Social Mobilization

Who follows through? Different factors predict initial commitment vs. Following through in a national survey of organ donor registration

OBJECTIVE

Little research has investigated factors that determine whether people falter in the face of an obstacle or successfully follow through on an initial commitment to act. We integrated multiple theories (the Reasoned Action Approach [RAA], Prototype Willingness Model, and anticipated regret theory) to test which factors predict initial commitment to register as an organ donor and to discover whether different factors predict initial commitment vs. following through with registration.

METHODS

Participants from a nationally representative UK sample (N = 1,008) reported their beliefs about organ donation and indicated their decision to register. An obstacle that participants could not foresee was that they had to complete registration in a second survey 3 days after making their initial commitment.

RESULTS

Findings showed that 14.8% of participants followed through, 19.7% demonstrated initial commitment, and 65.5% declined to register. Linear discriminant function analysis derived two functions that distinguished these registration patterns. The first function discriminated participants who declined to register from the other groups. The declined group had lower scores on RAA variables compared to their counterparts. The second function distinguished participants who made an initial commitment to register from those who followed through. Follow-through was associated with less anticipated negative affect, more favorable descriptive norms, and stronger identification with organ donors.

CONCLUSIONS

The present findings indicate that even modest friction leads to a large reduction in follow-through. Moreover, different factors influence initial commitment vs. following through. Whereas RAA variables predicted initial commitment, following through was a function of anticipated negative affect and social processes.

Health-seeking behaviour regarding schistosomiasis treatment in the absence of a mass drug administration (MDA) program: the case of endemic communities along Lake Albert in Western Uganda

INTRODUCTION

Schistosomiasis poses a serious public health problem and a social challenge affecting over 240 million people, the majority of whom live in sub-Saharan Africa. The World Health Organization (WHO) recommends praziquantel (PZQ) drug treatment through regular mass drug administration (MDA) accompanied by social mobilisation and health education and sensitisation. With social mobilisation and health education and sensitisation, there is bound to be increased demand for the PZQ, especially in the case of endemic communities. However, it is not clear where communities go for PZQ treatment in the absence of PZQ MDA. We explored the health-seeking behaviours regarding schistosomiasis treatment among communities along Lake Albert in Western Uganda when MDA had delayed, to inform a review of the implementation policy for the achievement of the WHO's 2030 target of 75% coverage and uptake.

METHODS AND MATERIALS

We conducted a community-based qualitative study in Kagadi and Ntoroko, an endemic community in January and February 2020. We interviewed 12 individuals: local leaders, village health teams, and health workers, and conducted 28 focus group discussion sessions with 251 purposively selected community members. The audio recordings of the data were transcribed and analyzed using a thematic analysis model.

RESULTS

Generally, participants seldom seek medication for schistosomiasis-related signs and symptoms from government hospitals and health centres II, III and IV. Instead, they rely on community volunteers such as VHTs, private facilities, such as clinics and drug shops nearby, or traditional sources (e.g. witch doctors and herbalists). Results show that factors influencing people to seek treatment from sources other than the government are: the absence of PZQ drugs in the government health facility; health workers' negative attitude towards patients; long distances to the government hospitals and health facilities; poor and inaccessible roads; medication-related costs; and negative perceptions of the PZQ drug.

CONCLUSIONS

Availability and accessibility of PZQ seem to be a big challenge. PZQ uptake is further hampered by health systems and community-related and socio-cultural factors. Thus there is a need to bring schistosomiasis drug treatment and services closer to endemic communities, stock nearby facilities with PZQ and encourage endemic communities to take the drug. Contextualised awareness-raising campaigns are needed to debunk myths and misconceptions surrounding the drug.

Are you prepared for the next storm? Developing social norms messages to motivate community members to perform disaster risk mitigation behaviors

Preparing for natural disasters and adapting to climate change can save lives. Yet, minimal research has examined how governments can motivate community members to prepare for disasters (e.g., purchasing flood insurance or installing water barriers in homes for floods and hurricanes). Instead, studies have focused on how to communicate actions individuals should take during disasters, rather than before disasters. This study develops messages targeting social norms, which are promising approaches to motivate community members to adopt disaster risk preparedness and mitigation behaviors. Specifically, we developed a variety of messages integrating descriptive norms (i.e., what others do), injunctive norms (i.e., what others believe should be done), and a social norms-based fear appeal, or social disapproval rationale (i.e., a negative social result of [not] taking behaviors). Then, we tested these messages through two between-subject factorial online experiments in flood- and hurricane-prone U.S. states with adult samples (N = 2,286). In experiment 1 (i.e., purchasing flood insurance), the injunctive norms message using weather forecasters and the social disapproval rationale message significantly increased social norms perceptions, which in turn influenced behavioral intentions. In experiment 2 (i.e., installing water barriers), the injunctive norms message using weather forecasters, the injunctive norms message using neighbors, and the social disapproval rationale message significantly increased social norms perceptions, which in turn influenced mitigation intentions. However, the descriptive social norms message was not effective in increasing social norms perceptions. We provide some of the first empirical evidence on how organizations' risk communication can empower community members to prepare and mitigate the impact of disasters.

Refusing to tolerate ongoing prejudicial behavior toward immigrants: Together we can object to prejudicial flag displays

Over recent years, immigrants have been met with unjust prejudiced behavior instead of warm welcome. However, not all citizens of a nation endorse such behavior, instead they try to oppose it through social mobilization. In the context of an ongoing situation where the national flag is used as a prejudiced means to exclude immigrants, individuals who felt attached with all members of the nation felt significantly more shame for the unjust than individuals who glorify their nation. Consequently, attached identifiers expressed a significantly greater motivation than glorified identifiers to start thinking about social mobilization to reclaim the meaning of the flag as a symbol of inclusion, not exclusion. The current study contributes to the growing debate on how immigrants are received, and it helps explain how national identification and feelings such as shame motivate individuals to start thinking about objecting to prejudicial flag displays.

Evaluating the effectiveness of email-based nudges to reduce postoperative opioid prescribing: study protocol of a randomised controlled trial

INTRODUCTION

Surgical patients are commonly prescribed more opioids at discharge than needed to manage their postoperative pain. These excess opioids increase the risks of new persistent opioid use, opioid-induced ventilatory impairment and opioid diversion. This study tests the effectiveness of two behavioural nudges, one based on peer behaviour and one based on best practice guidelines, in reducing excessive postoperative opioid prescriptions.

METHODS AND ANALYSIS

The study will be conducted at 19 hospitals within a large healthcare delivery system in northern California, USA. Three surgical specialties (general surgery, orthopaedic surgery and obstetric/gynaecological surgery) at each hospital will be randomised either to a control group or to one of two active intervention arms. One intervention is grounded in the theory of injunctive norms, and provides feedback to surgeons on their postoperative opioid prescribing relative to prescribing guidelines endorsed by their institution. The other intervention draws from the theory of descriptive norms, and provides feedback similar to the first intervention but using peers' behaviour rather than guidelines as the benchmark for the surgeon's prescribing behaviour. The interventions will be delivered by a monthly email. Both interventions will be active for twelve months. The effects of each intervention relative to the control group and to each other will be tested using a four-level hierarchical model adjusted for multiple hypothesis testing.

ETHICS AND DISSEMINATION

Using behavioural nudges rather than rigid policy changes allows us to target excessive prescribing without preventing clinicians from using their clinical judgement to address patient pain. All study activities have been approved by the RAND Human Subjects Protection Committee (ID 2018-0988). Findings will be disseminated through conference presentations, peer-reviewed publications and social media accounts.

TRIAL REGISTRATION NUMBER

NCT05070338.

The language of cooperation: reputation and honest signalling

Large-scale non-kin cooperation is a unique ingredient of human success. This type of cooperation is challenging to explain in a world of self-interested individuals. There is overwhelming empirical evidence from different disciplines that reputation and gossip promote cooperation in humans in different contexts. Despite decades of research, important details of reputation systems are still unclear. Our goal with this theme issue is to promote an interdisciplinary approach that allows us to explore and understand the evolution and maintenance of reputation systems with a special emphasis on gossip and honest signalling. The theme issue is organized around four main questions: What are the necessary conditions for reputation-based systems? What is the content and context of reputation systems? How can reputations promote cooperation? And, what is the role of gossip in maintaining reputation systems and thus cooperation? This article is part of the theme issue 'The language of cooperation: reputation and honest signalling'.

Supporting communities of practice – A Journey to effective problem-solving

In contexts of scarce resources, varied assets, and diverse communities, engaging local stakeholders in the problem-solving process is critical to develop interventions for HIV prevention and treatment. Communities of practice (CoPs) – groups of people organized around a key purpose and a delivery point – can develop expertise in identifying their local community’s key challenges and selecting viable solutions. We propose a framework, adapted from the CoP model developed by Etienne Wenger, for systematically understanding the stages a CoP may go through as it develops its capacity to identify and solve problems and implement good practices. Our framework is based on the experience of practitioners of the LISTEN model (Local Initiatives Scaled Through Enterprise Networks) in eight local-level CoPs in Kenya and Eswatini. LISTEN seeks to help CoPs integrate continuous improvement processes, data, and human-centered design into their development and solutioning activities. The four stages in our framework for a CoP’s problem-solving journey are: 1) Community Identity: Identify and understand the CoP’s purpose and goals, and build rapport with its members and leaders; 2) Quick Win: Use a process of human-centered design to obtain a rapid and clear success in addressing a problem that the CoP has identified for itself and which it can tackle with its own resources; 3) Stewardship: Support the CoP in addressing more complex or long-term issues, including links to other CoPs at the local-community or higher levels to disseminate knowledge and obtain resources and support, where needed; and 4) Evolution: Support the CoP as it transitions into potentially new structures or functions. For each stage of the framework, we describe the kinds of support that may be provided to the CoP in the LISTEN model, and the types of tools that could be developed to assist them in problem-solving and in disseminating sustainable solutions.

The relationship between cultural tightness-looseness and COVID-19 cases and deaths: a global analysis

BACKGROUND

The COVID-19 pandemic is a global health crisis, yet certain countries have had far more success in limiting COVID-19 cases and deaths. We suggest that collective threats require a tremendous amount of coordination, and that strict adherence to social norms is a key mechanism that enables groups to do so. Here we examine how the strength of social norms-or cultural tightness-looseness-was associated with countries' success in limiting cases and deaths by October, 2020. We expected that tight cultures, which have strict norms and punishments for deviance, would have fewer cases and deaths per million as compared with loose cultures, which have weaker norms and are more permissive.

METHODS

We estimated the relationship between cultural tightness-looseness and COVID-19 case and mortality rates as of Oct 16, 2020, using ordinary least squares regression. We fit a series of stepwise models to capture whether cultural tightness-looseness explained variation in case and death rates controlling for under-reporting, demographics, geopolitical factors, other cultural dimensions, and climate.

FINDINGS

The results indicated that, compared with nations with high levels of cultural tightness, nations with high levels of cultural looseness are estimated to have had 4·99 times the number of cases (7132 per million vs 1428 per million, respectively) and 8·71 times the number of deaths (183 per million vs 21 per million, respectively), taking into account a number of controls. A formal evolutionary game theoretic model suggested that tight groups cooperate much faster under threat and have higher survival rates than loose groups. The results suggest that tightening social norms might confer an evolutionary advantage in times of collective threat.

INTERPRETATION

Nations that are tight and abide by strict norms have had more success than those that are looser as of the October, 2020. New interventions are needed to help countries tighten social norms as they continue to battle COVID-19 and other collective threats.

FUNDING

Office of Naval Research, US Navy.

Modelling collective action to change social norms around domestic violence: social dilemmas and the role of altruism

Interventions promoting collective action have been used to prevent domestic violence in a range of settings, but their mechanisms of operation remain unclear. We formalise and combine feminist theoretical approaches to domestic violence into a game-theoretic model of women's collective action to change gendered social norms and outcomes. We show that social norms create a social dilemma in which it is individually rational for women to abstain from action to prevent domestic violence among neighbours, but all women suffer negative consequences if none take action. Promoting altruism among women can overcome the social dilemma. Discouraging women from tolerating domestic violence, imposing additional external punishment on men for perpetrating violence, or lowering costs to women of taking action against violence may not work or even backfire. We invite researchers on community mobilisation to use our framework to frame their understandings of collective action to prevent domestic violence.

Supporting communities of practice – A Journey to effective problem-solving

In contexts of scarce resources, varied assets, and diverse communities, engaging local stakeholders in the problem-solving process is critical to develop interventions for HIV prevention and treatment. Communities of practice (CPs) – groups of people organized around a key purpose and a delivery point – can develop expertise in identifying their local community’s key challenges and selecting viable solutions. We propose a framework for systematically understanding the stages a CP may go through as it develops its capacity to identify and solve problems and implement good practices. Our framework is based on the experience of practitioners of the LISTEN model (Local Initiatives Scaled Through Enterprise Networks) in eight local-level CPs in Kenya and Eswatini. LISTEN seeks to help CPs integrate continuous improvement processes, data, and human-centered design into their development and solutioning activities. The four stages in our framework for a CP’s problem-solving journey are: 1) Community Identity: Identify and understand the community’s purpose and goals, and build rapport with its members and leaders; 2) Quick Win: Use a process of human-centered design to obtain a rapid and clear success in addressing a problem that the local community has identified for itself and which it can tackle with its own resources; 3) Stewardship: Support the CP in addressing more complex or long-term issues, including links to other CPs at the local-community or higher levels to disseminate knowledge and obtain resources and support, where needed; and 4) Evolution: Support the CP as it transitions into potentially new structures or functions. For each stage of the framework, we describe the kinds of support that may be provided to the CP in the LISTEN model, and the types of tools that could be developed to assist them in problem-solving and in disseminating sustainable solutions.

Scaling up behavioral science interventions in online education

Online education is rapidly expanding in response to rising demand for higher and continuing education, but many online students struggle to achieve their educational goals. Several behavioral science interventions have shown promise in raising student persistence and completion rates in a handful of courses, but evidence of their effectiveness across diverse educational contexts is limited. In this study, we test a set of established interventions over 2.5 y, with one-quarter million students, from nearly every country, across 247 online courses offered by Harvard, the Massachusetts Institute of Technology, and Stanford. We hypothesized that the interventions would produce medium-to-large effects as in prior studies, but this is not supported by our results. Instead, using an iterative scientific process of cyclically preregistering new hypotheses in between waves of data collection, we identified individual, contextual, and temporal conditions under which the interventions benefit students. Self-regulation interventions raised student engagement in the first few weeks but not final completion rates. Value-relevance interventions raised completion rates in developing countries to close the global achievement gap, but only in courses with a global gap. We found minimal evidence that state-of-the-art machine learning methods can forecast the occurrence of a global gap or learn effective individualized intervention policies. Scaling behavioral science interventions across various online learning contexts can reduce their average effectiveness by an order-of-magnitude. However, iterative scientific investigations can uncover what works where for whom.

Mobilize to vaccinate: lessons learned from social mobilization for immunization in low and middle-income countries

Creating and sustaining demand for immunization services is a global priority to ensure that vaccine-eligible populations are fully protected from vaccine-preventable diseases. Social mobilization remains a key health promotion strategy used by low- and middle-income countries (LMICs) to promote vaccination demand. In this commentary, we synthesize illustrative evidence on successful social mobilization efforts promoting the uptake of immunization services in select LMICs. The first example focuses on Sierra Leone’s routine immunization program during the Universal Child Immunization initiative in the late 1980s. We then give an example of India’s establishment of a social mobilization network in the early- to mid-2000s to support polio elimination in high-risk communities. Thirdly, we highlight the complexities of social mobilization in a humanitarian emergency during the 2017–2018 diphtheria outbreak among displaced Rohingyas in camps and settlements in Bangladesh. Lastly, we draw upon examples from the introduction of the human papillomavirus vaccine in several countries. We then critically examine recurring challenges faced when implementing social mobilization for immunization in LMICs and offer practical recommendations for improvement.

Understanding participation dilemmas in community mobilisation: can collective action theory help?

Community mobilisation interventions have been used to promote health in many low-income and middle-income settings. They frequently involve collective action to address shared determinants of ill-health, which often requires high levels of participation to be effective. However, the non-excludable nature of benefits produced often generates participation dilemmas: community members have an individual interest in abstaining from collective action and free riding on others’ contributions, but no benefit is produced if nobody participates. For example, marches, rallies or other awareness-raising activities to change entrenched social norms affect the social environment shared by community members whether they participate or not. This creates a temptation to let other community members invest time and effort. Collective action theory provides a rich, principled framework for analysing such participation dilemmas. Over the past 50 years, political scientists, economists, sociologists and psychologists have proposed a plethora of incentive mechanisms to solve participation dilemmas: selective incentives, intrinsic benefits, social incentives, outsize stakes, intermediate goals, interdependency and critical mass theory. We discuss how such incentive mechanisms might be used by global health researchers to produce new questions about how community mobilisation works and conclude with theoretical predictions to be explored in future quantitative or qualitative research.