Intentionally Incorporating the Social Determinants of Health into Social and Behavior Change Programming for Family Planning

"Most effective SBC [social and behaviour change] frameworks and process models...aim to include and review many social determinants....Despite these and other efforts to call attention to the deep structural barriers that impede health, the field of SBC is often drawn back to focus on the individual and must do more to address these determinants where possible."

The field of social and behaviour change (SBC) recognises that factors beyond the biomedical model of health affect health and well-being, but SBC programmes too often overlook the root causes of health disparities. From Breakthrough ACTION, this document provides evidence to guide strategic decision-making among donors and governments in support of SBC initiatives to reduce inequities in family planning (FP)/reproductive health (RH), though its content is broadly applicable to SBC across all health and development areas.

In providing background, the brief explains that social determinants of health (SDOH) impact several FP/RH indicators, including unintended pregnancy. For instance, women from disadvantaged circumstances are both more likely to experience an unintended pregnancy and face more severe consequences as a result. Further, youth experiencing social inequity have a higher unmet need for contraception due to economic, cultural, social, religious, logistical, and legal constraints that limit their access to safe, affordable contraceptives.

Thus, the FP/RH community must start by looking beyond access to RH services and identify gaps in areas such as poverty, education, childcare, housing, business, law, media, community planning, transportation, and agriculture. The current evidence suggests the following to guide thinking in this area:

• Require SBC programmes to provide evidence of meaningful partnership with communities in all aspects of SBC programme design, implementation, and evaluation to ensure that project activities are driven by community needs and values.
• Explore long-term, multi-sectoral, and co-funded partnerships to address the social determinants of FP/RH inequities more effectively.
• Prioritise SBC interventions that address the structural and intermediary determinants of FP/RH outcomes.
• Ensure FP/RH programmes provide equitable coverage of FP/RH products and services (note: interventions delivered at community level are usually more equitably distributed than those primarily delivered in fixed facilities).
• Incorporate a life-course perspective into FP/RH programme strategies and portfolios.
• Encourage community-based participatory approaches, such as human-centred design (HCD), to address community-level determinants of FP/RH outcomes.
• Strengthen national and global health equity surveillance systems to monitor FP/RH and other health inequities.
• Use an intersectional gender lens to analyse and address the SDOH that disadvantage specific subgroups. (For example, the intersection of gender norms, economic and educational inequality, and other SDOH lead to poorer health outcomes for adolescent girls, who, compared to boys, tend to receive less education and information about sexuality and reproduction, have poorer access to health services, and be at higher risk of unsafe sex.)

A series of examples, largely from the peer-reviewed literature, provides a starting point to inform future programming decisions, particularly related to FP/RH outcomes:

• Client-centred care, which might involve providing mobile outreach services, offering a wide choice of contraceptive methods, ensuring affordable quality care, integrating services for maximum efficiency, and focusing on mobile populations, including migrants and refugees.
• FP/RH service vouchers, which can be used to increase demand for FP/RH services.
• Social accountability, which encourages monitoring and oversight of public and private sector performance and responsiveness through collective action.
• Diagnosing inequity and determining barriers to use, which can be facilitated by links to tools included here that facilitate collection and use of data for a more granular segmentation to ensure FP/RH services reach underserved populations.

Per Breakthrough ACTION, more research is needed to better understand how the SDOH impact FP/RH outcomes and how SBC strategies are best placed to address them. For example: How should SBC strategies be used to improve equity within FP/RH (e.g., advocating for policy change, influencing public conversation and norms, and contributing to/supporting collective action, among others)?

In conclusion: "The evidence and considerations presented here will hopefully inspire decision-makers to address the SDOH and, in doing so, reduce inequities in FP."