From Social and Behavaiour Change Communication to From Social and Behavaiour

Change: The Evolution:

*** Reading Chapter 1: Theoretical Divides and Convergence in Global Health

Communication, Pg. 9-27 in the Handbook of Global Health Communication by Rafael
Obregon and Silvio Waisbord.

Social and Behavaiour Change Communication (SBCC) has evolved greatly over the last four
decades. Its development can be traced back to the emergence of development communication
in the middle of the 20th century. More specifically, concerns about communication and its
place in promoting health worldwide, also called health communication, dominated the early
years of the development of the field. Traditional health communication represented the idea
that individuals play the most decisive role in their health and well-being depending on the
knowledge and information they possessed. This reflected heavily in the early generation of
health interventions, so that many were designed, executed and evaluated to influence public
knowledge and attitudes. As programmes embraced health information transmission and
subsequent public reception as means to alter individual practices, health communication was
equated to the one-way communicative act that involved materials development, health
campaigns, target audiences and messaging (Waisbord and Obregon, 2012), leading to the
development of Information, Education and Communication (IEC) as one of the earliest
approaches for influencing health outcomes and status. In Uganda for example, the Ministry of
Health established the Health Educational Information, Education and Communication
Campaign in 1989, majorly to tackle HIV/AIDS. Among others, this campaign aimed to
provide IEC materials and ensuring decentralised district level information and training
(Slutkin et al., 2006). As an IEC tenet, health problems were thought to be rooted in the lack
of information and poor public attitudes —as long as the two persisted, health communication
professionals argued, good health behaviour and social change were unattainable (Waisbord
and Obregon, 2012). The use of mass media for health information transmission became critical
in this generation of health communication practice. Health communication became associated
with terms such as health education and health promotion, all of which emphasized the
intersection between information, individual decision making and health behaviours. Although
such an approach was always important for increasing public awareness about diseases, its
impact was eclipsed by the persistent absence of translation of mass public awareness about
diseases into actual health behaviour.

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The Rise of Behaviour Change Communication
By the 1980s and 1990s, scholar-practitioner concerns about behavioural issues that pertain to
health behaviour had come into play. Thus, health communication in both inquiry and
programming took interest in behaviour change issues and goals, leading to the rise of
Behavior Change Communication as a new term. Emphasis shifted from just information to
the understanding of cognitive issues as well as internal and external factors that explain why
people do what they do. Anchored in the workings of the broad field of human communication,
BCC carried over basic premises from fields such as psychology, sociology and economics, to
reinforce the role of cognition and individual attributes in dynamic health behaviors, health
decision making and processes of changing behaviour (Nutbeam, 2000). BCC turned to the use
of systematic research and evidence-based interventions. During this time, the application of
theory in health communication interventions gained traction as a basis for understanding
health problems, developing appropriate interventions, identifying suitable audiences and
evaluating success (Taylor and Shimp 2010). Interventions relied on the dissemination of well-
packaged information through interpersonal and mediated means intended to address
individual-level attributes of cognition, learning and decision making as they related to health
behaviour change. For example, applications of health communication emphasized perceived
threats, benefits, barriers, readiness to act, subjective norms, behavioural intentions and a range
of other cognitive concepts directly anchored in individual and cognitive social-psychological
theories (Glanz et al., 2004). A good example of an intervention that was based on the BCC
approach was the ABC (abstinence, be faithful and condom use) strategy that was pioneered in
Uganda at the height of the HIV/AIDS pandemic (Gunuis & Gunuis, 2005). In addition,
Uganda relied on the BCC approach and launched the Delivery for Improved Services for
Health (DISH) campaigns in 1999 to promote health services and preventive bahaviour around
issues of child and maternal health, immunisation, malaria, sexually transmitted disease and
HIV/AIDS.

The explicit emphasis on behaviour change as a central objective of public health interventions
brought gains to health communication interventions especially because it became easier to
measure communication processes and outcomes reliably (Storey and Figueroa, 2012).
However, the over-emphasis on individual-level behaviour change also meant that
interventions remained blind to the structural factors, such as power relations, inequalities, and
determinants of health that are known to stifle social change. For example, numerous
researchers interested in interventions in the health sector to address HIV/AIDS, Polio, Malaria

2
and Family Planning have previously expressed concerns over the ever-emphasis on
individuals and their behaviours (Coates, Richter & Caceres, 2008). In Uganda, evaluations of
BCC interventions in malaria have for example reported increased public knowledge of the
disease and improved attitudes for use of prevention tools, such as mosquito nets and early
testing (Helinski et al., 2015; Mugisa & Muzoora, 2012). Others have elaborated the limitations
of the individual behavioral approach in HIV interventions and further called on
interventionists to pay attention to the underlying determinants of the pandemic (Vincent,
2006). Writing about traditional BCC initiative that relied upon mass media, Corcoran (2013,
p. 70) notes that they were heavily driven by the assumptions about the powerful effects of
mediated messages on the receiving audience, especially that whole populations would heed
such messages. However, this view as Corcoran elaborates neglects the macro-level factors
such as politics, community resources that impact health, thus health practitioners have now
become more realistic about over-emphasis on media use the individual. In 1999, UNAIDS
drew up a communication framework that recommended five contextual factors: gender,
culture, policy, spirituality and socioeconomic status that needed to be addressed in order to
change the practice of HIV/AIDS interventions.

The Birth of Social and Behaviour Change Communication

The inevitable shift to the orientation that acknowledges structural factors and impediments to
health behaviour in order to advance the global health agenda resulted in a new term: social
and behavior change communication (SBCC). The appreciation of the role of underlying
factors in health was not entirely new having been initially postulated by the World Health
Organisation (WHO)’s Ottawa Charter that recognised health not merely as absence of disease,
but a state of complete physical, mental and social wellbeing (WHO, 1986). It is this
postulation that shifted the responsibility of health behaviour change from individuals to the
considerations of underlying social determinants of health. Social and Behavior Change
Communication (SBCC) is defined as an approach that develops, implements and evaluates
appropriate evidence-based interventions to improve population health (Christofides et al.
2013). According to Christofides et al (2013) SBCC comprises three interlinked approaches
of: i) Health Communication which focuses on the development, dissemination and evaluation
of health information to and from the public, ii) Health Promotions which focuses on catalysing
change, leadership, assessment, planning, implementation, evaluation, advocacy and
partnerships and, iii) Communication for Development which focuses on facilitating dialogue
and community participation. Programmatically, SBCC emphasises social and structural views

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of communication that address multi-level (social) determinants of health, starting with
individual-level psychosocial, to social networks, community and societal factors. It is
anchored in a more holistic approach, leading toward the socio-ecological perspective that has
dominated global health communication programs for over two decades. The move to SBBC
aimed to repel the emphasis on dominant approaches that continued to theorise communication
in terms of information dissemination intended to change individual’s perceptions and
readiness to act on health/development problems. This emphasis on the ‘media effects’ and the
‘importance of knowledge’ as the most important aspects in behaviour change problematic.
Thus, critics to this dominant perspective in global health and development reoriented the field
around the complexity of the social determinants of health (behaviour change) that encompass
individual, social and policy levels. The new direction focused on communication programs
that involved a more nuanced, multi-level analysis of behaviourl determinants and rethink the
meaning of communication to address such challenges. The SBCC perspective marked the
move from individual theories of communication to the social ecological models.

A Critique of BCC by the SBCC Approach:

• Knowledge alone is not in itself adequate for behavior change/
• The individual premises of health behavior is incorrect. The application of individual-
centred models to achieve health behaviour is highly question especially in non-
Western societies. In some societies, communal values are predominant.
• Failure to consider cultural diversity as a central dimension of global health
communication is problematic
• Narrow and simplicity definition of communication process that focuses of messages
and information dissemination. This focus on transmission alone is incorrect.
• The rationalistic, modernistic premises of health behavioralism and communication is
also problematic and questioned. That ‘if individuals were properly informed, they
would act rationally to maximise individual benefits’ is not in tandem with modern
thinking and research.
• The behavioural focus of health and development programs is also questioned. There
are other complex issues such as participation, power and others that important to
consider.

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The Recent Shift to Social and Behaviour Change
The continuing evolution of SBCC has recently redirected focus towards Social and Behaviuor
Change (SBC) as a pathway to further encourage transformational change around the world’s
pressing challenges including poverty, gender equality, peace, health among others. The SBC
approach is driven by the recognition that the determinants of health and human development
are multi- dimensional, cut across sectors, and are influenced by and take shape within different
human domains, contexts, and disciplines beyond health and communication, which have
traditionally been the primary entry points. Thus, the shift to SBC moves away from the
centrality of communication to also focus on other domains and disciplines that impinge on
development and social change. While communication has remained central in global public
health and development in general, extensive research has revealed new questions that remain
unanswered and new challenges that have emerged about the role of communication in
improving broader social change in international health and development contexts. The shift to
SBC calls into action multi-disciplinary approaches because social and development problems
to be tackled are complex, requiring multiple methods, perspectives and solutions (Addis
Declaration on New Principles of Global SBCC, 2016). Against that backdrop, the SBC
approach fundamentally aims to integrate and build bridges across development areas,
communities of practice, fields of knowledge, methodologies, as well as social and behavioral
programme interventions that have traditionally operated independently of each other.

This integration implies a number of things. Programmatically, SBC interventions are designed
to operate from national to the sub-national levels through the regional and decentralized
district structures and programs implemented by local partners. Institutionally, the SBC
approach creates room for and brings together actors and stakeholders from different sectors:
public, private, for-profit, non-for-profit, academia, civil society, as well as culture- and faith-
based organisations. Theoretically, the SBC approach is informed by and draws on multiple
disciplines that offer evidence and insights into the factors that determine health status of a
country from the lowest individual level to the highest societal level.

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