Expanding the "S" in Social and Behavior Change: Addressing Social Determinants of Health and Health Equity in SBC Programming

"Only by explicitly and systematically considering and addressing SDOH [social determinants of health] and health equity in the design, implementation, monitoring, and evaluation of interventions can SBC [social and behaviour change] researchers, practitioners, and funding organizations truly expect to bring about equitable structural and social change."

Social and behaviour change (SBC) interventions frequently focus on identifying and shifting or maintaining recommended behaviours. However, according to Breakthrough ACTION and many others, SBC practitioners need to pay attention to the "S" - the social - in SBC to create more equitable conditions within and across societies. To that end, this thinking tool is designed to guide practitioners as they consider how to identify, prioritise, and address social determinants of health (SDOH) through their programming. As such, viewed through a social justice lens, the tool presents key considerations and illustrative actions for advancing structural and social change with the aim of improving health equity through SBC programming that engages diverse partners and stakeholders in cross-sector partnerships and collaborations. Although the tool focuses on family planning (FP)/reproductive health (RH), its content is broadly applicable to SBC programming across any health and development area.

To develop this tool, Breakthrough ACTION conducted a rapid literature review of models and frameworks for understanding and addressing SDOH and health equity, as well as interventions for addressing the same with a focus on FP/RH. The organisation also convened a technical advisory group (TAG) composed of SBC and public health practitioners to refine key areas and content.

As outlined here, Healthy People 2030 groups SDOH into the following five domains:

1. Economic Stability - e.g., limited access to financial resources to cover cost of FP/RH accessing information, services, and products;
2. Education Access and Quality - e.g., poor quality of language and literacy instruction in schools and linkages to health literacy;
3. Health Care Access and Quality - e.g., stigma and discrimination against adolescents and youth, racial and ethnic minorities, and sexual and gender minorities in health facilities offering FP/RH information, services, and products;
4. Neighborhood and Built Environment - e.g., limited access to telecommunications and technology for accessing information, services, and products; and
5. Social and Community Context - e.g., limited or inequitable engagement of men and boys in FP/RH communication, negotiation, and decision-making.

Breakthrough ACTION stresses that SBC programmes should focus especially on addressing poverty and the priorities and needs of people living in poverty.

The tool goes on to highlight overarching considerations for incorporating SDOH into various phases of SBC programming, including:

• Design phase: In partnership with the most impacted individuals and groups, identify and prioritise SDOH domains, and consider existing initiatives/programmes and diverse partners/stakeholders across sectors to engage in partnerships and coalitions for addressing relevant SDOH.
• Implementation phase: Within a single SBC intervention, combine and build upon strategies and activities across as many SDOH domains as feasible, and engage with existing and new partnerships and coalitions across sectors to broaden the SBC programme's reach and impact.
• Monitoring and evaluation: Using quantitative and qualitative methods as relevant, measure how different SDOH overlap and interact to influence priority groups, behavioural determinants, behaviours, and outcomes, and monitor activities for the impact of social determinants across relevant SDOH domains throughout the SBC programme cycle. Also, include SDOH indicators in evaluation and impact studies of SBC programmes.

The document also offers a series of recommendations (and related resources) in these areas:

• Identifying and prioritising the most impacted individuals and groups - e.g., apply an intersectional lens to consider how social class, gender, race, ethnicity, disability, and other social identities intersect and overlap and, ultimately, influence how priority groups experience social determinants across all domains.
• Developing essential partnerships and coalitions - e.g., develop a shared sense of purpose, unifying message, and transparent structure that motivates diverse partners and stakeholders to champion their respective roles in multi-sectoral action and commit institutionally to health equity.
• Identifying and analysing SDOH and health inequities - e.g., facilitate participatory design workshops that foster dialogue about SDOH and health equity and promote creative thinking around multi-sectoral solutions and actions.
• Engaging community members from start to finish - e.g., develop a common language for discussing and measuring changes to SDOH and health equity in locally relevant ways and transparent mechanisms for increasing community ownership of SBC programming and results over time.
• Selecting, designing, and implementing appropriate strategies and activities - e.g., strategically sequence programme strategies and activities in mutually reinforcing ways and thoughtfully consider the frequency and intensity needed to effect sustainable change across SDOH domains and at higher levels of the socio-ecological model.
• Measuring social determinants of health and health equity - e.g., monitor and track changes in laws and policies that impact SDOH - conducting media content analysis monitoring and interviewing key informants at different socio-ecological levels to learn about laws and policies and their impact on selected social determinants.

Pages 25-27 provide a table featuring examples of strategies and activities for addressing SDOH impacting behavioral determinants, behaviours, and outcomes related to FP/RH and other health areas. The first column specifies the relevant SDOH domains from the Healthy People 2030 framework. The second and third columns provide examples of programme components that can be feasibly implemented within the scope of an SBC programme and those that may require multi-level, multi-sectoral partnerships or coalitions, respectively, for successful implementation.

In conclusion, Breakthrough ACTION notes that this document is "only a starting point, given that the SBC field is in the early stages of applying SDOH more intentionally. Discussion and documentation of how this work is being done, with what results, and the implications for improved health equity will be vital as the SBC field seeks to bring these efforts to scale (see Appendix 1). As SBC practitioners around the world strive to advance structural and social change, multi-sectoral coordination and collaboration remain as important as ever as the field builds more evidence around what works, helping them to collectively expand the 'S' in SBC programming."