The Role of Social and Behavioral Change Communication To Address Inequities and Disparities in Public Health: Reflecting on Themes from the 3^rd International Social and Behavior Change Summit

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In December 2022, the 3^rd International Social & Behavior Change Communication (SBCC) Summit took place in Marrakech, Morocco, building on previous conferences in 2016 and 2018 in Ethiopia and Indonesia, respectively. This conference brought together 1,800 participants from 129 countries to share research and practice aimed at creating and accelerating transformational change in critical, interconnected areas of global, regional and local concern: environmental crisis; gender equity; disparities in health, wealth, and social and racial justice; and humanitarian action. Beyond individual behavior change, the Summit emphasized ways to address structural determinants of behavior, and to nurture social movements and new voices for change. More than 40% of the participants were from low- and middle-income countries and 10% represented youth under the age of 24 years old. Reports from the Summit can be found here: https://sbccsummit.org/en/summit-reports/.

Over the course of five days and nearly 600 sessions, presentations and discussions explored and critically assessed what we know about how to generate transformational change, how the world of SBCC is changing and the future of the field, and how to foster cross-sectoral, cross-disciplinary North–South collaboration and co-creation. This Supplemental issue of the Journal of Health Communication contains papers based on themes and presentations from the Summit with a special emphasis on disparities and inequities in public health. The call for papers highlighted the following themes and questions:

1. Transformational Change. What have we learned about how SBCC can affect some of the world’s most pressing challenges including climate crisis, gender equity, disparities in health and wealth, humanitarian action, and others, and help to accelerate and achieve change at scale?

2. Future Forward. What do recent experiences, programs, and research suggest about where SBCC is going, the future of technology, of democracy and social justice, of pandemics and infodemics, of ethics, and of new challenges, innovations and methodologies that can advance the field?

3. Connecting the Dots. How can we grow our field by building bridges between sectors, disciplines, stakeholder groups, and areas of praxis and research, in order to collaborate, strengthen networks, share resources and skills, and elevate the potential and impact of our field?

The Summit was originally planned to occur in 2020, but the COVID-19 outbreak forced postponement. It was expected that the timing of the Summit, coming just as the world was beginning to emerge from the pandemic, would generate considerable research and practice reflecting the impact of COVID-19 on society in general and on SBCC specifically, and it did: what challenges were faced, what health issues were prioritized, and how social and political structures and relationships were disrupted, repaired, and reconceptualized. Indeed, the collection of papers here reflects various ways that SBCC—and those using and studying it—responded to those conditions, disruptions, and opportunities, whether or not the focus was on COVID-19 per se.

Despite the overarching influence of the pandemic experience, articles in this volume reflect considerable diversity. They report on work in diverse geographic locations: five Sub-Saharan and Francophone and Lusophone countries in Africa (South Africa, Mozambique, Cote d’Ivoire, Kenya and Rwanda), two European countries (Portugal and Turkey), three countries in Asia (South Korea, Singapore, and India), and the United States. They also represent a broad range of methodological approaches including longitudinal content analysis of social media data, television news data, and epidemiological data; use of human-centered design and qualitative research; quantitative analysis of survey data and structural equation modeling; audience segmentation analysis; a quantitative pre-post evaluation of an in-school intervention; desk review; mixed methods case studies and participatory action research.

Content diversity continues across the Summit themes. Studies focusing on the Transformational Change theme were aimed at identifying what approaches and strategies may work to create sustainable change on a large scale. For example, in a study from South Africa, Jones et al. focus on the use of behavioral nudges to address barriers and facilitators related to COVID vaccine acceptance. Their analysis of population-based survey data and use of audience segmentation techniques identified key hesitancy factors including complacency, lack of confidence in the vaccine, lack of access, and convenience. They compared four different strategies to address barriers: Informing (“mindset” barriers), Enabling (barriers related to faith-based and community-based support), Incentivizing (barriers related to financial inputs), and Mandating (e.g., initiatives to reduce barriers in the workplace). Incentivizing had limited impact, while others showed promise. This paper also illustrates the importance of embracing failure as part of test and retest initiatives guided by behavioral science. In another South African study, Mazonde and Goldstein address some of the tensions emerging around the evolution of digital technologies and describe how to leverage social media—despite its pernicious ability to spread misinformation—for positive message framing related to stigmatization around obesity. Their analysis suggests possible structural and policy changes that can help to reduce the individual blame bias that discriminates against overweight persons. In India, Gupta and Anand focus on what works to address another vulnerable population: children in poverty settings. Their study reports on the evaluation of an experiential classroom learning approach to teaching germ theory and hand hygiene using colorful glitter to demonstrate disease transmission and the effectiveness of washing with soap. Their simple pre-post study with a four-week follow-up test of knowledge and behavior change highlights the use of entertainment education (music) to reinforce and sustain learning. They remind us of the central role that story telling continues to play in SBCC initiatives. Last under this theme, although Kim et al. do not focus on mental health per se, they tested emotional pathways to support for COVID policy and protective behaviors such as physical distancing. Their analysis differentiates between types of negative emotions (anger, fear, sadness, anxiety) and finds that fear motivates support for government policies while anger does not. Those emotional reactions are influenced by exposure to partisan media especially when media content opposes current government policies. Similar results are found in the individualistic US culture and the collectivist South Korean culture, suggesting a mechanism underlying the relationship between media partisanship, public trust in and support for information sources and policies, and public health behavioral decision-making.

Other studies in this volume focused on the Future Forward theme, considering emerging technologies, opportunities, and challenges related to closing gaps in SBCC reach and impact. For example, Akin, Turkel and Umul analyze university-based community service practices courses in Turkey, that aim to strengthen youth civic engagement, and the ability to challenge negative social norms and build new generational perspectives. During COVID, student work-study projects focused on developing digital citizenship skills to combat misinformation (e.g., anti-vax altudes), reduce “semantic noise” (i.e., misleading or confusing jargon) in social media, and improve Wikipedia content related to the pandemic. Their experience suggests that this approach may be scalable and, perhaps, serve as a platform to engage youth on other social issues such as climate change. Developing new theoretical insights is another Future Forward endeavor. For example, Hopkins et al. developed an elaborated version of inoculation theory and used it to pilot an online game for audiences—especially youth—aimed at reducing susceptibility to misinformation about vaccines in general (not just for COVID). Specifically, they attempt to increase media literacy by drawing attention to key features of misinformation (the FLICC framework: False experts, Logical fallacies, Impossible expectations, Cherry picking facts, and Conspiracy theories) and using humorous parallel argumentation to make gentle fun of one’s “Cranky Uncle.” Their creative use of HCD helped them develop scripts, characters, and pertinent FLICC characteristics for the game. In Singapore, Bao and Lee considered what a new technology had to offer and how to get people to trust it and to use it. They examined efforts to improve the use of a new contact tracing mobile app for COVID control. Like Hopkins et al., they expanded on an existing framework, in this case the cognitive mediation model (surveillance gratification, media attention, news elaboration), by adding intrinsic motivations (threat perception and health valuation). Using survey data and structural equation modeling, they identified differences in sources of health information and levels of attention by medium, with social media generating the highest levels of attention and motivation to use the app. In a very different domain, Koné and Tchéré consider changes in SBCC training approaches in Francophone Africa, specifically Cote d’Ivoire, that were severely disrupted by repeated COVID and Ebola outbreaks; they look ahead to new opportunities and technologies that emerged. Their documentary review describes the multisectoral and multinational collaboration on communication training that took root beginning in the HIV/AIDS PEPFAR era and then shifted to online training, development of distance learning technologies, and the addition of new topics such as risk and crisis communication, countering misinformation, advocacy for training and funding, and community mobilization that were catalyzed by pandemic conditions. When the COVID pandemic waned, approaches shifted back toward more localized, smaller scale in-person learning, but retained some of the features and content that emerged during the crises. Their analysis also draws attention to the need for more anthropological perspectives on orality and learning in the African context.

Two articles in this volume addressed the Connecting the Dots theme that emphasizes building disciplinary bridges, expanding networks, and increasing collaboration. In Mozambique, Costa et al., focus on infant and child feeding in rural, low-resource settings in the form of an effort to link peer educators and mobilizers to deliver an interactive community-based learning activity. They evaluate the use of “emo-demo,” a technique designed to evoke emotional response, and reinforce learning and behavioral motivation. Engaging community volunteer trainers to lead group-based learning sessions was meant to create local connection and relevance and increase scalability. However, they identified difficulties in training volunteers in the theory of change and in implementing interactive, participatory activities, again demonstrating the value of embracing failure in order to learn. Their analysis derives recommendations for how to overcome these challenges. Finally, in Portugal, Lopes and her colleagues focused their study on coordination between television news organizations and epidemiological scientists and the challenges of public service journalism during an extended crisis. They describe the rhythms of coverage over time as the media responded and adjusted to the complexity of a pandemic, of emerging epidemiological science, and—eventually—pandemic fatigue. In their case, media provided relatively low emphasis on protective behavior during the period of greatest severity as they shifted news emphasis to policy changes and vaccine development, which may have contributed to a longer period of severity. Their analysis indicates a need for the development of pre-pandemic preparedness plans for coordination on the part of both media and public health partners to avoid mismatches between public information needs and epidemiological trends. In Mozambique, Costa et al. focus on infant and child feeding in rural, low-resource settings in the form of an effort to link peer educators and mobilizers to deliver an interactive community-based learning activity. They evaluate the use of “emo-demo,” a technique designed to evoke emotional response, and reinforce learning and behavioral motivation. Engaging community volunteer trainers to lead group-based learning sessions was meant to create local connection and relevance and increase scalability. However, they identified difficulties in training volunteers in the theory of change and in implementing interactive, participatory activities, again demonstrating the value of embracing failure in order to learn. Their analysis derives recommendations for how to overcome these challenges.

Taken together, the collection of articles in this supplemental issue provides a sample of the diverse and important work that was shared during the Summit and is a testament to the ability of a global community to respond to and learn from a period of unprecedented social and political upheaval. It is our hope that this collection will stimulate further and broader consideration of what SBCC can do, a deeper appreciation for the kinds of evidence that exist for the effectiveness of SBCC within and across multiple domains of public health and development, and of creative ways to respond to the ongoing challenges we face as a community of research and practice and as citizens of the world.

Where do we see the field moving to in the future? As in previous SBCC summits, a volunteer group of participants reviewed presentations, events, and social media engagement, and canvased many other participants to identify broad themes and key insights emerging from the conference. They provided a report of those insights along with recommendations that may help to continue moving the SBCC field forward (see Table 1).

Table 1. Insights generated from the SBCC summit

Insights	Recommendations
We (the SBCC community) need to break paralysis around climate behaviors at every level.	Following the lead of youth, we need to advocate for governments to take positive climate actions, and integrate climate into SBCC programs, now.
We have a duty to systematically infuse community voices into program design, implementation and evaluation.	We collect the lived experiences of community members in the formative research, but don’t always include in our strategies what we gathered from the communities or what already exists in our evidence-based programs. Those experiencing the change should define success and how data are collected and utilized to inform programming. Empathy and co-design are no longer optional principles in social and behavior change programs.
The language we use can drive accountability and inclusion, and shift power dynamics.	Words have the power to connect and catalyze, divide, regress, include or exclude. For example, reference to the “North/South” dichotomy has the potential to perpetuate or dismantle that power dynamic; the “donor/recipient” labels may impede the creation of an accountable partnership; jargon may exclude and disenfranchise key stakeholders. Let’s listen and make space for new language that reflects our desired future. It is imperative that we “include the voices and use language that helps all participate in the dialogue.”
Reframing communication as a human right puts equity at the heart of SBCC.	Communication is not just a tool to make change happen. When people can openly express themselves, be heard, and understood, they become the principal architects of their futures.
Digital approaches require respectful, ethical engagement.	Given the tension between the speed at which digital technology is evolving and our ability to ethically, safely, equitably, and systematically ensure protection of people and data, we need to: protect data, particularly when working with communities that are at greatest risk of harm when their privacy is violated; become active fact-checkers; continue to experiment with software and AI; and ensure free expression.
Embrace failure.	We need to turn away from competition and turn toward more generosity and collaboration. We should strive to create an SBCC community that feels safe enough for us to honestly share our programs’ failures and generous enough to receive them as a gift. Competition, lack of coordination, and duplication across SBCC sectors and countries limits our potential to improve the human condition and the health of our planet.
Create spaces to expose distress – including our own.	Poverty, sexism, disease, violence, and mental health have a compounding effect on key audiences and those who work to address those challenges. Incorporating opportunities to process and address mental health should be integrated into SBCC programs.
Storytelling helps create meaning and connection and brings data to life.	Many participants spoke passionately about the power of storytelling to motivate behavior change and connect people to an issue. Yet, we need to do a better job of sharing and elevating these stories.

Although no papers were submitted for this issue that addressed the issue of climate change—a matter of considerable concern at the Summit (readers may want to consider reading the Summit’s report using the link provided above to access information from specific climate change sessions and presentations through the Summit’s website)—the collection nevertheless reflects most of the other insights derived. First, it makes clear that communication processes and channels remain at the heart of the health and development agenda, across continents. Second, SBCC continues to operate across a continuum of low tech to high tech environments in response to specific social and communication contexts, including the disruptions of COVID-19. Third, papers document a wide range of interventions and analytic approaches across the spectrum of individual behavior, community engagement, social mobilization, and structural change. Fourth, theory and evidence continue to evolve in response to needs, technological development, and sociocultural conditions. Fifth, the role of news media remains critical and the growing purposive use of misinformation in social media channels has become extremely concerning if we are truly committed to ensuring that individuals and communities have the right information and are empowered to make informed decisions about their health and other development issues.

Both the SBCC Summit insights and this collection of papers point toward a field of constant fermentation, growth, redefinition, innovation, and most importantly, interdisciplinary dialogue. Global events like the Summit will continue to provide critical opportunities to learn, share, debate, and evolve as a field, with a strong focus on the role of theory and evidence. The Summit and these papers reinforce the centrality of communication, inclusive engagement, culture, and human rights in our efforts to support social and behavioral change.

We thank the SBCC Summit Secretariat and the JOHC for the opportunity to put together this supplemental issue and hope that it will contribute to strengthening knowledge, learning, and collaboration in our field. We also hope that future Summits will undertake similar efforts to grow the capacity of the SBCC community to have an impact on the critical issues that affect our world and the future of humanity.

Additional information

Funding

Funding for the publication of this supplemental issue of JOHC was provided by the Special Issue Sponsor, the Johns Hopkins Center for Communication Programs, which was one of the organizers of the 2022 International SBCC Summit. The authors of this article did not receive personal financial support for their efforts.