How Do Social and Behavioral Change Interventions Respond to Social Norms to Improve Women's Diets in Low- and Middle-Income Countries? A Scoping Review

"There is increasing, although still limited, integration of social and gender norms perspectives in the design, implementation, and assessment of interventions to improve women's diets..."

Although financial resources and food security (or lack thereof) have long been recognised as determinants of an individual's dietary intake, social and cultural factors related to gender roles and women's status in households, communities, and societies, such as family support, are increasingly considered in health and nutrition social and behaviour change (SBC) interventions in low- and middle-income countries (LMICs). Norms may support or constrain uptake of recommended evidence-based nutrition behaviours. For example, the expectation that women be provided with nutritious diets or "special" foods during pregnancy or postpartum is a positive norm. Perceptions that women should sacrifice their own nutrition for the sake of other family members create norms that negatively influence women's diets. This scoping review identifies and describes SBC interventions designed to improve women's dietary practices and nutritional intake that integrate the influence of social and gender norms.

The researchers systematically searched 4 databases (Scopus, Web of Science, PubMed, and CINAHL) for peer-reviewed articles describing design, implementation, and/or assessment of nutrition interventions in LMICs that were published between January 1990 and August 2023 and written in English. The review identified 27 relevant articles from 25 projects or research studies describing intervention approaches designed and/or implemented in sub-Saharan Africa (n = 9) and Asia (n = 16). The majority focused on the pregnancy and lactation periods, and a few aimed to reach all women of reproductive age.

The researchers summarised the range of social norms addressed in the articles by grouping norms into 2 categories: food-focused social norms and gender norms. These categories overlap. Food-focused norms included those related to food selection or choice, food quantity, and perceived value of foods. Gender norms includes those related to women's roles and household decision making, intrahousehold food allocation, and ideals and expectations related to gender.

Interventions covered in the review most often endeavoured to shift norms through multiple activities, channels, and platforms, aiming to reach not only the primary participants but also influencers and reference groups. Intervention approaches ranged from home visits and support groups to engage influential family members to community-level outreach with opinion leaders such as religious leaders, healthcare workers, and peer change agents. Most interventions were delivered through the health sector or were community-based, with some nutrition-sensitive agriculture interventions.

All except 4 interventions referred to a programme framework, theory, or conceptual model. Ten of the interventions were based on SBC or systems theories, such as the theory of normative social behaviour, family systems theory, and the socioecological model. Only 2 projects or programmes used the same model (Theory of Planned Behavior). Eleven interventions applied programme frameworks, including theories of change and programme impact pathways that included the influence of norms as a determinant on behavioural intention.

To identify sociocultural beliefs and practices, 16 of the 27 articles in the review described conducting formative research. Most used focus group discussions and/or in-depth interviews, and other methods included participatory activities (e.g., drawings, vignettes, voting, transect walks), trials of improved practices, and surveys. Such research helped authors of the reviewed studies to identify family and community members who were influential in defining and enforcing norms, as well as food customs for women, for example.

Although the reviewed studies described interventions designed to shift or build on social norms, there was wide variation in the assessment of norms and methods used to evaluate if or how norms changed over time. As this was a scoping review, summarising data on effectiveness was not a key objective. To guide future work, however, it is notable that, while 14 of the 25 projects measured norms as a process or final outcome, only 9 assessed changes in social norms related to women's dietary practices. For example, one project reported that recognising and encouraging grandmothers and other elders to support women's nutrition led to changes in community norms related to nutrition during pregnancy. Sometimes, intervention effectiveness in shifting harmful norms was limited by the challenges of engaging key influencers and reference groups; one study found that improved nutrition knowledge and attitudes of women in postpartum did not translate to behaviour change without more engagement of female elders.

Reflecting on the review's findings, the researchers note that the potential harm of advising women to eat better when they lack the family and community support to do so should be considered as part of programme design (in consultation with community members) and monitored during implementation. Because social norms are embedded within institutions, change may be needed at the level of laws and policies, as well as among communities and individuals, to effectively shift "meta-norms".

Future research and programmes that address norms can focus on filling key knowledge gaps. These gaps include, for example, understanding the multiple pathways of influence between social and gender norms and women's diets and the effect of different intervention approaches on these pathways. Knowledge development in this area would be facilitated by a comprehensive theoretical model, impact pathway, and/or theory of change that considers social norms as one set of influences within the larger array of factors to consider when designing public health interventions. Furthermore, this review did not identify any interventions that used social media, radio, or television to address norms that influence women's diets, which suggests an opportunity for future investigation.

In conclusion: "The strategies summarized in this review provide a starting point for further implementation and evaluation of norms-focused and gender-transformative approaches, which hold promise for enhancing women's nutritional outcomes. Ensuring that women consume healthy diets is critical to achieving nutrition goals and sustaining global food security; this requires moving beyond traditional SBC interventions that focus on knowledge and attitudes of individuals to also consider and respond to social and gender norms that influence relevant behaviors."