The ABCs of SBC

The ABCs of SBC

• UNICEF SBC • Season 1 • Episode 1

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Social and Behaviour Change (SBC) brings together a variety of tools to shift the way people and societies behave. When applied to policy, it’s helped reduce traffic deaths. When brought into clinics, it’s helped tuberculosis patients complete their treatments. When brought to US college campuses, it can even help explain why students won’t stop binge drinking. In this episode, Qali speaks to SBC practitioners at UNICEF and beyond about behavioural theory and the power of social norms and how to leverage them for positive change.

More resources on Antanas Mockus:

Guests

  • Mónica Wills-Silva, Director of International Programmes EMEA at the Behavioural Insights Team
  • Xaher Gul, Public Health Physician and Development Practitioner 
  • Naureen Naqvi, Lead SBC Specialist in Humanitarian Action at UNICEF
  • Laura de Molière, former Head of Behavioural Science for the UK Government’s Cabinet Office
  • Deborah Prentice, Vice Chancellor of the University of Cambridge 

Resources

The views and opinions expressed by the contributors are their own and do not necessarily reflect the views or positions of UNICEF or any entities they represent. The content here is for information purposes only.

The ABCs of SBC is hosted by Qali Id and produced and developed by Helena Ballester Bon in partnership with Common Thread.

Check out UNICEF’s latest publication on Social and Behaviour Change, Why don’t you just behave! For more information about UNICEF SBC, check out the programme guidance.

We care about what you think — you can share your thoughts on the podcast using this feedback form. For all other inquiries, please contact sbc@unicef.org.

Qali Id: Depending on where you are in the world, you might know UNICEF as the orange trick or treat boxes or the people in blue vests. With presence in over 190 countries and territories, there are a lot of different ways UNICEF is working to protect and uphold the rights of children. But with such enormous responsibility in an ever complex world, How is UNICEF adapting to meet the needs of the world's most vulnerable children?

This is the ABCs of SBC, a new podcast from UNICEF on a secret sauce they've been developing for decades. SBC, or for those in the know, social and behaviour change. But what does that mean exactly? My name is Qali Id, and before we embark on this journey together, there are four things that you need to know about me.

I'm a natural born storyteller. I'm curious about the human experience. I'm dedicated to advocacy and change making, and I'm a child of the world, or as people would call, a third culture kid. These four things are why I work in the humanitarian and development sector, have become a published writer and documentary photographer, and the creator of the Qonnect podcast, which has been on The Guardian list for the best African podcasts.

So in other words, I'm the millennial stereotype of being indecisive. I'm familiar with social and behaviour change, but I've been hearing more about it over the years, and I'm on a mission to understand what it actually is, what it looks like, and how it can make a real difference in the challenges that we see across the world.

So if you're interested in understanding the levers of change and meeting the people behind this work, keep listening. Our first stop, Colombia.

Monica Wills-Silva: I’m Monica Wills-Silva. I am a principal advisor at the behavioural Insights team in our International programmes team. I grew up in Bogotá, Colombia in the 90s, which at the time was one of the most dangerous cities in the world.

And here comes this mayor with this quirky alternative approach to public policy to introduce policies that better reflected our behaviour, our norms, that ultimately start to change people's behaviours and lives.

That mayor of Bogotá was Antanas Mockus who was in office between 1994 and 2003. I was surprised to come to learn of his unorthodox approaches like employing mimes to control traffic and showering on television during a water shortage. Now I don't know about you but I'm a comic book fan and I understand that it's all fiction.

So I was surprised to learn that he would wear red tights and roam the city calling himself super citizen. And although citizens must have found this incredibly entertaining to witness, it also got results. While he was mayor, average traffic fatalities dropped from 1, 300 to 600 per year, and water usage dropped by 40%.

Fast forward to my Master's, I took a class called Governing by Ideas. Where we were studying alternative approaches to public policy, one of which was behavioural science and how it could be applied to improve policies. But also we saw this anecdotal case of Antanas Mockus in Bogotá in the 90s. And that's where I realised that this was something that I had seen worked in my life and that I just wanted to bring to others and to other places.

Qali Id: Do you mind telling me what you do at the Behavioural Insights team? 

Monica Wills-Silva: We try and introduce a more realistic, evidence based model of human behaviour into the design of policies and programmes. And we do this also by trying to understand the context where the behaviour is happening, try and understand the sort of local population, their needs, their priorities.

This allows us to understand what works and, importantly, also what doesn't work. 

Qali Id: In your experience, what have you seen that's really worked? 

Monica Wills-Silva: One of the projects that I think really illustrates the impact that these approaches can have is a project that we did with UNDP in Moldova. Moldova is a country that has one of the highest tuberculosis rates in Europe.

Even today, and even till we have a treatment, around 1. 5 million people die of tuberculosis, largely because a few of them did not complete their treatments. And so we were working with UNDP in that case to see whether there was something that we could do to help some of the tuberculosis patients achieve or complete their treatments and address some of the barriers that they were facing.

And so in Moldova, they follow the WHO guidance, which is a directly observed treatment, which means that you've got to go to a clinic and be observed by a medical practitioner, taking your medication to make sure that you're doing it well. Which, as you can imagine, brings in all sorts of barriers, right?

You've got to make sure you're arranging for someone to look after your children if you've got children. You need to make sure you've got time to go every day to a clinic. There's also a lot of stigma around being identified as a tuberculosis patient. And so, this is some of the barriers that people were facing to complete their treatments.

In order to address them, we designed an intervention which was basically a video observed treatment. Patients would record themselves following a very strict protocol, where they would be interacting with a specific medical practitioner. We saw an increase in 40 percent in adherence with the medication, which is roughly the same rate that we see in other places in Europe, like in the UK.

Qali Id: That is a real difference. And as someone who has a background in public health, I completely understand the real stigma that exists with TB patients. Would you be able to help myself and the listeners understand what it is about your process that leads to these sorts of solutions that work? 

Monica Wills-Silva: We take programmes that are already there and try and create interventions that are not largely disruptive but that are working with the sort of programmes that are already in place.

We try and do small modifications that reflect this understanding of human behaviour that we have from the literature and also we try and incorporate these sort of insights that we gather from the qualitative work to make them as impactful as possible. 

Qali Id: Sounds like SBC is my favourite kind of science. It's all about forming a deep understanding of people and their context by mixing what the literature says with what you discover through your own qualitative research. Think of it as book smart and street smart at the same time. But not every practitioner was brought up in cities and classrooms that preach the value of an approach that focuses on people.

Let's meet Xaher Gul, a clinician based in Karachi, Pakistan, who specialises in integrating SBC in the health sector. 

Xaher Gul: My journey to this role began 22 years ago when I graduated from med school in 1999. I was all of 24 years old and I truly believed that I now possessed all that is sacred and holy to help people.

I would spend about 15 minutes with my patients in which I would take a detailed history, do an examination, prescribe treatment, and then whatever was left over, maybe about a minute or so, I would spend counselling them on how to help themselves stay healthy. More often than not, when they came back, they would have not done what they were counselled to do, but that was okay, because that's what patients did.

And we were never trained to think that it was our job to help them achieve those changes that need to be achieved. It wasn't until I shifted from clinical medicine to public health and started working as a health manager, looking after programmes, delivering primary health care and emergency services in humanitarian and crisis-affected settings, that my paradigm shifted. I was looking at numbers coming in from the programmes regarding service uptake.

No matter what we did, the service numbers were always low. They were far below what we would project. And, uh, even though services were available, they were free of cost. Women wouldn't come in for antenatal checkups. They wouldn't come in for contraception. Families wouldn't bring children in for immunisation or growth monitoring.

I was coming from a very strong biomedical paradigm where people were patients who needed to be told what to do and saved as passive recipients of care. I'd heard of terms like community mobilisation and behaviour change communication, but this was technical jargon with very little bearing on what we did on the ground in the real world. This made me curious. I was introduced by one of my mentors to the works of, uh, the Brazilian educator and philosopher Paulo Freire, and in his very powerful book, Pedagogy of the Oppressed, he states something which has stayed with me as my guiding beacon through all these years.

Freire states that nobody is a blank slate. Individuals are shaped by their experiences and impressions, and that women and men can learn through learning that they can make and remake themselves. And I realised with some restrained horror that I had spent the better part of a decade talking at people, throwing information at them, being paternalistic about what they should be doing for themselves.

It eventually led me to try to figure out how do we facilitate individuals and groups of people to shape and reshape their lives. And the answer to that I found when I discovered behaviour theory. 

Qali Id: Okay, sidebar for a second. Remember at the beginning of this episode I said that I'm very curious and interested in people?

Well, I've never been very good with theories. I like practical, tangible examples in the here and now, so I hope that I'll be able to follow the answer to this question. What is behaviour theory? 

Xaher Gul: Behaviour theory bridges the gap between psychology and the more systems oriented public health programmes. This notion is considered too technical, too resource intensive, too time consuming for public health programmes to be of any practical significance at the field level.

But these are exciting times. A paradigm shift is taking place, and times are changing. Our programmes, if they mean to deliver impact, must engage with individuals and groups of individuals in their communities and be able to identify, understand, and empathise with individual perceptions of how they think and feel, how they see the world and perceive themselves in it.

Qali Id: Now, one of the criticisms of the development sector is that it's very easy for these programmes to make communities passive recipients of care. And to be honest, this is something that I found frustrating and also struggled with working in the sector. How can we give people the reins to shape and reshape their lives?

How can we encourage people and communities to participate in the decisions that impact them? To help me wrap my head around this better, I turn to Naureen Naqvi, an SBC Specialist at UNICEF, who's been faced with these same questions her entire career. 

Naureen Naqvi: We also talk to people, what are their needs, what do they think about the services that they are getting? How we can serve them better?

For example, if there is a disease outbreak somewhere, so much we all know is related to the behaviours and actions of people. How we can prevent diseases, how we can prevent more harm. Now, more than ever, because of COVID, and there was more and more realisation that people's behaviours really matter, and we all understood the importance of behaviours when COVID-19 hit us, you know, wash your hands 20 seconds and six feet social distancing and stuff like that.

So what were we talking about? We were talking about behaviours, right? After that, I think that social behaviour change and community engagement has gained a lot of, uh, let's say more traction because it's no more just about sitting somewhere and thinking what people need, but really talking to people and then deciding about what they need and how they want the things to be done.

Qali Id: When the COVID-19 pandemic began, I was in Nairobi and I vividly remember people being resistant to wearing masks and practising social distancing. So I wasn't so surprised when people were also resistant to taking the vaccine. But everywhere I turned, the narrative that was being pushed was that people that were against the vaccine were irrational.

So what happens when the communities you work with advocate for behaviours that seem irrational? I wanted to hear from Laura de Molière, former Head of Behavioural Science for UK Government's Cabinet Office, on her perspective on all of this. 

Laura de Molière: I purposely stepped away from this kind of language and approach.

That's for many different reasons, but one of the core ones is that the key of behavioural science is actually to help you empathise with your target audience. If I hear someone describe behaviour as irrational, usually it just tells me that they've not understood the current person's context well enough.

Qali Id: I completely agree. There has been a long history of distrust in the medical system across the world. I've seen it in refugee populations, we've heard of African American women having poor maternal health outcomes in the United States, and let's not forget the 15 month boycott of the polio vaccine that happened in Nigeria in the early 2000s.

But with so many examples in the health sector, does this mean that SBC is accepted as mainstream in public health now? Let's hear from Xaher. 

Xaher Gul: Public health practitioners still feel challenged by several of these theoretical concepts within behaviour change theory, which are perceived to be sometimes too soft and mushy or agranular to be able to be of any practical significance in public health programmes.

It is deemed by certain scholars to be too Western to be of relevance to the operating context of Eastern cultures. 

Qali Id: So what do you say about the value of behaviour theory to those same sceptics? 

Xaher Gul: These theories provide programmes with a common lens through which they can view the audiences that they engage.

These theories also help us understand what needs to change, how an intervention should be designed, and how to measure the impact. This framework also tells us that where our programmes need to shift attitudes, we must focus on how people feel about a behaviour in addition to what they think about it. Our programmes must focus on building personal agency amongst girls and women, boys and men, so that they are able to access the services we are supporting.

Qali Id: You use these theories to understand people and what programmes to design and how to measure the impact. But at the end of the day, you need to shift behaviour. Does all of this really get people to do the thing that you actually want them to do? 

Xaher Gul: Scholarship on SBC indicates that attitudes and personal agency are strongly influenced by perceptions of norms and existing social norms within a community.

And shifting social norms can be very challenging, but also downright dangerous at times. This is where theory helps us. It guides us that it is not the actual collective social norms that we must shift. It is the individual's perceptions of these social norms, specifically whether the behaviour in question is likely in their community.

Is it a common behaviour? And whether it is socially approved and that is what our programmes must focus on for shifting social norms. 

Qali Id: So far in this episode, most of our SBC examples have been health related. But if we're going to talk about shifting perceptions of social norms, I wanted to see what other examples outside of the development and humanitarian sector we might be able to find.

I reached out to Debbie Prentice, a professor of psychology and the Vice Chancellor of the University of Cambridge on shifting perceptions of norms on a particular vexing problem for North American and European universities - drinking to excess. 

Debbie Prentice: What I found was, in fact, that one of the main motivations for students to drink to excess, and here we're trying to keep people from drinking to excess, not, not just moderate drinking.

But one of the primary motivations for binge drinking, for example, was that students thought that everybody thought that was a cool thing to do, right? In fact, if you did surveys, which we did, we found that everyone didn't think that was a cool thing to do, but nobody knew that that was the case. In other words, that the social norms that had developed around drinking, privileged this excessive drinking behaviour, even though people's private attitudes didn't support it.

Uh, that's a phenomenon called pluralistic ignorance, which psychologists have dominated. And it's a great lever that one can use to change behaviour because what you can do, in fact, is simply show people or make them aware of the fact that the behaviour that they thought was cool and, and would make them popular is not going to be seen as cool and, and make them popular - takes away the primary basis for the behaviour. 

Qali Id: So if I understand correctly, people are being informed and they understand that it's not cool and obviously it's detrimental to their health. So why hasn't this worked? 

Debbie Prentice: Well, the main reason there's still binge drinking on campus is that this step of showing them that the, what they think their peers approve of, what they think is a true social norm is in fact not the true social norm, that's a good first step, but it doesn't tell them what to do instead, right?

If they're going to parties and they're drinking in order to fit in and you tell them, well, that's not going to help you fit in. Well, okay, what is going to help me fit in? How should I be drinking or not drinking or doing something else without actually giving them the healthy behaviour, right? What is it that people do want you to do?

How can I be popular, right? They've still got the motivation and you can say, you can decouple the motivation from the behaviour, but that's not going to completely solve their problem. And so in those kinds of situations, people often go back to the behaviour that you're trying to get rid of. 

Qali Id: And unfortunately, the cycle continues, and this social norm is just binge drinking on university campuses.

What happens to the social norms that have been around even longer, that are even deadlier, and impact so many more vulnerable groups all around the world? When I was working in Somalia, I was working on gender and child protection, particularly around advocacy policy and campaigning. And I was astonished at the numbers when it came to practices such as female genital mutilation, or corporal punishment, or even gender-based violence.

According to UNICEF, there are at least 200 million girls and women alive today who've undergone FGM. And when faced with these social norms, it can feel very overwhelming, and daunting, and sometimes even impossible, because they are so deeply rooted, and there are so many people that need help. But like Xaher said, it's not about shifting the norm itself, it's about shifting the perception of it.

Remember Super Citizen Antanas Mockus, the mayor from Colombia? I forgot to tell you that not only did his traffic mimes run around mocking people, they also had green and red signs that they would use to signal bad behaviour on the road, flagging bad drivers and celebrating good drivers. Without any physical rewards or even repercussions beyond flashing a colour, annual traffic deaths were reduced by 50%.

Why? Antanas understood the people of Bogotá, what they responded to and what they didn't. They cared a lot about what other people thought of them, so it was never about the mimes. It was about understanding the people, and that continues to be something that has come up in this episode. Social and behaviour change is about understanding the people that you are trying to serve, their culture, their customs, and their social norms.

And the solution obviously isn't always going to be mimes. Though I would love to see what a few mimes at a college party might get up to.

I don't know about you, but there's been a lot of information in this episode. So let's recap. So far, we've heard from Monica and Laura, who are both behavioural scientists. Xaher, who is a medical doctor and public health SBC specialist, Naureen, an emergency response specialist, and Debbie, a psychology scholar.

Clearly, social and behaviour change invites people from all types of disciplines. Throughout this podcast series, we'll continue to hear from experts just like them, who will share their experiences and learnings from applying SBC to different challenges. We'll ask questions to help break these concepts and theoretical frameworks down and try and make SBC as clear as well, ABC.

You'll hear questions from SBC practitioners at UNICEF who want to know more about what SBC can do in their context.

Luca Solimeo: We live in a world which is more and more insecure. Exposed to conflicts, climate change, emergencies, and more recently, new pandemics. 

Jawahir Habib: Where we do not have access to, let's say, certain populations, the basic health and education services. 

Luca Solimeo: With the recent tragic events in Ukraine, Ethiopia, and Sudan, and now in Palestine.

Jawahir Habib: How can SBC principles help us to create access in those areas for the most vulnerable populations? 

Luca Solimeo: How do we think that behavioural science can still play a critical role and benefit vulnerable populations? 

Rachana Sharma: Do you really think that in the near future there is a possibility that the funding, the systems, the functionaries are easily available for social and behaviour change? For quantum leaps, and also to be able to do programmes which are at scale?

Luca Solimeo: How can we explain this to the communities, to partners, to donors, and also to our management, without sounding theoretical, abstract, or too academic? 

Qali Id: We'll invite experts like some of the people you heard from today to respond, share their advice, and even pose their own questions. 

Laura de Molière: I wish everyone asked, is this realistic?

Is this a realistic aim? Can we actually achieve this with the use of behavioural science? 

Monica Wills-Silva: I would love for people to ask more about what the Global North can learn from the Global South, what we can learn from like low and middle income countries and the sort of research that we're doing. 

Qali Id: And share their hopes for the future.

Monica Wills-Silva: So I think my dream in the future would be that people look back to this time and it'll feel like behavioural science is a common place. Like the research that we're doing is just everything is part of the day-to-day in terms of policy making and like programme design. And people will actually be wondering more how we weren't doing this in the first place, if that makes sense.

I hope that we get to a point where like evidence based policymaking and programme design is, is just our default. Basically that we're just defaulting to think about what works and what doesn't work. Every time we're thinking about designing everything for people and with behaviours in the centre of it, hopefully filled by the evidence that we're generating in low and middle income countries and not just looking at more western countries and the Global North.

Qali Id: Together, we'll arrive at the opportunities and limits of social and behaviour change in achieving gender equality, fighting the climate crisis, responding to emergencies, and more. To learn more about Antanas Mockus and the expert guests featured in this episode, check out our show notes. If you're eager to learn more about SBC, UNICEF has this great online resource which has over 43 tools to help experts and non experts understand, practice, advocate for, and explain SBC.

Visit sbcguidance.org and check out the tool on social norms if you're curious about how to leverage and address these unwritten rules. That's all linked in our show notes. And if you have a burning question about SBC, we'd love to hear it. You can submit your questions to sbc@unicef.org, and we might be able to answer it in a future episode.

My name is Qali Id, and I'm so excited to be on this journey with you. Stay tuned for our next episode, where we'll be exploring the role of SBC in conflicts and emergencies. Thank you for listening.