Most social and behavior change (SBC) interventions seek to improve lives by influencing individual behaviors and challenging social norms – from encouraging the use of insecticide-treated nets to prevent malaria to promoting modern contraception to allow families to decide if and when to have children.
While these approaches have brought success, the bigger, more structural reasons behind pressing health concerns “have too often been neglected,” say researchers, led by the Johns Hopkins Center for Communication Programs, published in the August issue of Health Promotion International.
In focusing primarily on individuals and their roles to spur behavior change, programs may ignore the need for structural changes, including the underlying social, economic, and political causes of health inequities.
It is essential, the researchers note, to refocus the SBC lens to prioritize these social and environmental factors – which impact life opportunities, health status, and well-being – rather than overemphasizing individual’s behaviors when larger forces are at play.
“SBC programs have an obligation to reach those most often left behind, which cannot be fully achieved without considering structural determinants,” the authors write. “SBC can play a key role but must move beyond a primary reliance on nudging, cajoling, and persuading people to change their individual behaviors and focus more on working in concert with others at multiple levels for sustained behavior change.”
Carol Underwood, PhD, the article’s lead author, says that “identifying, and developing programs for the groups and communities who have poor health outcomes due to inadequate access to essential resources is necessary.”
While some SBC practitioners may counter that changing structures is beyond the scope of the SBC field, the authors suggest that, at minimum, SBC programs should hold themselves accountable for measurable improvements among the least-resourced segments of the populations with whom they work even as they seek partners in the longer-term effort to enable viable structural change.
Before women seek out contraception, for example, they likely need the financial resources to travel to a health facility, the means to ensure their children are cared for at home while they are away and the basic literacy to make an informed decision about the family planning methods offered. Designing programs for individuals and communities without these essential resources will improve overall health outcomes as well as health equity, Underwood says.
Understanding how the environments where people live and work shape their health is essential, says CCP’s Lynn Van Lith, one of the study’s co-authors.
“We need to be intentional so that we are not missing people with our interventions,” she says. “I think we must recognize that the differences in access to and control over resources can lead to disparate and unequal outcomes with people falling through the cracks because they have little to no power.”
In the new research, which is based on a literature review and a set of webinars co-led by practitioners in low- and middle-income countries, the authors note that SBC programmers sometimes overlook the evidence that SBC interventions tend to work best for people with access to a range of social and economic resources. This oversight too often leaves behind those with limited access to essential social, economic, political or cultural resources due to inequitable laws and policies, and their implementation.
“SBC programming in unique, diverse and challenging landscapes without consideration for the gaps communities face – due to inadequate structures and systems – does more harm than good in the long run,” says Babafunke Fagbemi, another co-author, who leads the Centre for Communication and Social Impact in Nigeria. “With a supportive environment that addresses structural barriers, community members are more likely to tune in and believe they can benefit by adopting recommended practices and confidently advocate that others do the same.”
Making structural changes, Van Lith says, can also be accomplished with the help of social and behavior change interventions.
The CCP-led group cites research showing that individuals in impoverished regions of low-income countries endure elevated levels of illness, infectious diseases, malnutrition, inadequate access to food, unsanitary water and sanitation facilities, and a dearth of suitable medical attention. Previous research also found “extensive evidence compellingly connects such disadvantage to preventable illness, disability, suffering, and untimely death.”
“Re-aligning social and behavior change to address structural determinants of health and improve health equity” was written by Carol R. Underwood, Telesphore E.L. Kabore, Babafunke Fagbemi, Foyeke Oyedokun-Adebagbo, Arame Gueye Sène, Catherine Lengewa, and Lynn M. Van Lith.
