In recent years, Social and Behavioural Change Communication (SBCC) has emerged as a critical strategy to address and improve health-related outcomes. However, evidence of the impact of these programs, and their use and scalability, is scarce.
This begs the question — why is SBCC programming important, and why is it then not utilized more?
Quite simply, SBCC is a model which uses communication — this can be through mass media platforms, social media, etc. — to positively influence social norms, knowledge, and attitudes about critical aspects in a person’s life and bring about changes in behavior that consider their lived realities. Within the arena of public health, SBCC provides a unique avenue through which people are not only influenced but are active participants in shaping the behaviors that need shifts by bringing about change across a continuum of care, starting, but not limited to, prevention. A very simple (and relevant) example of this is the messaging that came out during the COVID-19 pandemic around wearing masks, hand-washing, social distancing, etc. This messaging positively influenced behavior change in people around the world to ensure that the spread of COVID-19 was reduced.
However, influencing behavior and social change is not an easy task — it requires a near constant curation, understanding, and sensitivity of and toward messaging to suit a population's needs and contexts, making it somewhat of an expensive and arduous task. Additionally, health communication as a discipline and a methodology often remains underutilized or is included as an afterthought within the research process.
But, it works — and we know it works. So now what?
IAVI, in partnership with Campbell Collaboration South Asia, conceptualized and developed an evidence and gap map (EGM), which characterizes the evidence base on SBCC interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.
The reason behind this is that, although various international agencies — including the Joint United Nations Programme on HIV/AIDS (2016), United Nations Population Fund (2016), World Health Organization (2017), and national bodies like the National AIDS Control Organization (NACO) (n.d.) of India — have recognized the serious and multi-pronged challenges AGYW around the world face with regard to their sexual and reproductive health rights, including vulnerability to HIV and sexually transmitted infections (STIs), converging social, cultural, and economic factors yet affect how this diverse population understands, negotiates, and accesses information and biomedical treatment related to HIV.
The need to address AGYWs unique challenges is clear, and the global buy-in for socio-behavioral interventions to support demand and uptake of HIV services is on the rise. However, evidence mapping of the scope and impact of this in the context of AGYW needs to be systematically outlined to help further adoption by researchers, policymakers, and program managers. This is exactly the objective of this evidence and gap mapping exercise.
So, what have we found?
Learning 1: Considering intersectionality, diversity, and the necessity of contextualizing AGYW needs
The current landscape of evidence highlights the need for a more nuanced and intersectional approach. Few studies explore the effectiveness of SBCC interventions across diverse groups — such as pregnant women and new mothers, sex workers, and people living with HIV. This scarcity of research leads to a limited understanding of the use of these interventions across critical sub-populations and multiple user segments.
Learning 2: Moving beyond mapping knowledge building and information sharing
The evidence gathered through this EGM highlights that the most measured outcomes focused on knowledge-related capabilities such as knowledge and awareness about HIV/STIs and HIV/STI risk perception. Other capability-related outcomes focusing on the skills of the AGYW or their influencers were relatively less studied. For example, skills that help translate knowledge into real action like negotiation and life skills or provider sensitization and engagement skills were some of the areas with low evidence, and very few studies measured outcomes related to social and community norms, household dynamics, and health care services, among others.
But behavior change is not just about increasing knowledge-related capabilities. The COM-B framework (Michie et al., 2011), a bedrock within the applied behavioral sciences, cites capabilities (C), opportunities (O), and motivation (M) as the key factors necessary to induce behavior (B) change. More simply, changing behavior requires understanding and apprehending all aspects of a person's life — the why, when, how, where, and what. This is particularly important for the field of public health where interventions need to stick, i.e. interventions targeting behavior change need to be sustainable over a long period of time.
Learning 3: Tapping into digital mediums and enabling blended learning
A majority of SBCC work done in the past has been through the medium of interpersonal counselling or community-based engagements. Despite the penetration and influence of mass media and digital media-based tools, the lack of evidence for the utilization of the same for engaging AGYW is surprising. Given that media can shape and control “the scale and form of human association and action” (McLuhan, 1964), it still remains an untapped opportunity. More simply put, given the blurring line between digital and physical spaces, it is immensely important to understand the changing media ecologies of AGYW networks and meet them where they are (and where they are may not solely be in digital spaces, rather highly blended ones).
It is important to be cognizant, however, that while the potential reach of these tools makes these valuable methods of engaging these diverse population, growing concerns around gendered access, issues of privacy, confidentiality, and cyber security warrant the need for more evidence to be generated to better understand and utilize these media forms in appropriate and ethical ways.
Learning 4: Critically engaging influencers of AGYW
Certain intervention subtypes, such as peer-led interactions, facilitated community dialogues, and counselling, were predominantly utilized as interventions. It is interesting to note that the rollout of these interventions among AGYW is heavily dependent on peers, educators, and health care providers, who are key actors in delivering them. While the engagement of peers is understandable given they are key influencers within AGYW networks, the lack of engagement of others — such as partners — highlights a gap in the way interventions are conceptualized and designed. While educators and health care providers can play a critical role in knowledge dissemination, their role in creating enabling ecosystems for behavior change is limited without the engagement of key influencers like family, community elders, religious leaders, etc., who play a direct role in facilitating the uptake of safe and positive sexual health behaviors among adolescent girls and young women.
Moving forward, understanding how SBCC interventions can be utilized in more impactful ways to encompass the diversity of lived realities and health-seeking behaviors of adolescent girls and young women is integral. This will, subsequently, help bridge the translation into action gap that programs and research often witness. This includes utilizing more innovative ways of engaging at-risk populations, such as gamification, while also acknowledging and ensuring self-reflexivity within this research to ensure that the people who are a part of these interventions/programs are aware of the goals, challenges, and potential impacts (negative and positive) of their involvement. This EGM, and similar exercises to it, are just a first step in developing a repository of knowledge and practice speaking to the same, not only for AGYW, but those most affected by the HIV epidemic at large.
Access and download the protocol for this EGM and the complete report.