Bringing ethical thinking to social change initiatives: Why it matters

ABSTRACT

Norms-shifting interventions (NSI) seek to improve people’s well-being by facilitating the transformation of harmful social norms, the shared rules of acceptable actions in a group that prop up harmful health behaviours. Community-based NSI aim for incremental normative change and complement other social and behaviour change strategies, addressing gender, other inequalities, and the power structures that hold inequalities in place. Consequently, they demand that designers and implementers–many who are outsiders-grapple with power, history, and community agency operating in complicated social contexts. Ethical questions include whose voices and values, at which levels, should inform intervention design; who should be accountable for managing resistance that arises during implementation? As interest and funding for NSI increases in lower and middle-income countries, their potential to yield sustained change is balanced by unintentionally reinforcing inequities that violate human rights and social justice pillars guiding health promotion efforts. A review of 125 articles on ethical considerations in public health, social justice, and human rights–where NSI actions intersect–indicated little guidance on practice. To begin to address this gap, we propose ten ethical values and practical ways to engage ethically with the social complexities of NSI and the social change they seek, and a way forward.

KEYWORDS:

• Social change
• social and behaviour change programmes
• ethical considerations
• norms-shifting interventions
• ethics and health promotion

Introduction

Norms-shifting interventions (NSI) seek to improve people’s well-being by facilitating the transformation of harmful social norms – the shared rules of acceptable actions in a group that prop up harmful practices (Legros & Cislaghi, 2020; Mackie et al., 2015; Miller & Prentice, 2016; The Learning Collaborative to Advance Normative Change, 2017). While high-income countries have used NSI since the 1980s to promote social and health behaviour change, their use in low and middle-income countries only started to grow in the last two decades (Cislaghi & Berkowitz, n.d.) with the increasing evidence of the influence that social norms can have on people’s health. By their actions, NSI often address gender and other inequalities and the power structures that hold inequalities in place, which makes then particularly relevant as interventions to support the type of sustainable change envisioned in the 2030 Sustainable Development Goals (SDGs) of the United Nations.

While a range of NSI exist, from those seeking incremental normative shifts to those seeking disruptive shifts (Berhane et al., 2019; de la Sablonnière, 2017; Marcus, 2018); from those working structurally (Afolabi, 2015; Malhotra et al., 2019) such as initiatives to keep girls in school (Hagen-Zanker et al., 2017; Nanda et al., 2016) to those employing mass media such as campaigns to shift community norms about harmful socially-condoned practices (Arias, 2019; Marcus & Harper, 2015), this article focuses on community-based NSI, which typically use safe spaces and critical reflection to create and reinforce new and existing positive norms that are rooted within the already-existing values of that community (Institute for Reproductive Health, Georgetown University, 2019; The Learning Collaborative to Advance Normative Change, 2017). Such NSI generally aim for incremental normative change at a community level versus social change at a societal level. Within programmes, these NSI complement social and behaviour change (SBC) strategies that address other individual, social, material, and institutional factors.

As interest and funding for NSI increases in lower and middle-income countries, we hold the promise of their potential and a sense of unease as to how NSI are designed and implemented. Non-governmental organizations (NGOs) often engage in NSI design without recognising the power differential between better-resourced organisations and lesser-resourced communities who ‘receive’ the project and can inadvertently drown out local voices. Communities also represent a very heterogeneous mix of stakeholders organised by economic, social, gender, age, and other statuses representing different levels of power and influence. The question of power is an important one for designers and implementers, as community outsiders, to grapple with before and during implementation. An example: An NSI designed by an international NGO aims to shift a widely-held norm relating to child marriage, a child rights-focused behaviour change of interest of the central government and funding agency but not necessarily an interest of local government administrators, community leaders, and families including young girls who value early marriage as a way to maintain family legitimacy and protect the girl child from illegitimate encounters with men in their community. In such realities, whose voices and values, and at which levels, should programmers take into account when designing interventions? Who should decide which norms to promote and which strategies to employ? Who should be accountable for managing resistance and backlash that often arise? As implementation occurs, should an organisation implement an NSI knowing that there exists a risk of participants perceiving change as externally driven, moving too fast or too soon, resulting in change agents or early adopters suffering? And, it is not possible to fully anticipate and monitor resistance during implementation. These ethical challenges necessitate deliberation and thoughtful planning and implementation decision-making.

Our conversations and collaborations with international and local NGO partners working on NSI to improve community health have raised concerns about the risk of projects doing harm while trying to do good. Without clarity on what bringing ethical thinking into NSI means and how to engage with ethics, there are limited ways to understand if we are considering the key ethical questions, whether outside NGOs are engaging with communities with the same framework, and what should guide decision making. Consequently, the achievement of the 2030 SDGs may be limited by programmes that unintentionally exacerbate the real challenges the SDGs seek to address.

We hope to spark conversations that can raise our field’s awareness of the need to engage with the ethical questions that arise in the design and implementation of NSI and to set a foundation for the development of practical tools and guidelines. This paper aims to fill a gap by reviewing ethical guidance in different fields, proposing a set of values for outsider organisations to more systematically inform NSI practice, and offering ideas and actions that illustrate the integration of ethical decision-making in the design and implementation of NSI. We want to provide a practical way to think about how to engage ethically with the social complexities of NSI and the social change they seek.

What can we learn from those exploring health programming from different ethical lenses?

In their work to engage and shift power dynamics and address social inequalities, NSI work at the intersection of public health, human rights, and social justice. Each of these domains derives from different and often overlapping, health and human development philosophies. Understanding ethical reflections in each can guide NSI moving forward.

We conducted a literature review in the three domains to identify frameworks and practical guidance in applied ethics to guide work in NSI. The non-systematic review, conducted in 2018 using Pubmed, Google Scholar, and Google included various fields: norms-focused interventions, bioethics, public health, health promotion, social marketing, social and behaviour-change communication, medical anthropology, participatory research, social work/community organising, women’s empowerment programmes, and humanitarian programmes. It used predetermined search terms listed in Box 1. The review yielded 125 articles. The goal was not to provide a review of the state of the field, but to draw on deeper ethical thinking and action to inform our work on ethics and NSI. As a result, the review started with an annotated bibliography. Articles that were potentially most relevant for NSI understanding and programme action were reviewed in full. Most articles in the annotated bibliography came from the public health and health promotion literature, and most discussed ethical issues without engaging in applications that could be used by designers and implementers. One dozen offered different frameworks, but most frameworks remained at a conceptual rather than actionable level. Our observation is that there is little practical guidance for ethical decision-making at the programme design and implementation level despite conceptual reflection on the relevance of ethics to programme implementation.

Box 1. Literature review search terms.

Table

‘social norms’ AND ethics ‘social norms intervention’ AND ethics ‘social norms intervention’ ‘social norms change’ AND ethics ‘normative change’/norms-shifting/norms-focused AND ethics ethics AND norms ‘normative change’ AND ethics ‘norms-focused’ AND ethics ‘norms-shifting’ AND ethics ‘social change’ AND ethics ethical norms cultural dilemma ‘community norms change’ AND programme ethics ‘social norms’ AND ethics ‘social norms change’ AND ethics ‘social norms interventions’ AND ethics critique of ‘social norms interventions’ philosophy and ‘social norms interventions’ ‘normative change’ AND ‘programme ethics’

‘normative change intervention’ AND ethics ‘ethical framework’ AND programme ‘women’s empowerment’ AND ethics ‘community organizing’ AND ethics ethics of fostering cultural change controversies in normative change interventions/programmes normative and behaviour change and ethical controversies ethical issues and social change ‘social norms change’ AND ethics critique of ‘social norms interventions’ philosophy and ‘social norms interventions’ ‘social behavior change’ AND ethical considerations ‘social and behavior change communication’ AND ethics Social and behaviour change AND ethical challenges

In this section, we focus on a subset of the articles in the three domains that we found particularly relevant to developing an ethical framework for community-based NSI, identifying a common set of values that we can use for social and behaviour change programming. Of note, each domain has challenges in finding the balance between individual and community, the critical programme intersection of NSI. Still, much can be gleaned to guide NSI decision-making; key points are summarised below.

Public health ethics applied to SBC

Social and behaviour change approaches (falling within the broader field of health promotion) seek to change attitudes, perceptions, norms, and practices that affect health and well-being. A multidisciplinary field informed by communication theory, social psychology, anthropology, and behavioural sciences, SBC employs multiple strategies (e.g. awareness-raising, media campaigns, norms transformation) to achieve improved health and well-being and prevent illness. Ethical questions underpinning SBC programming fall under two areas: ‘Does it indeed promote people’s health? Whom does it benefit (e.g. is the benefit distributed fairly? does it contribute to equity?)’ (Guttman, 2017, p. 5). In responding to such questions, the SBC literature often summons ethical values (Guttman calls them principles in the article) guiding public health programming; five, which are particularly relevant to NSI and presented below:

1. Doing harm includes the possibility of ‘directly or indirectly harming individuals or communities, whether on a physiological, psychological, social, or cultural level’ (Guttman, 2017, p. 5).

2. Doing good encompasses the obligation to actively pursue ‘means to help individuals and communities to reach a positive state of health or by preventing them from being endangered by risks and potential harm’ (Guttman, 2017, pp. 5–6).

3. Respecting people’s right to privacy and autonomy is grounded in self-determination, respecting that one person’s decisions should not bring harm to others. A common critique of this principle is it does not adequately account for the values of family, community, and social well-being that influence and are influenced by autonomy and where autonomy is balanced by these family, community, and social values.

4. Choosing issues and obtaining consent is more commonly applied in research and medical care, despite the direct engagement that health promotion has on individuals and communities. SBC efforts to engage with this principle could include understanding who represents communities and should be involved in prioritising issues, goals, and strategies.

5. Effective and efficient health promotion to benefit the most people in outcome and cost. This principle raises some challenges, including to what extent are effectiveness and efficiency sufficient considerations for determining health promotion priorities.

These five values can guide questioning, reflection, and ethical decision-making for public health, SBC, and NSI. For example, doing good and not doing harm encompass obligations to both the individuals implicated in programme activities as well as the family, community, and societal levels where others are affected directly or indirectly by the programme (Beauchamp & Childress, 2013; Guttman, 2017). Yet sometimes NSI, and SBC initiatives more broadly, prioritise the individual right to privacy and autonomy without considering how local communities weigh the individual benefit compared to collective benefits. When strategies to shift norms and the consequences of implementing NSI create harm in the short term (e.g. stigmatising early adopters and positive deviants, challenging tradition and identity) but result in the behavioural outcome of interest in the long term, how do programmes weigh these factors? How much does programme cost matter as compared to equity? How should project resources, opportunities, benefits, and risks be distributed while accounting for multiple, intersecting inequities that underlie relationships and behaviour?

Human rights ethics applied to public health

Gostin (2001) proposed three domains of ethics and public health: the ethics of public health (i.e. professional ethics), ethics in public health (i.e. applied ethics), and ethics for public health (i.e. advocacy ethics). We consider NSI most closely related to ethics in public health, which concerns the ‘ethical dimensions of the public health enterprise, the moral standing of population’s health, trade-offs between collective goods and individual interests and social justice’ and requires careful thinking and decision-making in creating and implementing public health policy (Gostin, 2001, p. 124). Gostin describes ethical questions in public health as including: How can society equitably distribute benefits and services on the one hand, and burdens on the other?

Jonathan Mann brought human rights and ethics into the forefront of public health. From Mann and others, human rights are a grounding value of public health informing, for example, how we envision the scope of the field, make decisions, identify and prioritise solutions, engage with partners, seek equity and evaluate our work. Mann argued that the promotion of human rights, including the importance of treating people with dignity and respect as essential to, and not separate from, health and well-being (Gostin & Powers, 2006; Mann, 1997). Ethics and human rights have not been sufficiently challenged to address values of community, mutual security, and solidarity, all of which are principles that enter into question with SBC, including NSI. The introduction of human rights to public health (including SBC programming) has brought forward the values of dignity and respect as central elements of such programmes. The rights and obligations language of human rights has been criticised as too grounded in Western moral principles and social structures that value the individual over the community, without accounting for how equity and access limit autonomy (Hickey & Mitlin, 2009). This issue of Western world view extends to how Northern and other outsider NGOs can hold power over communities, at the expense of local values, views and desires. Inequitable access to relationships, resources, decision-making and a world view of how things should work often determines directions in programme design and implementation. Guidance remains inadequate in the ways that ethics fits within these discussions and how programmatic decisions can be made when ethics, human rights, and health are not easily aligned. Implementers are challenged to ask ethical questions and engage with identifying and redressing power imbalances that directly affect individual well-being and illness.

Social justice ethics applied to public health

Social justice is considered a core value of public health (Gostin & Powers, 2006) and thus should guide how organisations design and implement programmes. Many definitions of social justice exist, including ‘justice in terms of the distribution of wealth, opportunities and privileges within a society’ (‘Social Justice’, 2020) and fair and equitable treatment of people (Ruger, 2004). Social justice, in part, brings an obligation to understand and address the root causes of health, behaviour, and well-being. In doing so, projects seeking health improvements have an obligation to look at elements of the social environment that influence individual and social well-being, including social norms and the various pathways in which they are developed, upheld, enforced, and influence health and well-being. Social justice forces an initial and ongoing examination of how benefits and burdens are distributed across peoples, considering their prior advantage and disadvantage. Though justice and equity are core principles to SBC programmes, there is not enough attention paid within the domains to how these programmes may inadvertently create or reinforce inequities.

NSI directly engages with these issues, for example, by seeking to transform power and voice in communities. How these programmes do this, who is engaged in the challenges seen during a process of change, whether benefits and burdens are justifiable, and how they may shift significantly throughout the programme life cycle, are evident in norms-shifting programming. Yet, the lack of a commonly-accepted framework to engage with this thinking in the design and implementation of NSI limits our ability to understand whether and how we may be increasing equity and justice or exacerbating inequity and injustice.

Where does this leave norms-shifting interventions?

NSI work at the intersection of individual and community. They aim for social and norms change, while uplifting individual and group agency and shifting power dynamics for equitable relationships. NSI address the root causes of behaviour; their effects last beyond the lifetime of projects. The literature review summarised above shows a set of shared ethical concepts operating across public health, human rights, and social change that can guide NSI design and implementation. It also reveals that the direct application of any one domain is not sufficient to address the ethical challenges of NSI. In the next section, we draw from public health, human rights, and social change reflections and propose how ethical thinking can guide NSI design and implementation.

Getting practical: Embedding ethical thinking into NSI design and implementation

The nature of social change and the range of NSI project aims, strategies, and social contexts are too diverse to provide prescriptive ethical guidance. Instead, in this section, we offer a practical way forward to be explicit about ethical thinking during project design and implementation.

Ethical thinking is ‘the process of analysing and understanding multiple connected variables in a changing context AND applying ethical values to make responsible choices. It requires doing the work to understand issues clearly before making decisions or taking actions that are ethical’. (Thornton, 2019)

Ethical thinking is concerned with the application of values (Fawcett, 1991), in particular, using values to inform how we make decisions and what decisions we make.

Values are ‘our guidelines for living and behaviour. Each of us has a set of deeply held beliefs about how the world should be. For some, that set of beliefs is largely dictated by a religion, a culture, a peer group, or the society at large. For others, it has been arrived at through careful thought and reflection on experience and is unique. For most of us, it is probably a combination of the two. Values often concern the core issues of our lives: personal relationships, morality, gender and social roles, race, social class, and the organization of society, to name just a few. [Community and norms-change work are founded on deeply-held beliefs and values:] Devotion to democratic process, to equity and fair distribution of resources, to the obligation of people to help one another – these all come not from logic or scientific experiment, but from a value system that puts a premium on human dignity and relationships’. (Center for Community Health and Development, University of Kansas, n.d.)

These definitions seem straightforward, yet considering ethical values in programme contexts is complex. There are multiple ethical decision-making points, and how one reflects on decisions may shift over time. An NSI interacts with many actors and groups. Communities and outsider organisations, and different social groups within communities, may interpret an NSI aim and strategies through different value systems. Without structured reflection, people often do not know or are not able to explicitly state the values guiding their actions. This leads to situations where Northern NGOs or other financed organisations assuming their intentions to do good are sufficient, without considering the perspectives, values and needs of local populations and organisations and how these views may inform programme focus and strategies. These Northern and other outsider organisations hold power over, justifying their approach as focused on achieving good, without considering that local communities are more deeply invested, now and long term, in doing good for their community. Therefore, how to engage in these relationships and how programmes are designed and implemented are essential. Dialogue and negotiation with community stakeholders and NSI designers and implementers can include discussion of values systems, aiming for agreed-upon values for moving forward. This approach, referred to as hybridity, recognises the need to appreciate and reflect on different values and value systems of a range of stakeholders before reaching a compromise in the design of NSI (Bukuluki, 2013a, 2013b). As outsiders, we can start to systematically and intentionally apply ethical thinking and actions guided by our values and the values expressed by communities with which we engage, and an understanding of community power structures. The risk of not engaging in hybridity-type approaches is that we incorrectly assume common values, and make assumptions about priorities and the value internal and external stakeholders give to different strategies and decisions. Skipping over this risks harm and may exacerbate inequities on a larger scale.

Ethical thinking in designing NSI: Avoiding ethical centrism. Seeing new possibilities of acting in values-informed ways

NSI design involves multiple levels of decision-making – from defining project outcomes; to whom to involve as partners and beneficiaries versus who not to involve; to defining outreach strategies to engage communities in critical reflection on what is versus what could be (often normatively- defined); to developing activities and materials that lead to new ideas and behaviours that can serve as catalysts to normative shifts. These decisions interact with project management considerations of effectiveness and efficiency, ease of implementation, and community acceptability. Our own experience in past and current projects (including Tékponen Jikuagou in Benin, Belle Bajao! in India, GREAT in Uganda, and current collaborations via the global Passages Project and Learning Collaborative to Advance Normative Change) has shown the challenges of articulating which outcomes are essential, which norms are important for behaviour change in a specific population, and whom to engage in a change process, are not always clear. For example, in family planning programming, are we more interested in addressing unmet need or increasing uptake of family planning? This choice directly influences how the programme seeks to achieve change. Ethical thinking brings to light some of these challenges and forces us to explicitly engage with this challenge rather than assume agreement.

Several issues unique to NSI pose questions on the parameters framing high-level programme design questions. What is the common good being sought (in the case of NSI, what are the specific behaviours and social norms to address in SBC projects)? Do priorities shift, depending on your role or position, such as organisational affiliation, group identity? Who decides which social norms to address (for example, who represents ‘community’ in NSI programme design)? To what extent is a programme design a participatory process, and who is involved or not in this process? Thus, an overarching challenge in the NSI design process is how to move away from ‘ethical centrism’ where one perspective dominates (Unnithan-Kumar, n.d.) and allow multiple viewpoints and hybridity approaches to the design table.

Defining a set of shared values about how we make decisions can help guide ethical thinking during the community assessment and project design phase. We suggest designers create spaces to engage community members as part of formative assessments and, when possible, in strategic decision-making during the definition of key project parameters and strategies. Incorporating values that expand the design environment – such as inclusiveness, openness, reasonableness, responsiveness, and responsibleness – brings in the level of complexity analysis needed for formative assessments and NSI design decisions. How outsider organisations communicate and interact with receiving communities and other stakeholders can clarify expectations and engagement and lay the foundation for project implementation. Actions guided by explicit attention to and discussions about values can build trust and demonstrate transparency to stakeholders. These efforts can assure people that the organisation implementing the NSI has integrity and holds a common belief about a common community good, even when universal agreement on decisions is not achieved.

Of course, the challenge of developing guidance for ethical thinking starts with identifying common values that have meaning for different levels and types of stakeholders and beneficiaries. We offer operational definitions for ten values, adapted from the New Zealand National Ethics Advisory Committee document, Getting Through Together: Ethical Values for a Pandemic (National Ethics Advisory Committee, 2007). Of the dozen ethical frameworks identified in the literature review, the New Zealand work was most applied and programme-practical. The New Zealand document focuses on values guiding how we make ethical decisions and what decisions should be made. We have further grouped values by how we make ethical decisions during a design phase, and what decisions are needed to manage/mitigate social change during implementation, well aware that the ten values below operate at all points in a project cycle. The values highlighted in the New Zealand document also offer some level of universality: They are recognised across cultures in New Zealand and, in our own experience, are common to different cultures.

Table 1. Five values that can guide how to make ethical decisions during NSI programme design.

Inclusiveness	Including those who will be affected by the decision Including people representing all cultures and communities Taking everyone’s contribution seriously
Openness	Letting others know what decisions need to be made, how they will be made and on what basis they will be made Letting others know what decisions have been made and why Letting others know what will come next
Reasonableness	Systematically considering alternative options and ways of thinking Being conscious to reflect cultural diversity Using a fair process to make decisions Basing decisions on shared values and best evidence.
Responsiveness	Being willing to make changes and be innovative Changing when relevant information or the context changes Enabling others to contribute whenever we (and they) can Enabling others to challenge our decisions and actions.
Responsibleness	Acting on our responsibility to others for our decisions and actions Helping others to take responsibility for their decisions and actions.

Source: Adapted from Getting Through Together: Ethical Values for a Pandemic from the New Zealand National Ethics Advisory Committee.

Table 2. Five values guiding ethical decision-making during NSI implementation.

Do good; Minimise harm	Helping individuals and communities attain good health, minimising risks and potential harm Not harming other individuals or groups Protecting one another from harm
Respect	Recognising that every person matters and treating people accordingly Supporting others to make their own decisions whenever possible
Fairness	Ensuring everyone gets a fair go Prioritising fairly when there are not enough resources for all to get the services they need Supporting others to get what they are entitled to Minimising inequalities.
Reciprocity	Helping one another Acting on any special responsibilities we may have, such as those associated with professionalism or outsider project status (power of holding resources) Agreeing to extra support for those who have extra responsibilities in catalyzing social change.
Solidarity	Working together when there is a need to be met. Showing our commitment to strengthening individuals and communities. Helping and caring for our neighbours and friends Helping and caring for our family and relations

NB: The terms in the left-hand column are often cited as follows in the ethics literature: Do Good ≈ Beneficence; Minimise Harm ≈ Nonmaleficence; Respect ≈ Autonomy to Make Free Choice; Fairness ≈ Justice and Equity; Reciprocity ≈ Interpersonal Caring and Connectedness; Solidarity ≈ Community Connectedness.

Source: Adapted from Getting Through Together: Ethical Values for a Pandemic from the New Zealand National Ethics Advisory Committee.

For NSI design, then, we propose five values that can inform how to make design decisions (Table 1). Immediately after, are some ideas for action that may be useful to those charged with design in contexts where outsider NGOs or other entities lead the design process.

What might this mean for practice? The unique characteristics of NSI imply a need to expand formative assessment frameworks from exploring technical gaps and individual needs to exploring value systems and social and power configurations across the socio-ecological levels.

• An ethical lens would engage stakeholders in negotiations on core values that may be commonly held.

• Widely-used assessment can be adjusted, such as participatory approaches to engage communities in analysing their health issues and norms that negatively impact health, to create foundations of transparency and equity in which to embed ethical reflection within the design phase. An ethical lens would insist that the assessment includes important voices, including more marginalised groups.

• NGO designers would vet alternative strategies to influence normative factors with communities.

• As designs are being finalised, internal checks on who is included as participants and who is not, and which power structures are most affected, would be done.

The case study below from Breakthrough-India, a human rights organisation seeking to make violence and discrimination against women and girls unacceptable, shows the kinds of ethical decisions that designers grapple with when working in the normative space.

Case study: Designing Bell Bajao!, a gender-transformative NSI to engage people in questioning and acting to prevent domestic violence

In many parts of the world, domestic and other forms of violence are accepted, unquestioned behaviours, and viewed normatively as a mechanism of discipline and control. Bell Bajao!, implemented by Breakthrough-India from 2008 to 2011 and then expanded, illustrates ethical decision-making during the design phase. Bell Bajao! sought to make domestic violence unacceptable and aimed to include men as part of the solution. To disrupt the prevalent binary of men as perpetrators and women as victims, Bell Bajao! asked men to play a role in challenging violence, moving away from dominant frameworks of masculinity and machismo. In a context where men had great power over their spouses, the design of Bell Bajao! incorporated values of inclusiveness and responsibleness at community and organisational levels, and dignity and respect toward communities, while seeking social justice and a shift in power dynamics.

Bell Bajao!’s design drew on existing action research, which by definition, engages communities in understanding and analysing issues and can incorporate hybridity approaches. Exploring social norms and community behaviours around domestic violence, including why people were afraid to report cases to authorities, staff learned that there was a surface-level understanding of what constituted domestic violence. Many thought it was limited to physical violence and mental abuse. The community’s belief in the realm of possible actions to prevent domestic violence was equally restricted. Domestic violence is considered private, and even if family and friends know about it, they are unlikely to interfere. Many thought intervening would lead to new issues and personal harm, and when intervening actions did occur, they were often by men.

In the initial design phase, staff debated how to engage men while creating space for women without harming women in the process. The staff’s power analyses led to ‘do no harm’ decisions about locations for project activities, including community mobilisation efforts. For example, it is acceptable behaviour for men to inhabit certain public spaces, including online social platforms, but not acceptable for women. Would women occupy such public spaces if they were invited to do so? Was there a way to create women’s spaces without stigma and male reproach? The discussion check-ins with community members and subsequent design decisions ensured the Bell Bajao! project would not inadvertently reinforce power structures or put women at higher risk of violence than before.

Another design decision related to oral and visible language to convey new normative behaviours. Bell Bajao! carefully used video and other media campaigns and interpersonal activities to break the silence around private behaviours. The video campaign was conscious to not reduce women to roles of powerless victims with men as saviours. It intentionally avoided typical images of who can be a perpetrator, for example, ensuring the key male protagonist who rang the bell was not perceived as using stereotypical ‘assertive male’ behaviour. The act of ringing a physical bell in a community was seen as an immediate intervention of an incremental norms-change effort to end violence and create a community-wide norm that the community can hear and that DV is not acceptable and not private.

Project monitoring during implementation allowed staff to see if their design choices were working as planned, creating good and minimising harm during a process aiming to shift normative expectations of women and men.

                       (S. Khan, personal communication, January 9, 2020)

Ethical thinking in NSI implementation: Expecting social pushback and unexpected effects. Taking values-informed positions as outsider organisations

As implementation gets underway in complex social systems with embedded power structures, the unique capacities of an NSI to catalyse normative and power shifts lead to expected and unexpected pathways of community reaction. Experience shows that communities can take off with an idea and move forward actions either to further or inhibit those who wish to further it (that is, sanction them). Project staff and other community stakeholders may quickly find themselves in catch-up mode and need to be ready to support or mitigate such reactions. Attention to previously defined values can promote ethical decision-making during implementation.

Because they aim for normative change, an issue unique to NSI implementation is how to manage and mitigate social pushback or opposition or resistance, which often emerges when social change efforts begin. For example, adolescents engaged in club-based family life education that includes contraception information may be punished by their parents (e.g. forced to leave the club) who fear the information will lead to sexual experimentation. Frontline workers may be confronted or ostracised by community leaders and parents (e.g. verbally abused or socially condemned) for daring to discuss taboo family planning topics with young people. Since those who experience social pushback are often those individuals or groups who, early in a change process, deviate from the accepted norm, what are project and community ethical responsibilities for risk management and standing in solidarity when social pushback emerges?

Likewise, sometimes actions viewed as positive by some may lead to new inequalities. What should be project and community ethical responsibilities when project-catalysed change actions inadvertently create new harms or diminished goods? For example, creating a community bylaw to sanction child marriage by imposing fines on families may seem favourable to local leaders. Families who view child marriage as the only way to protect a girl-child from harm may take the practice underground to escape sanctions and perpetuate the practice but perhaps in increasingly-risky ways.

In complex contexts, social change is not linear, and the ricochet effect that often accompanies NSI implementation should be monitored regularly to provide information on changes, including unintended negative consequences that occur. Projects should conduct regular environmental scans to monitor the changing environment via regular feedback meetings between project staff, frontline workers, and other community stakeholders. As new issues emerge, returning to project values can be helpful during deliberations of how to support/mitigate in ethically-considered ways the new effects of social change processes.

Defining a shared set of values can guide what decisions are made vis-a-vis emerging social changes throughout the NSI implementation cycle. In Table 2, below, are five values from human rights and social justice domains. These values include operational definitions from the guidance document, Getting Through Together: Ethical Values for a Pandemic (adapted from the National Ethics Advisory Committee, 2007). Just after, are a few ideas on how to practically incorporate ethical values during NSI implementation.

What might this mean in practice? Implementers can anticipate social pushback and expect other unanticipated social change that requires a reaction, whether mitigation or direct support.

• Projects can do scenario planning in advance to determine potential project responses informed by ethical values before pushback or new ethical issues emerge.

• Organisations can prepare staff for the work of fostering change, including organising personal values reflection sessions. Do they understand their power and privilege? What are the project staffs’ position vis-à-vis behavioural and normative shifts of the NSI? How do staff see the normative beliefs and moral paradoxes lived by communities and themselves? For example, how do staff understand unmarried youth learning about family planning vis-a-vis adults wanting to protect young people from potential harms? Both sides aim to prevent life-altering consequences of unwanted pregnancy and sexually-transmitted infections.

• Who is accountable to communities when pushback is harmful, such as frontline workers being menaced by those opposed – the project, community elders, local government? An ethical lens would allow safe spaces to reflect on how the direction of resulting actions and how they might reinforce power rather than move towards its redistribution. Early discussions and debate around values that are widely shared among all those who may be affected can clarify where accountability lies.

The Breakthrough-India case study below shows what kinds of ethical decisions implementers might grapple with in response to opportunities and potential social pushback.

Case study: Stand with me. Be my safe space: Being ready for the unexpected during NSI implementation

The positive learning experience of Bell Bajao! led Breakthrough-India to explore the prevention of sexual harassment experienced by young people. The Stand With Me. Be My Safe Space campaign used media and interpersonal dialogue strategies, and was underpinned by values of openness and inclusiveness found in the NSI design, and by values of fairness and solidarity during implementation through non-judgmental dialogues with young people. The project incorporated a flexible implementation approach of listening-learning-acting that allowed real-time ethical decision-making to be integrated into the programme to allow flexibility to address new issues as they emerged.

In the early phase of project implementation, discussions with youth initially focused on violence against girls and transgender youth. Over time, these discussions served to open new understandings of who experienced violence and why. A critical project milestone occurred when the Project Director (Sonali Khan) created a ‘safe space’ herself. In a college-wide discussion in Haryana that explored how girls experienced harassment and what should be done to stop it, the auditorium was divided into two, with girls on one side and boys on the other. When discussing who was most affected by harassment, Khan asked boys on their side of the room whether boys needed to stand up to support girls and transgender youth. There was silence; it was clear that something was not being acknowledged. Instead of emphasising the effects of violence on girls and transgender youth or pushing boys to respond, Khan allowed youth to shift the focus of the conversation without ignoring the issue. Later, Khan raised the issue of violence again. Suddenly the energy in the room shifted. Girls spoke up for boys, acknowledging the unspoken issue of sexual violence that boys face. After the event closed, boys joined girls to talk with Khan to share how they had experienced violence. The safe, inclusive space allowed girls and boys to confront, with respect and reciprocity, the powerful normative belief of machismo and the inviolability of boys. The taboo subject now broken, programme implementers moved on this new understanding. A new film-discussion series on violence against boys, underpinned by values including respect and reciprocity, allowed for discussion and subsequent actions to prevent violence against boys and girls and transgender youth.

The Haryana college dialogue was possible because Breakthrough-India created organisational spaces for staff to grapple with norms-transformation. For example, during monthly meetings, staff were asked, ‘How does it feels to walk in the shoes of the people who perpetrate a harmful norm? What about those who experience the effects of that norm? How does it feel to be the person who chooses to behave against a norm? What are their intentions, compulsions, and desires for themselves and their families?’ Breakthrough-India aimed to create an organisational culture based on humility, solidarity and negating us-them dichotomies, building a set of shared values that supported staff ethical actions in the field. These reflections strengthened the programme’s ability to engage in ethical decision-making.

                         (S. Khan, personal communication, January 9, 2020)

More field-tested tools are needed that incorporate an ethical lens in the NSI design and implementation toolkit. Tools should assess the normative environment and its links to behaviour, analyse community power structures concerning health practices, and assess the agency and capacity of communities to absorb planned social change efforts and effects (Igras et al., 2019). Existing tools could be modified for broader applications. For example, gender-transformative and gender-based violence projects already have values clarification tools for use by project staff. Environmental scanning and adaptive management techniques exist, although not widely used and not necessarily adapted for monitoring and adjusting implementation in response to social change. To our best knowledge, practical guides for ethical decision-making do not exist yet.

Conclusion and a way forward

This article raises crucial considerations in designing and implementing NSI. We argue that an ethical frame is a needed and valuable contribution because, without one, programmes may be reinforcing or creating power structures, inequities, and harm that violate the human rights and social justice pillars that guide health and other social development efforts. Working ethically insists on sensitivity to power and substantive community engagement, to monitoring for unintended and intended effects and allowing programme flexibility to make adjustments mid-course. This need is even more significant as more outsider agencies have an interest in working with normative issues but are not attuned to power, history, and community agency and capacity to engage in sensitive issues. There is a need for real-life case studies highlighting the kinds of ethical issues and decision points that arise with NSI. We need additional tools such as formative assessment tools to analyse community power structures and community capacity to absorb social change.

As NSI programming grows, we need to move the social and health behaviour change sector and other sectors working for social development to the level of consciousness that changing norms can be powerful while recognising normative shifts in one direction can affect how other norms operate or play out in the same community in different directions. Ethical thinking and the integration of ethical values is essential to NSI as it provides guidance that can contribute to building community social capital and contribute to health and SDG achievements.

While we have focused on the community and organisational levels of the social development ecology, there is more thinking to be done by institutional donors about how they support NSI efforts. It is not only a matter of allowing flexibility for programming in complex settings and longer project duration but also responsibleness in how resources are used in NSI design and implementation and the integration of ethical thinking.

We have an opportunity to engage more deeply with the values underpinning public health, human rights, and social justice as part of an SBC framework for norms-shifting programming. These domains can deepen our understanding of how we think about and capture the dynamism of the continuous changes in local and global contexts, and how we use hybridity to bridge different world views and values through partnerships. To that end, we have proposed a values-based approach that can be used by NSI more generally. We need more systematic embedding/conscious inclusion of ethical decision-making as NSI move into mainstream SBC programming, both in their design and implementation.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This writing of this article and related background research were supported under USAID [grant number AID-OAA-A-15-00042]; Passages Project