Social and Behavior Change Communication in Integrated Health Programs: A Scoping and Rapid Review

The aim of this review is to understand the nature and scope of social and behaviour change communication (SBCC) in integrated health programmes, as well as to examine the associated knowledge, attitudinal, behavioural, and health outcomes. The review specifically examined studies or programmes where one or more SBCC approaches were utilised in any programme that integrated across two or more health conditions across the reproductive, maternal, newborn, and child health (RMNCH) continuum of care in low- or middle-income countries (LMICs). The review was developed with the support of the United States Agency for International Development (USAID) through the Health Communication Capacity Collaborative (HC3) project, which is based at the Johns Hopkins Center for Communication Programs (CCP), and the United Nations Children's Fund (UNICEF) with funding from the RMNCH Trust Fund on behalf of the United Nations Commission on Life Saving Commodities for Women and Children (UNCoLSC).

SBCC categories explored in the review include:

1. Community-based approaches: tend to focus on group processes (e.g., participation, consensus building, community dialogue) and the use of public events as ways of reaching and involving community members on a broad scale. Outcomes of community-based interventions usually include some kind of collective action, rather than individual action, although the health benefits of the intervention may be realised at the individual as well as the community level.
2. Interpersonal communication (IPC) interventions: involve face-to-face interaction between health promoters/educators/communicators/service providers and clients. IPC interventions focus on the advantages of personal contact, namely, the ability to tailor information to a client's needs and the power of persuasion and social influence in a face-to-face encounter. IPC may occur in small group as well as one-on-one settings. Counseling is a specialized form of IPC that involves some degree of formal training in the techniques of effective interaction.
3. Group-based approaches: emphasise and take advantage of social structural factors that influence behaviuoral choices. Such factors include the network structure of a social group (and an individual's position or role within that network) and the nature of the interpersonal relationships within a group. This category also includes intervention approaches that focus on normative pressures (both positive and negative) that influence attitudes and behavioural choices among members of the group.
4. Behavioural economics approaches: employ a variety of channels or delivery modes - from mass media to community-based to interpersonal - but are distinct in their focus on economic factors in decision-making, under the assumption that people attach value to behaviours and associate choices with gain or loss.
5. Media and social marketing approaches: includes a broad range of media technologies, including large mass media (e.g., national television) and smaller, more local media and approaches (e.g., community radio). Social marketing approaches adapt traditional marketing theories and principles to the promotion of a behaviour or product that improves personal or social welfare. Media are often used in an integrated way, with multiple delivery mechanisms deployed simultaneously to carry complementary and mutually reinforcing content.
6. Internet/digital media/mobile health: includes a variety of web-based and mobile technologies and software applications that permit information sharing, interaction, and collaboration among users and that allow the creation and exchange of user-generated content.

This review includes 14 key informant interviews with individuals at 11 organisations that are likely to have implemented integrated programmes that have a SBCC component, as well as a mapping of the existing peer-reviewed and grey literature about SBCC approaches in integrated programmes. Of the 36 studies identified, only 14 were from peer-reviewed journals. Although 20 of the 36 studies addressed four or more health outcomes, rarely did the authors specifically discuss the topic of integration, or integration using SBCC, directly.

The majority of programmes (28) used a combination of SBCC approaches. The review revealed that integration of health outcomes tended to follow two major models: "co-occurring" (that is, where behaviours and/or health conditions tend to occur together) and "life-cycle" (in which health conditions that occur at a particular stage in an individual's life are addressed together). The vast majority of studies were focused on health outcomes across a particular stage in the life-cycle, most often the 1000-day cycle of pregnancy, neonatal and early childhood. Many of the co-occurring integration programmes addressed substance abuse, HIV/AIDS, tuberculosis (TB), and violence, and were mostly based in Asia. Of those studies that did discuss integration explicitly, the critical role of partnerships in synchronised and harmonised integrated programmes was stressed - such as those between national reproductive health and malaria control programmes and law enforcement and public health. One study also highlighted the efficiency of an integrated health model, in recognition of the opportunity for cost-saving by coordinating messages and activities for families.

The dose-response relationship identified in a media-only intervention that targeted multiple health outcomes suggests that strategically balancing messages in integrated health programmes should be explicitly considered in programme design based on the priority of outcomes or level of difficulty in changing the behaviour. The review showed that using a combination of SBCC approaches was regarded as a key design factor to increase the effectiveness of programmes. Community-based approaches, IPC approaches, and media and social marketing were the most commonly used, and these three approaches were frequently used together. For example, advocacy and mobilisation were identified as important complementary interventions in programmes using interpersonal communication in order to build community support and ownership of the project, especially when the intervention is designed for stigmatised populations or behaviours. Among those studies using multiple approaches, the importance of consistent messaging across approaches and channels was emphasised.

Findings from this review suggest the need for more explicit examination and greater discussion in the literature of the advantages and challenges of implementing integrated health programmes using SBCC approaches in order to facilitate dissemination of good practices and lessons learned. Among future avenues for research, it is described here as potentially beneficial to explore whether effectiveness is affected by the integration model (e.g., whether the health outcomes being integrated are co-occurring, life-cycle-based, household-based, etc.). Integrated programmes that are using SBCC should consider how different SBCC approaches could be used to create a package of interventions that are harmonious and complementary, while ensuring the consistency and clarity of messages being delivered across different interventions. Messages should also be carefully balanced based on strategic analysis of the priority of health outcomes and difficulty involved in changing behaviours.