What is Social and Behavior Change?
Tomas Jensen in a training session with MoH and UNICEF staff in Cambodia in 2022, on how to use social and behavior change to improve nutrition outcomes for children. RBC/2022
Tomas Jensen sits down with Ellen Weiss to highlight the expertise that has come to define Rain Barrel’s primary work as a consultancy network of SBC experts.
Ellen Weiss: Just so everyone can understand, what is SBC?
Tomas Jensen: SBC stands for social and behavior change. We use the term to describe how we work toward specific social and behavioral outcomes. Communication is a part of it, but it also includes design of policies, of environmental factors, technology and economic mechanisms that can support change. It's a broader scope than what was previously considered communication for development. The focus is the same, but the toolbox has expanded.
Why is it important?
If, say, we agree as a world that we want to live in a peaceful place where infants and children are loved and cared for, and not subjected to verbal or physical abuse, then we need to work on establishing that as a social norm. So, for example, if you have a community where everyone agrees that it’s unacceptable to be violent towards children, that becomes the guiding social norm for that group of people. If we want to have change that is deep and sustainable, caregivers need to both know why it’s important to not be violent with children, and they need alternative behaviors. They need to know the benefits and they need to be supported to practice these behaviors.
We share information with caregivers that when you’re violent with your child, you're actually teaching your child to be afraid of you, and not to learn and or test or try. In the long run that’s not only unacceptable from a moral perspective, but it's a bad investment in your child's future. But without long-term engagement to establish the right conditions for adoption of the desired norms and behaviors, we're not going to see the desired change. We also advocate for laws, policies and services needed to enable new norms to gain traction over time. So, not only is it good for the individual family to practice positive discipline instead of violent discipline, but it's also good for the entire nation, right?
We always base our work on science and evidence, and the available evidence is overwhelmingly clear that children who are nurtured develop their capacity to learn, adapt, and innovate in a much stronger way than children who are punished. Which translates to how they engage in school and in the job market. That has a clear socio-economic benefit throughout society. Also, of course, children exposed to abuse and violence develop trauma, and that often translates into very bad coping mechanisms like alcoholism or drug abuse. It’s much more costly for society to help a traumatized person than a person who contributes positively to society.
How quickly does SBC produce results?
It’s important to understand that in most cases, working with social and behavior change is a long-term process. It can take many years -- sometimes decades -- to achieve results. Take smoking, for example. When I was younger, people smoked on planes, on the train, in restaurants, and at work. Today, in many countries, nobody is smoking in these places. That change has taken 40 years at least. That's an example of how sustained and coordinated change efforts over time have really worked.
Back in the days when smoking anywhere at any time was the prevailing social norm. Photo: https://www.bikechaser.com.au/news/old-school-cycling/
On the flipside, social and behavior change can come around very quickly when we are confronted with immediate and significant risk. The changes that affected us all and very quickly when the global COVID outbreak began in early 2020, is an example of that.
Rain Barrel usually works with different phases of the SBC process. It’s rare that we are recruited to support a process for a decade. We may be contracted to focus first on the research to understand behavioral drivers and barriers. Later we might work with communities and other stakeholders on the strategy, and then maybe on the design of an initiative, or a campaign, and then later perhaps on the evaluation and reporting on the process and outcomes.
We've done plenty of behavioral research, for example, that has helped us better understand what keeps families from prioritizing breastfeeding, and what will motivate more mothers to breastfeed. This is an important part of early childhood development. We use the findings from research to help design related strategies, initiatives and tools that will contribute to an increase in the practice of exclusive breastfeeding. This may include a focus on developing or revising relevant national policies, caregiver education curriculum, or guidance for corporations, for example, on how to make sure that women can keep breastfeeding their children when they go back to work.
Have you ever seen such results from your work?
Let me give you just one example. Before joining Rain Barrel, I was the manager of a five-year initiative to strengthen the national health promotion capacity in Cambodia. At the time, less than 7% of families utilized antenatal care services. This meant that a lot of treatable illnesses and infections were not being discovered and prevented, contributing to very high maternal and infant mortality rates. We had the time and the resources to strengthen health workers’ capacity to engage with families at health clinics, while at the same time roads were being built that made it easier to get to the clinic. Media outreach was also expanded. And the community engagement capacity of health teams was increased as well, right down to the village level. All these things combined to enable us to say to Cambodian women, very simply, “If you miss your period, go to the health clinic within the first month of missing it.” We could then say, “When you come in, you get medicine, you get counseling, you get immunizations that will prevent you and your child from getting sick.” By using all these approaches, over the course of 12 months we managed to go from less than 7% of families using these services in the first trimester to more than 25%. That has a huge impact on health-related outcomes. Over time that grew to above 50% of families coming in during the first trimester of pregnancy, and maternal and infant mortality rates have dropped significantly. We see the evidence that every time you invest properly in social and behavior change, and give it sufficient time, it really works.
Banner from the Cambodia ANC campaign launched in 2008: If you miss your period, go to the health clinic within the first month. NCHP/2008
So, it has an additive effect, because when women see their friends getting prenatal care it makes them more likely to do it right?
Yes exactly, we've seen time and time again that when proper and robust community engagement and capacity development of systems, structures and service providers is not prioritized, these initiatives don't work. We have to study the communities, to listen to their concerns, and identify what they’re influenced by. We're not just influenced by what we see on the media, we’re strongly influenced by what our families and friends and communities do too.
So just seeing a poster telling you what to do isn’t enough, right?
A poster by itself rarely has any impact on how you behave. If there isn’t a trusted person sharing the information, it’s very easy to disregard it. And you may never see the poster in the first place. So we have to be more sophisticated in integrating our work in every aspect of our environment. It has to be the poster, television and, now more than ever, social media. It has to be the health worker, the teacher, the youth leader, and also the politician as well as your neighbor and your family. We need to have a holistic and integrated approach, and we need to ensure that we work to include everyone – all genders, all ethnicities and people living with disabilities. If we don’t make a special effort to do so, it is very easy to leave out people who have both a right to be included, and who are key to the change to be meaningful and sustainable.
Why is SBC work a good fit for Rain Barrel?
Rain Barrel was established by Robert Cohen and Paul Hoeffel in 2008, after they had spent their time in the United Nations, to assist the UN system and other clients with communication and social and behavior change support. It's a good fit for us because SBC is needed in achieving pretty much any of the UN’s Sustainable Development Goals, which aim to greatly reduce poverty and make our world more just and sustainable by the end of this decade. Many of the changemakers we have in our network have a background in the UN and in SBC. We also have people who have other and related experience -- with corporations, governments, and with non-governmental organizations. For example, behavioral designers who consider how a hospital should be designed to help patients get to the right place, and innovators who design technological solutions for improved energy efficiency. It's so important to look at social and behavioral issues from all angles.
Many of Rain Barrel’s professionals have extensive experience in this field, so we know what is more likely and less likely to work. Embedded in our approach are all the good practices that we’ve learned.
Can you tell me about one of your favorite initiatives?
We recently completed work in Lao People's Democratic Republic on strengthening handwashing practices. We first did research to figure out what's keeping people from washing their hands with soap, and what motivates them to do it. Working at the community level, we found out that the single most important factor is that they don't have soap and water at the place and time when they need to wash their hands. That’s not always because they don't know it's important to wash their hands -- it's because they may live in settings where latrines with running water haven’t been built because it hasn't been made a priority. Or they don't have soap at the latrine; they keep soap for when they have a shower. So when we work with communities, we come up with solutions together. For example, local cafeterias, canteens, and restaurants can make sure that there’s a handwashing facility with water and soap right at the entrance. Or we can help communities have handwashing stations with soap at their latrines and in kitchens. That starts creating a systematic approach toward the social norm. We've also found that when people feel more clean and comfortable they're more confident with other people. So we focus on that. We see that mothers are much more likely to wash their hands with soap to protect the health of their children. And we can also amplify the mothers’ practice for fathers, to also start prioritizing this for their children. I'm very excited about it because it shows how important it is to really understand what drives behavior, and use this to inform relevant and effective SBC initiatives and solutions.
A representative from the Lao Women’s Union in the process of co-creating an innovative prototype low-cost soap dispenser, at a community co-creation workshop. RBC/2022
It also makes me want to emphasize how important and essential it often is to take a systems-building approach to SBC. In many affluent countries, infrastructure elements like water and sewage systems are developed and supported through a taxation and administrative system that constantly maintains them. I think in the past we've had a tendency in our understanding of how things work in different parts of the world to just say, “It's because they don't know.” It's not only because people don't know, but also often because they cannot do. So in this case we really need to take a longer-term approach to SBC. In the case of handwashing with soap, it may require first the establishment of the social norm that we should as a society invest in the infrastructure that allows people to wash their hands. That doesn't happen over three or five years. But it's much more cost-effective for society to have good infrastructure than it is to have poor infrastructure and treat the poor health outcomes. So if that is lacking – that is where we have to start. There are no shortcuts to targeted and sustainable change.
Let's talk about the future of Rain Barrel regarding SBC.
We've positioned ourselves to take the best of our knowledge and experience into the future, particularly focusing on how we use digital technology to reach people. We’ve expanded our network to include more experts who specialize in climate action. We have people specializing in health, child protection, nutrition, education, gender, and disability inclusion. So we’re very broad in what we can do, and we have a lot of really experienced professionals who are helping our younger change experts learn, and take into the future, our best and combined knowledge about what works and what doesn’t. In that sense, Rain Barrel’s future is really all about working with communities, organizations, governments, and partners, to use our skills to contribute to more social justice and more environmental sustainability in our world. Nothing more, nothing less.