Improving Adolescents’ Driving Behaviors through a Personal Narrative-Based Psychosocial Intervention in Serbia

Objectives: Road traffic crashes continue to be the leading cause of death among adolescents. While males are more vulnerable to crashes than females, driver education interventions are less likely to succeed among males than females. Some studies suggest that stronger optimistic bias and overconfidence bias in males may be the reason for this. Methods: In a quasi-experiment conducted in Serbia, forty schools were stratified by size and randomly assigned to watch a road traffic safety presentation utilizing personal narratives or to a control arm. Surveys were administered before the intervention (N=1,449) and again six months later (N=1,072). Data was analyzed by gender in order to investigate gender differences. Results: Risk perceptions improved for both males and females, and injunctive norms improved for females (t= 1.87, p \u3c .05 for males and t= 2.0, p \u3c .01 for females). Improvements in overconfidence bias and descriptive norms were predictive of improvements in high-risk driving behaviors (β= .21, p \u3c .001 for males and β= .25, p \u3c .001 for females; β= -.15, p \u3c .001 for males and β= -.11, p \u3c .01 for females, respectively). A significant interaction between improvements in injunctive norms and the intervention revealed that males whose injunctive norms improved were significantly more likely to be affected by the intervention, compared to the other groups (β= .13, p \u3c .05). Conclusions: Interventions targeting road traffic safety behaviors in adolescents should utilize a gendered approach. For males in particular, influencing perceptions of injunctive norms is important for intervention efficacy

Multilevel theorizing in health communication: integrating the Risk Perception Attitude (RPA) framework and the Theory of Normative Social Behavior (TNSB)

Research testing the risk perception attitudes (RPA) framework has demonstrated that efficacy can moderate the effect of risk perceptions on behavior. This effect of efficacy has also been seen at the social-level through tests of the theory of normative social behavior (TNSB). We tested if efficacy could bridge normative factors at a social-level and risk perception at an individual-level. Data for this study come from the Reduction in Anemia through Normative Innovations (RANI) project’s baseline survey in Odisha, India. We used hierarchical regressions to analyze interactions between predictors at various levels and efficacy to predict behavioral intention. Efficacy beliefs moderated the effect of injunctive norms (β = 0.07, p < 0.01), collective norms (β = 0.06, p < 0.01), and risk perception (β = 0.04, p < 0.01) on intentions. This study provides preliminary evidence for a multilevel theoretical framework.Published versio

Designing a socio-normative intervention to reduce anemia in Odisha India: A formative research protocol [version 1; referees: 2 approved]

Background: More than half of women of reproductive age in India are anemic. Anemia is associated with increased risk of preterm delivery, higher maternal mortality and contributes to fatigue, which affects women’s work productivity. The World Health Organization (WHO) recommends daily oral iron and folic acid (IFA) supplements during pregnancy and weekly supplements for women of reproductive age. Government programs and global donors have distributed and promoted IFA supplements in India for over four decades. However, initial intake and compliance remain inadequate. Objectives: This protocol describes the formative research phase of a larger study, which will test, through a randomized controlled trial, the hypothesis that a social norms-based behavioral intervention in Odisha, India will improve uptake of IFA supplements and reduce anemia among reproductive age women as compared to usual care. The focus of this paper is on the formative research required to develop a sound intervention. We will examine socio-normative barriers to and facilitators of IFA supplement uptake. Methods and analysis: Based on the Theory of Normative Social Behavior, we will adopt a mixed-method, multilevel approach. We will collect data using focus groups, in-depth interviews, observations, Rapid Participatory Ethnographic Evaluation and Research (PEER) techniques, and perceptual mapping methods. Our sample includes reproductive age women (pregnant and not pregnant), their husbands, their mothers/in law and key stakeholders. After analyzing the results, we will hold a convening in India to collaboratively design the intervention. Following the intervention design, we will test components of the intervention, gather user feedback and tweak as necessary. Additionally, to improve adoption and sustainability of the intervention, we will conduct policy dialogue with stakeholders throughout the formative research. Impact: This study will contribute to the social norms and behavioral intervention research and inform policymakers about th

If fear of infertility restricts contraception use, what do we know about this fear? An examination in rural Ethiopia

BACKGROUND: Ethiopia has made great progress toward reducing unmet need for family planning and increasing contraception use over the last decade. However, almost one-quarter of women still have an unmet need. The primary reason for non-use is “method-related health concerns” and, within this broad category, the belief that using contraception will cause infertility is common. This belief extends beyond Ethiopia to low-, middle-, and high-income countries across the world. The objective of this paper is to examine associations with the belief that contraception use causes infertility and to subsequently suggest potential strategies to address this misperception. METHODS: We collected data from women of reproductive age (between 15 and 49 years old) in 115 rural districts of Ethiopia (n = 706). Our main outcome variable was the belief that contraception causes infertility. We analyzed data, both individual-level factors and interpersonal factors, using nested logistic regression models. RESULTS: Almost half of women in our sample (48.2%) believed that contraceptive use causes infertility. In the final model that included factors from both levels, self-efficacy to use contraception (AOR = 0.81, p < 0.05), visiting a health center and speaking to a provider about family planning in the last 12 months (AOR = 0.78, p < 0.05), and husband support of contraception (AOR = 0.77, p < 0.01) were associated with a reduction in the odds of believing that contraception causes infertility. The belief that infertility will result in abandonment from one’s husband (AOR = 3.06, p < 0.001) was associated with an increase in the odds of holding the belief that contraception causes infertility. A home visit in the last 12 months from a health worker who discussed family planning was not associated with the belief that contraceptive use causes infertility. CONCLUSIONS: Given that this belief is both salient and positively associated with other fears such as abandonment from one’s husband, it is critical for family planning programs to address it. Communication campaigns or interventions that address this misperception among couples may diminish this belief, thereby increasing contraception use and reducing unmet need in rural Ethiopia.Published versio

Designing a social norms-based intervention to reduce anemia in India: A formative research protocol

Background: Economic and gender inequalities are important determinants of anemia in low and middle income countries. Gender dimensions of food security contribute to the undernutrition among women. More than half of women of reproductive age in India are anemic. Anemia causes increased risk of preterm delivery, higher maternal mortality and contributes to fatigue, which influences women’s work productivity. The World Health Organization (WHO) recommends daily oral iron and folic acid (IFA) supplements during pregnancy and weekly supplements for women of reproductive age. Despite the efforts of government programs and global donors to reduce anemia in India, both initial uptake and compliance of IFA remain inadequate. Innovative, multi-level, theory-based methods are urgently needed to address the problem. Objective: This study will design and test the hypothesis that a social norms-based intervention in Odisha, India will promote changes in social norms, knowledge, attitudes, and behaviors of women of reproductive age and pregnant women. Methods and Analysis: Based on the Theory of Normative Social Behavior (TNSB), we will use a mixed-method approach that uses both qualitative and quantitative techniques. For our formative research, focus group discussions, in depth interviews, observations, and perceptual mapping techniques will be adopted. Our study sample will include reproductive age women (both pregnant and not pregnant), their husbands, their mothers/in-laws, women’s self-help group leaders, local health officials, and health care providers. The formative research will examine the barriers, facilitators, attitudes and availability of IFA supplements. After analyzing the results, we will hold a convening in India with stakeholders, participants, interventionists, and researchers to collaboratively design the intervention. Following the intervention design, we will test various components of the intervention, gather user feedback and make edits as necessary. Additionally, to improve adoption and sustainability of the intervention, we will conduct ongoing policy dialogue with key stakeholders throughout the formative research

Designing a socio-normative intervention to reduce anemia in Odisha India: A formative research protocol [version 1; referees: 2 approved]

Background: More than half of women of reproductive age in India are anemic. Anemia is associated with increased risk of preterm delivery, higher maternal mortality and contributes to fatigue, which affects women’s work productivity. The World Health Organization (WHO) recommends daily oral iron and folic acid (IFA) supplements during pregnancy and weekly supplements for women of reproductive age. Government programs and global donors have distributed and promoted IFA supplements in India for over four decades. However, initial intake and compliance remain inadequate. Objectives: This protocol describes the formative research phase of a larger study, which will test, through a randomized controlled trial, the hypothesis that a social norms-based behavioral intervention in Odisha, India will improve uptake of IFA supplements and reduce anemia among reproductive age women as compared to usual care. The focus of this paper is on the formative research required to develop a sound intervention. We will examine socio-normative barriers to and facilitators of IFA supplement uptake. Methods and analysis: Based on the Theory of Normative Social Behavior, we will adopt a mixed-method, multilevel approach. We will collect data using focus groups, in-depth interviews, observations, Rapid Participatory Ethnographic Evaluation and Research (PEER) techniques, and perceptual mapping methods. Our sample includes reproductive age women (pregnant and not pregnant), their husbands, their mothers/in law and key stakeholders. After analyzing the results, we will hold a convening in India to collaboratively design the intervention. Following the intervention design, we will test components of the intervention, gather user feedback and tweak as necessary. Additionally, to improve adoption and sustainability of the intervention, we will conduct policy dialogue with stakeholders throughout the formative research. Impact: This study will contribute to the social norms and behavioral intervention research and inform policymakers about the value of adopting a socio-normative approach

mHealth for anemia reduction: protocol for an entertainment education–based dual intervention

BACKGROUND: More than half of the women of reproductive age (aged 15-49 years) are anemic in India. The uptake of and adherence to iron folic acid (IFA) supplements remain low despite sustained efforts to increase their use. With India’s burgeoning digital environment, mobile phones offer a potential medium for increasing their uptake, especially when combined with interactive voice messages that deliver entertaining stories infused with norms-based educational messages. OBJECTIVE: This study aims to investigate whether a norms-based entertainment education mobile health intervention can increase self-efficacy for IFA adherence among women of reproductive age in Odisha, India. METHODS: Mobile reduction in anemia through normative innovations (mRANI) is a randomized 2-arm study that includes assessments before and after the intervention. All study participants will be recruited from the intervention arm of the parent reduction in anemia through normative innovations trial only. Although the usual practice is to randomize participants either to a treatment arm or a usual care control arm, we will assign the mRANI control group to another entertainment education–based treatment group that is designed to improve bystander intervention to reduce violence against women. Data collection for the mRANI study is embedded in the parent trial and will include baseline and end line assessments. The primary outcomes are self-efficacy for IFA adherence and violence against women–related bystander intervention. The inclusion criteria for the mRANI study are participation in the parent trial and phone ownership. Women (approximately n=400) who meet the mRANI inclusion criteria will be randomly assigned to the IFA arm or the bystander arm. Ordinary least squares regression with robust SEs will be conducted to assess between-group comparisons at the end line. A mediation analysis will be conducted to examine whether social norms and interactivity mediate the relationship between intervention exposure and primary outcomes in both arms. Real-time monitoring data will offer insights into intervention receptivity and audience engagement. RESULTS: Data collection for the mRANI study is integrated within the parent trial. Household surveys were conducted between February and March of 2021. Responses on the mRANI study’s primary and secondary outcomes were collected from 381 participants. The data analysis is expected to be completed by October 2021. CONCLUSIONS: This study will provide evidence on whether a mobile health norms–based entertainment education intervention can increase self-efficacy for IFA adherence and violence against women–related bystander intervention.https://www.researchprotocols.org/2021/11/e26252

Iron and folic acid consumption and changing social norms: cluster randomized field trial, Odisha, India

OBJECTIVE: To assess whether improvements in social norms related to iron and folic acid consumption are associated with increased iron and folic acid consumption. METHODS: In a cluster randomized trial in Odisha, India, we implemented an intervention to improve descriptive norms (people’s perceptions about how many other people take iron and folic acid), injunctive norms (social pressures people feel to take iron and folic acid) and collective norms (actual levels of iron and folic acid consumption). We assessed changes in these norms and self-reported iron and folic acid consumption in control and intervention arms after 6 months (September 2019–February 2020). We collected data from control (n = 2048) and intervention (n = 2060) arms at baseline and follow-up (n = 1966 and n = 1987, respectively). FINDINGS: At follow-up, mean scores in self-reported iron and folic acid consumption in the control arm had decreased from 0.39 to 0.31 (21% decrease; not significant). In the intervention arm, mean scores increased from 0.39 to 1.62 (315% increase; P < 0.001). The difference between the two arms was statistically significant (P < 0.001). Each of the three norms also improved at significantly higher rates in the intervention than in the control arm (P < 0.001 for each norm). Changes in descriptive and collective norms (but not injunctive norms) were associated with changes in self-reported iron and folic acid consumption (P < 0.001 for both norms). CONCLUSION: Our results show that social norms can be improved and that these improvements are associated with positive behavioural changes. A social norms-based approach may help promote iron and folic acid consumption in India.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8542261/pdf/BLT.20.278820.pd

How road-safety interventions can incorporate social norms: A gender-driven approach

Normative influences have been explored across a variety of health domains and have increasingly been the targets of health communication efforts. Despite growth in norms literature, the influence of norms across gender isn’t well understood. Within the realm of road traffic safety, males carry three times a greater risk for crash than females; the urgency and stark gender-based differences in road traffic incidence risk provides an opportunity to investigate the normative influences across gender-based differences. The current study applied the Theory of Normative Social Behavior (TNSB) to road traffic safety behaviors in male and female adolescents in order to understand these gender-based differences in normative influences. In this quasi-experimental study, high-school age students were exposed to a road traffic safety presentation in their school. Surveys were administered to both treatment and control schools before the intervention, immediately after, and 6-months after, exploring social norms and high-risk driving intentions. Independent samples t-tests were used to test whether social norms and high-risk driving intentions differed across males and females. Zero-order Pearson correlations and hierarchical regression equations were used to investigate the association between social norms and high-risk driving intentions among males and females. Hierarchical regression equations were also used to investigate the moderating effects of collective norms and injunctive norms on the relationship between descriptive norms and high-risk driving intentions among males and females. Males and females differed in social norms and high-risk intentions. Additionally, descriptive norms were found to significantly predict change in high-risk driving intentions among females (β=0.14, p=.001), and marginally predict it among males (β=0.08, p=.085). The relationship between descriptive norms and change in high-risk driving intentions was moderated by collective norms among males, while it was moderated by injunctive norms among females.The findings support the hypothesis that descriptive norms are associated with behavior intentions, however, the context surrounding road traffic safety risk moderates the influence descriptive norms have on behavior intentions. Among the constructs of TNSB, gender must be considered as a contextual factor that shapes this relationship. In the context of road traffic safety, perceptions of social approval interacts with perceptions of behavior prevalence in females in a way that doesn’t occur in males. On the other hand, the influence of descriptive norms on intentions is strongest in males when collective risky behavior is low

Descriptive, Injunctive, and Collective Norms: An Expansion of the Theory of Normative Social Behavior (TNSB)

We propose and test several hypotheses derived from the expanded theory of normative social behavior (TNSB) that also includes collective norms (with descriptive and injunctive norms). Data come from a quasi-experiment intervention to promote safer driving among adolescents in Serbia. The intervention was administered among high school students, most of whom were on the verge of receiving their driver\u27s licenses. Longitudinal data were collected from treatment and control schools at baseline ( = 1,449) and four months later at end line ( = 1,072). Descriptive norms at baseline predicted six-month changes in safer-driving intentions among women (β = .010 \u3c .05) but not among men. Main-effects of injunctive and collective norms were not significant. However, a significant interaction between descriptive norms and collective norms emerged among men (though not among women) and injunctive norms interacted with both collective norms and descriptive norms among women (but not among men). Initial evidence adds credence to the idea of enhancing the TNSB by adding both injunctive and collective (together with descriptive) norms as drivers of behaviors