussed by the two authors until consensus was reached.We assessed methodological quality of all included studies using an adapted version of the Joanna Briggs Institute Quality appraisal tool for cross-sectional studies. Main Results: Our initial searches yielded 23,587 results, of which 56 studies were included in this review. The included studies were cross sectional in design, came from 22 countries and had a combined sample of 199,376 participants. The vast majority of studies had samples from the general public, with eight of the studies focusing on specific samples. All included studies considered people over the age of 18. The quality of the majority of the studies was good (n = 30 rated low risk of bias), with 8 rated high risk of bias, predominately due to lack of reporting of recruitment, sample characteristics and methodology. Thirty-four studies were included in the narrative synthesis and 28 in the meta-analysis.Findings indicated that emotions about COVID-19 (worry [0.381, confidence interval [CI] = 0.270-0.482, I 2 = 92%) and anxiety (0.308, CI = 0.154-0.448, I 2 = 91%]), knowledge of COVID-19 (0.323, CI = 0.223-0.417, I 2 = 94%), and perceived social norms (0.303, CI = 0.184-0.413, I 2 = 92%) were among the malleable determinants most associated with handwashing. Perceived severity (0.006, CI = -0.011-0.023) and susceptibility of COVID-19 (0.041, CI = -0.034 to 0.115) had little to no effect on handwashing behaviour. Authors' Conclusions: Understanding the effects of various malleable determinants on COVID-related handwashing can aid in the development and implementation of interventions and public health campaigns to promote handwashing behaviour in potential new waves of COVID-19 or other respiratory infections. Emotions about COVID, knowledge of COVID and perceived social norms warrant further consideration in future research and policy.

Effectiveness and context dependency of social norm interventions: five field experiments on nudging pro-environmental and pro-social behavior.

Social norm interventions hold the potential to change people's behavior. Five field experiments (N = 1,163) examined the effects of a simple and easily realizable social norm nudge based on the social media format "Be like Bill." The nudge consisted of a stick figure named Toni that communicated descriptive and injunctive norms regarding pro-environmental or pro-social behaviors. Nudge conditions were compared to no-intervention control conditions. Experiment 1 (N = 179) focused on paper towel consumption in a women's restroom at a German university. The nudge condition used less paper towels than the control condition, d = 0.48. Experiment 2 (N = 183) replicated this result (d = 0.32) in a more diverse setting of a women's restroom at a German Christmas market. Experiment 3 (N = 250) examined differences in the effects of prescriptive (i.e., 'do-norm') versus proscriptive (i.e., 'do not-norm') social norms on paper towel consumption again in a university women's restroom. The effectiveness of both social norm nudge conditions was shown in comparison to the control condition (d = 0.46; d = 0.40), while the prescriptive and proscriptive social norm manipulations did not differ. Experiment 4 (N = 206) applied the nudging approach to the use of plastic lids in a coffee shop, where no effect was found. Finally, Experiment 5 (N = 345) focused on the pro-social behavior of mask wearing in a bakery toward the end of the Covid-19 pandemic restrictions in Germany. In the nudge condition, more visitors put on face masks compared to the control group, d = 0.39. Limitations and contextual factors regarding the applicability of our social norm nudge are discussed.

They approve but they don't act: promoting sustainable minority behavior with (conflicting) social norm appeals.

Background: Social norm appeals are effective in promoting sustainable majority behavior but could backfire when the target behavior is only performed by a minority of people. However, emphasizing that an increasing number of people have started engaging in the behavior or that the majority approve the behavior might prevent such negative effects. However, only a few studies have investigated the combination of descriptive minority and injunctive majority social norm appeals, with inconsistent results. Some studies of minority behavior suggest that the characteristics of recipients might determine the inconsistent results regarding the impact of minority social norm appeals and that social norm appeals could have a greater impact on individuals with weaker environment related dispositions. Method: Two two-wave studies investigated how descriptive minority appeals, injunctive majority appeals, and their combination can be used to motivate sustainable minority behavior and what role environment related dispositions play in this context. In the first part, perceived social norms, environment related dispositions, behavioral intentions, and pre-attitudes were measured. Two weeks later, respondents participated in a 3 (descriptive social norm appeal: static vs. dynamic vs. absent) × 2 (injunctive majority social norm appeal: present vs. absent) between-subjects experiment and watched an explainer video on voluntary carbon offsets that included various social norm appeals. Results: In both studies, we found that social norm appeals influenced perceived social norms. However, persuasive effects were only observed in the first study, and an injunctive majority appeal increased persuasive outcomes, but there were no differences between the descriptive conditions and no differences in their impact depending on individuals' environment related dispositions in either study. Discussion: A single exposure may be insufficient to exert persuasive effects and the change in perceived social norms may first need to be internalized. In online explainer videos, the effects of social norm appeals could be amplified by algorithm-based suggestions and when social norm appeals draw attention to norm-conforming content. However, further research is required on the long-term effects and their possible amplification via social media.

Couples, alcohol use and experience of intimate partner violence among young women in urban informal settlements in Durban, South Africa: A mixed methods study.

Alcohol is recognized as a driver of intimate partner violence (IPV) perpetration and experience, but relatively little research has focused on the role of couples' drinking patterns, nor pathways between alcohol and violence. We draw on data collected among young (18-30 year old) people living in informal settlements who self-selected to enroll in an intervention trial to reduce IPV in Durban, South Africa to understand these dynamics. Between September 2015 and September 2016 quantitative data were collected from women, who reported on their own experiences of IPV and alcohol use, as well as their partner's own alcohol use. To contextualise and interpret the quantitative results, we use qualitative data from women and men (who were not in relationships with one another) to understand potential pathways through which alcohol use may shape conflict in relationships. All forms of IPV (physical and/or sexual, emotional and economic) were more common among women where either, they alone had problematic drinking levels, their partner was frequently drunk but they did not have problematic alcohol use, or they had problematic alcohol use and their partner was drunk frequently. Qualitative data suggested women and men in relationships rarely drank together. Three potential ways in which alcohol use increased conflict and IPV: disinhibition, with women and men more likely to get into arguments and speak 'badly' to one another; the impact of men's drinking on relationships, including economic provision and providing emotional support; and, the close association between alcohol consumption and infidelity, with women's public drinking being particularly stigmatized and male partner's seeing this as a challenge to their authority and control. Interventions addressing the alcohol-IPV nexus need to also address male patriarchal control and alcohol's close association with infidelity and the impact on finances, as well as reducing alcohol use.

Associations of Social Factors and Self-Efficacy with Skin-Self Examination Intentions Among Hispanics at Risk for Skin Cancer and Their Preferences for Digital Interventions.

Skin cancer ranks as the most prevalent cancer in the United States. Over the past two decades, the incidence of melanoma, the deadliest form of skin cancer, among Hispanics has risen by 20%. Melanoma mortality rates are higher in Hispanics than in non-Hispanic Whites (NHW). Early detection of melanoma via skin self-examination may lead to diagnosis of melanoma at an earlier stage, when they are thinner, less invasive, and more easily treatable, resulting in improved survival rates. Given the gap in research addressing culturally relevant factors related to skin cancer prevention and detection among Hispanics and informed by the Preventive Health Model, this study tested the associations between social and normative factors and self-efficacy with thorough skin self-examination (TSSE) intentions and queried participants about their preferences for skin cancer-related interventions. Among respondents (n = 79), 55.7% were female (n = 44), and 89.9% held a college or higher degree (n = 71). Self-efficacy fully mediated the effects of descriptive norms, injunctive norms, and provider-patient communication on TSSE intentions among Hispanics. On average, respondents demonstrated considerable interest in participating in a skin cancer-related behavioral intervention using a mobile application (75.6%) and/or using WhatsApp (71.8%). These preliminary findings provide new insights for development of future digital skin cancer intervention programs among Hispanics targeting social factors, including social norms and provider-patient communication, and utilizing preferred digital tools.

Female Genital Mutilation in Ethiopia's Afar Region: Patterning, Drivers, and Decision-Making.

PURPOSE: To explore the patterning, practices, and drivers of female genital mutilation (FGM) in Ethiopia's Afar region. METHODS: This article draws on mixed-methods research conducted in 2022 in 18 rural communities in three districts of Ethiopia's Afar region. Survey data were collected from 1,022 adolescents and their caregivers. Qualitative interviews were conducted with approximately 270 adults and adolescents. RESULTS: The survey found that FGM remains practically universal (97% of sampled adolescent girls), and infibulation remains the norm (87% of girls). Most adolescent girls and caregivers reported that FGM is required by religion and should continue. When queried about the main reason for FGM, however, most cited culture rather than religion. Female caregivers and adolescent girls were more likely to report that FGM has benefits than risks; the reverse was true for male caregivers. Qualitative evidence suggests that even girls who are not reported as infibulated generally, and that the social benefits of FGM--especially regarding controlling girls' sexuality and facilitating their marriageability--are perceived to outweigh health risks. Where there are shifts in type of FGM, it is largely due to efforts of religious leaders who preach against infibulation and for "milder" types--and the growing scope of fathers to input into mothers' FGM decision-making and advocate for less invasive types. DISCUSSION: Eliminating FGM requires focusing on contexts where the practice is most invasive and progress is not yet visible. Given complex intrahousehold and intragenerational dynamics, this will necessitate engaging whole communities with sustained multipronged approaches to shift social norms.

Distinguishing fast change in social norms and slow change in personal norms in cooperative decision-making.

Psychological research on norms has shown that norms are highly relevant for individuals' decision-making. Yet, there is so far little understanding of how norms change over time. Knowledge about how norms change may help better understanding their potential for as well as limitations in guiding decision-making and changing behavior. The present work investigated change in individuals' cooperation norms. As an indicator of different underlying processes of norm change, the temporal dynamics of different types of norms were examined. It was assumed that participants' social norms are adapted quickly whenever the social situation changes, while personal norms change more slowly and gradually, abstracting part of the situational learning in interaction with one's personality. In an experimental study, participants played a repeated prisoner's dilemma game with artificial co-players representing a predominantly cooperative or uncooperative social setting, depending on the experimental condition. The condition was expected to affect slow learning of personal norms. Additionally, the cooperativeness of the social setting was varied repeatedly within conditions, expected to result in fast changes in social norms. Participants' personal and social norms were assessed throughout the game. As predicted, the temporal dynamics differed between norms with social norms changing quickly and personal norms more slowly. Personal norms strongly predicted behavioral decision-making and were predicted by situational and personality factors. Potential qualitative differences of the underlying norm change processes are discussed.

Social norms, vaccine confidence, and interpersonal communication as predictors of vaccination intentions: Findings from slum areas in Varanasi, India.

In recent years, India has seen significant improvements in childhood immunization, but rates among the urban poor remain stagnant. Disruptions during COVID-19 pandemic have created further challenges. This paper focuses on how social norms, vaccine confidence, and interpersonal communication independently and jointly affect vaccine intentions among caregivers of infants living in six slum areas in Varanasi, India. Data for this study come from the baseline assessments conducted before implementing the Happy Baby Program, an intervention to improve vaccination attitudes and intentions. In-person interviews (N = 2,058) were conducted with caretakers of children up to two years old. Analyses showed that interpersonal communication about vaccines, descriptive norms, injunctive norms, and vaccine confidence were each associated with intentions to vaccinate in both a bivariate and, except for injunctive norms, a multivariate model. In addition, we found significant interactions among these variables, suggesting that the roles of interpersonal communication and vaccine confidence attenuated the relationship between social norms and vaccination intention. Overall, our model explained 46.2 % of the variance in vaccine intention. Given the strengths of the relationships observed in this study, intervention strategies should focus on enhancing social norms and vaccine confidence to promote vaccination.

"The burden is upon your shoulders to feed and take care of your children, not religion or culture": qualitative evaluation of participatory community dialogues to promote family planning's holistic benefits and reshape community norms on family success in rural Uganda.

BACKGROUND: Family planning has significant health and social benefits, but in settings like Uganda, is underutilized due to prevalent community and religious norms promoting large family size and gender inequity. Family Health = Family Wealth (FH = FW) is a multi-level, community-based intervention that used community dialogues grounded in Campbell and Cornish's social psychological theory of transformative communication to reshape individual endorsement of community norms that negatively affect gender equitable reproductive decision-making among couples in rural Uganda. METHODS: This study aimed to qualitatively evaluate the effect of FH = FW's community dialogue approach on participants' personal endorsement of community norms counter to family planning acceptance and gender equity. A pilot quasi-experimental controlled trial was implemented in 2021. This paper uses qualitative, post-intervention data collected from intervention arm participants (N = 70) at two time points: 3 weeks post-intervention (in-depth interviews, n = 64) and after 10-months follow-up (focus group discussions [n = 39] or semi-structured interviews [n = 27]). Data were analyzed through thematic analysis. RESULTS: The community dialogue approach helped couples to reassess community beliefs that reinforce gender inequity and disapproval of family planning. FH = FW's inclusion of economic and relationship content served as key entry points for couples to discuss family planning. Results are presented in five central themes: (1) Community family size expectations were reconsidered through discussions on economic factors; (2) Showcasing how relationship health and gender equity are central to economic health influenced men's acceptance of gender equity; (3) Linking relationship health and family planning helped increase positive attitudes towards family planning and the perceived importance of shared household decision-making to family wellness; (4) Program elements to strengthen relationship skills helped to translate gender equitable attitudes into changes in relationship dynamics and to facilitate equitable family planning communication; (5) FH = FW participation increased couples' collective family planning (and overall health) decision-making and uptake of contraceptive methods. CONCLUSION: Community dialogues may be an effective intervention approach to change individual endorsement of widespread community norms that reduce family planning acceptance. Future work should continue to explore innovative ways to use this approach to increase gender equitable reproductive decision-making among couples in settings where gender, religious, and community norms limit reproductive autonomy. Future evaluations of this work should aim to examine change in norms at the community-level. TRIAL REGISTRATION: Clinicaltrials.gov (NCT04262882).

The EMERGE framework to measure empowerment for health and development.

RATIONALE: Women's empowerment is a UN Sustainable Development Goal and a focus of global health and development but survey measures and data on gender empowerment remain weak. Existing indicators are often disconnected from theory; stronger operationalization is needed. OBJECTIVE: We present the EMERGE Framework to Measure Empowerment, a framework to strengthen empowerment measures for global health and development. METHOD: We initiated development of this framework in 2016 as part of EMERGE - an initiative designed to build the science of survey research and availability of high-quality survey measures and data on gender empowerment. The framework is guided by existing theories of empowerment, evidence, and expert input. We apply this framework to understand women's empowerment in family planning (FP) via review of state of the field measures. RESULTS: Our framework offers concrete measurable constructs to assess critical consciousness and choice, agency and backlash, and goal achievement as the empowerment process, recognizing its operation at multiple levels-from the individual to the collective. Internal attributes, social norms, and external contexts and resources create facilitators or barriers to the empowerment process. Review of best evidence FP measures assessing empowerment constructs, social norms, and key influencers (e.g., partners and providers) show a strong landscape of measures, including those with women, partners, and providers, but they are limited in assessing translation of choice to agency to achievement of women's self-determined fertility or contraceptive goals, instead relying on assumption of contraceptive use as the goal. We see no measures on collective empowerment toward women's reproductive choice and rights. CONCLUSION: The EMERGE Framework can guide development and analysis of survey measures on empowerment and is needed as the current state of the field shows limited coverage of empowerment constructs even in areas which have received more study, such as family planning.