The current art and science of social and behavior change (SBC) has benefited from the many lessons learned and documented over the years from a wide variety of disciplines and approaches—including anthropology, psychology, marketing, communication research, social marketing, and more recently behavioral economics and human-centered design. Over the years, SBC has accumulated a robust body of compelling evidence, consisting of both scientific research, and documented success stories that demonstrate how the tools and approaches of SBC have effectively influenced behavior change in almost every area of public health, as well as related sectors. The many creative products and events that have been developed within the field make it easy for us to see that art and creativity play an important role in SBC. However, the science behind SBC is less visible but has, arguably, been even more important to the field’s success.
In what might be the birth of social marketing 1951, Weibe famously asked the question “Why can’t we sell brotherhood the way we sell Coca Cola?” [1, 2]. As in Weibe’s famous paper, SBC has, from its earliest days, sought to identify, document, and implement the most effective means of influencing individual and community adoption of improved practices, whether these were technological or behavioral innovations, to improve health status. Central to his inquiry was the search for an approach that could provide results at scale for good value. And these efforts have been successful. Working in concert with the introduction of innovations from the biomedical field, SBC has contributed to significant reductions in mortality and increases in lifespan in every area of the globe. In recent years, we have seen an accelerated effort to document the evidence for SBC’s effectiveness . For example, in 2013, the United States Agency for International Development (USAID), in collaboration with the UNICEF, hosted the Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change in Washington, DC. The goal of the summit was to determine which evidence-based interventions and strategies support a sustainable shift in health-related behaviors in populations in lower- and middle-income countries to reduce under-5 morbidity and mortality. The results—documented in a special supplement to the Journal of Health Communication—clearly showed the tremendous successes in behavior change programs while carving a path forward to identify the most significant challenges and gaps for further exploration and research .
1.1. Adoption of products and services
It has long been recognized that simply having great products or services was insufficient, if people were unwilling to use them. This is the classic problem of “building a better mousetrap.” The product can only be successful if people recognize the problem, are aware of the solution, find the solution beneficial, know where to obtain the product, find the outlets to be convenient, have the means and willingness to pay, and the list goes on. The public health equivalent is the myriad services and products that have been proven to improve health if only they are adopted. For example, in the earliest years of international development, the USAID and other donors provided family planning and child health technologies, such as contraceptives, oral rehydration solution, and vaccines, to countries with very high rates of child and maternal mortality. They quickly realized that, in order for these new technologies to be successful, they would need to be paired with behavioral interventions to promote adoption, proper use, and adherence. Later, similar strategies were used to increase demand for services, such as skilled delivery and antenatal care visits among pregnant women. It was the behavioral response—adoption of the technological innovation—no less than the innovation itself, that proved crucial to achieve the health outcome. “Better” technologies, like better mousetraps, cannot be effective when communities do not use them or do not use them correctly. Today, we have even more amazing technologies, such as ARVs, rapid diagnostic tests for malaria, PrEP for prevention of HIV, and GeneXpert machines that can distinguish drug-sensitive from drug-resistant TB, with new innovations appearing every day. Optimizing the life-saving potential of these technologies means using the full suite of available behavior change tools and approaches to connect these new technologies with the audience segments that can most benefit from their adoption and use. It also requires effective partnerships and close coordination to ensure that behavioral interventions are well synchronized and coordinated with supply-side sectors such as R&D, service delivery, product distribution, and information systems.
1.2. Prioritize customer experience
Numerous public health strategies, for example, WHO’s End TB Strategy, remind us to develop “patient-centered” approaches . Nevertheless, public sector approaches, especially those in resource-poor settings, often struggle with issues of adequate supplies, staffing, and properly functioning equipment and supplies. Historically, public health has tended to prioritize biomedical over behavioral interventions and adherence to clinical protocols over consumer experience. After all, patients tend to be poor judges of the real quality of clinical care. As every marketer and retailer knows, consumers tend to prioritize subjective qualities such as convenience, friendliness, and appearance. Marketers naturally understand that it is important to be attentive to consumer experience and generally do this better than the public sector. Despite the advantages, this also has its drawbacks, for example, patients can be attracted to substandard care in the private sector, both formal and informal, avoiding more effective alternatives available in a public system fraught with long lines, limited hours, staffing problems, and poor customer service. However, increasingly, public health practitioners realize that, in order to achieve the ambitious health goals that have been set, such as SDG 2030 Goal 3, new tools will be needed and the consumer perspective will need to be featured more prominently . In recent years, in order to bridge this gap, new tools, such as human-centered design (HCD) and nudging, are being adapted from the commercial sector and quickly taken up. Such approaches—that place the customers’ experience at the center of their strategy—are being increasingly adopted and evaluated, in order to increase uptake of priority practices, reduce the gap between clinical and consumer perceptions of quality, and lead to better health outcomes [7, 8].
1.3. Identify behavioral bottlenecks
There are a class of diseases, often termed as “lifestyle diseases,” which include atherosclerosis, heart disease, stroke, obesity, and type 2 diabetes and diseases associated with smoking, alcohol, and drug abuse. Most people are well aware that lifestyle changes—such as regular physical exercise combined with a healthy diet—can help reduce the risk of such serious diseases and lead to a longer better quality life, yet they do not act on what they know so well. Research has shown that these diseases can often be prevented by “simple” modifications in lifestyle behaviors such as eating a healthy diet, regular exercise, avoiding tobacco, and getting proper sleep. This begs the often asked question “why don’t people do what is good for them,” or why do not people act (more) rationally? If people acted rationally, we would not see these diseases at the levels we do. Nevertheless, changing such lifestyle behaviors has proven challenging, involving the full spectrum of SBC approaches to affect all of the factors that can influence decision-making. These include (1) internal factors such as knowledge, attitudes, and beliefs; (2) social factors such as social norms, traditional practices, and the influence of important others; and (3) structural factors such as policies, regulations, and changes in the physical environment that determine access, convenience, and availability.
“Why won’t people do what is best for them?” is a question that has challenged the field of behavior change since its origins and has led us to go beyond addressing individual factors (such as awareness, knowledge, and beliefs) to address the social and structural factors that can have such a powerful influence on individual behaviors. This fight has recently been joined by behavioral economists (BE) who have developed a new field that bridges economics and behavioral sciences to provide a fresh perspective on the seemingly irrational human decision-making and behavior. The field of behavior change has expanded and benefited significantly from the emergence and broad acceptance of this new field and the fresh perspective and tools it provides. Brought into the public spotlight in the past several years, through several best-selling books, as well as numerous podcasts, TED talks, and other popular media, behavioral economics has been able to shed new light on human behavior and what shapes behavioral choice. The BE practitioners have been rewarded not only with popular acceptance but have also been awarded the Nobel Prize in economics three times between 1992 and 2017. BE’s contributions to SBC are relatively recent, so another of our key challenges will be to fully document how significant its contributions can be.
1.4. Negotiate behavior change
For the past 60 years or more, social causes and public health programs have adopted all manners of media to inform and persuade, often to good effect, especially when media channels were combined and paired with interpersonal means of community engagement. Disease outbreaks in recent years have offered an opportunity to examine the role that various forms of communication play as communities and outside experts work and struggle to negotiate local solutions. The West African Ebola outbreak 2014–2015 clearly showed that media was able to quickly and broadly convey information about the risk to audiences near and far. However, suspicion and rumors could also spread quickly through social media and social networks and just as quickly lead to detrimental results. We also saw that medical solutions could be stalled or ineffective without community dialog and effective, negotiated community engagement . Disease outbreaks such as Ebola have clearly shown that communities need to be engaged from the outset, and, if their concerns are ignored, they can mobilize to thwart the efforts of public health workers. In outbreak situations, decisions must be made quickly, so it is not uncommon to find a small village besieged by technical experts from the outside—whether from the district, the capital, or other countries. It should not be surprising that communities that have become accustomed to receiving few services from the outside may be suspicious of the sudden attention, and it is not unusual for rumors to spring up questioning the motives of the outsiders. “Community engagement” has become the broadly accepted term to describe the strategy for creating dialog with communities to gain or regain their trust and cooperation in the face of an outbreak or other unusual health event. An important aspect of community engagement is the recognition that behaviors are not determined solely by individuals. The “social” in social and behavior change is important because individual choice has its limits and behaviors often involve social norms, traditions, and taboos. In order to successfully influence individuals to make better choices, we need to engage social networks effectively, for example, by building on the important roles played by respected leaders in the community and elders within the family . For example, during the Ebola crisis, traditional burial practices and customs were found to be a major conduit of disease transmission. However, the solution was not to end traditional practices. Community leaders and technical experts worked with experts in SBC, including anthropologists, to find out ways to accommodate traditional beliefs and practices in behaviors that were also effective in stopping transmission.
2. Looking forward
The field of SBC has come so far from its origins in the middle of the last century. Over the years, it has built a strong evidence base, demonstrating the link between health outcomes and key behaviors. Moreover, through science and practice we now have a broad and robust set of tools and approaches available to identify and address the individual, social, and structural factors that influence behaviors. We have gone from simple awareness-raising campaigns to the use of scientific methods to build evidence-based approaches. In order to achieve the ambitious 2030 SDG health goals, however, SBC will need to provide support to the technological innovations that will be necessary and can only realize their potential if they are adopted and put to use. And technological breakthroughs are not limited to the medical field. We should expect that the important media technologies that connect our communities will also continue to evolve. Even potential disruptive policy solutions, such as Universal Health Care (UHC), will need to draw on SBC approaches to influence policymakers; target and monitor uptake among key audiences, such as lower-income or marginalized audience segments; and educate providers.
To meet these challenges, we’ll need to continue to develop and draw on behavioral science, have an open mind, be open to new learning, and continue to add to the evidence base of what works and what does not. We will need to work and coordinate ever more effectively across multiple sectors and across ever more partners, defining roles and responsibilities so as to optimize the contributions of our various contributing partners—host country governments, multilateral agencies, international and local implementing partners, community-based groups, NGOs, donors, media, research agencies, and local communities themselves. We’ll need the field to continue to develop tools and advocate for approaches that bring the consumer experience to the central focus of strategic design, implementation, and research. After all, SBC must continue to prioritize the voluntary nature of behaviors and the importance of incorporating community sensibilities, traditions, and preferences. We need to strive to ensure that respect for our key audiences, especially the poorest and most marginalized, is brought to the front and center of considerations regarding planning and implementation. In that spirit, practitioners should strive to elevate the experience of the humble villager and represent their perspective at the decision-making table with more powerful policymakers and technical experts where strategies are developed and implementation plans are drawn up. As behavior change planners, researchers, and practitioners, we should strive to sharpen our instruments to identify and address the factors that will reduce the barriers to behavior change for our beneficiaries so as to make voluntary behavior change as positive experience as possible. And lastly, we will need to keep an eye on the needs of policymakers and funders because the decision to fund behavior change approaches ultimately rests on our ability to provide solid evidence that SBC can deliver health outcomes at scale for a good value.