The HTSP Implementation Kit

Section 3: Use SBCC to Address AMA and HP Pregnancies

What Influences People’s Behavior?

A person’s behavior is influenced by many factors at the individual level and beyond. The levels of influence can be summarized by the Socio-Ecological Approach  (Figure 1).

This approach recognizes that behavior change can be achieved through activities that intervene at four levels: individual, interpersonal (family/peer), community and social/structural.

Figure 1: Socio-Ecological Approach


At each level, there are factors that affect behavior in a positive way (facilitators) and factors that affect behavior in a negative way (barriers). Consider the example of women who are nearing 35 years old or who are approaching their fifth birth. Your program wants to encourage these women to avoid future pregnancies or get the extra care they need to help ensure the health of both the mother and the child. Here are some of the factors at each level of the Socio-Ecological Approach that can influence these women and their ability to stay healthy.

IndividualAt the individual level, women need information and skills related to the risks of AMA and HP, including knowing where to get information, knowing how to access services offering FP methods and counseling, and knowing how to negotiate and use the FP method she chooses.

Family-and-peer-networksAt the family and peer level (also called “interpersonal”), women need husbands, friends, siblings and family members to whom they can turn to for accurate information and support.

CommunityIn the community, women need support and an enabling environment to get information about AMA and HP pregnancy risks and FP methods. They may also need reassurance that there will be no negative consequences from the community for accessing services, using FP methods or choosing whether and when to have children.

ScaleAt the social/structural level, women need supportive norms around gender and relationships, including spousal communication and shared decision-making. They also need norms that support smaller family size as a way to ensure maternal and child health, financial security, and/ or happiness. Finally, they need religious leaders who acknowledge the benefits of HTSP, and policies that support affordable, high-quality FP methods and services that are accessible to everyone.



To most effectively change behaviors, communication efforts should address factors at each level.

Since it may not always be possible for a single organization to do so, it is important to build partnerships and collaborate with organizations and institutions that operate at the levels that your organization does not, and to strategically focus efforts on those barriers and facilitators that are most likely to lead to change.

Develop an SBCC Strategy to Effect Change

Previously known as behavior change communication (BCC), SBCC is an approach that promotes and facilitates changes in knowledge, attitudes, norms, beliefs and behaviors. The terms BCC and SBCC are similar – both refer to a series of activities and strategies that promote healthy patterns of behavior. The word “social” has been added to BCC to indicate that, for improved health outcomes, it is necessary to support broader social change. Throughout this I-Kit, the term SBCC will be used, rather than BCC.

It is important to use a strategic, systematic SBCC approach to analyze the problem, define key barriers and motivators to change and design and implement a comprehensive set of interventions to support and encourage positive behaviors. A communication strategy provides the guiding design for SBCC campaigns and interventions and ensures that:

  • Communication objectives are set
  • Intended audiences are identified
  • Consistent and relevant messages are determined for all materials audiences and interventions
  • Communication approaches, channels and activities are strategically chosen
  • Realistic evaluation indicators and methods are defined

You likely have seen or been involved in SBCC activities in your area, such as:

A mass media campaign that promotes condom use to prevent HIV through public service announcements and/or serial dramas on radio or TV.

A theater group performing a play about gender-based violence and holding a discussion afterward.

A radio talk show that answers listeners’ questions about family planning.

A school-based program that encourages students to delay sexual debut.

A short message service (SMS) or hotline service to provide information on family planning or HIV.

Effective SBCC programs use a variety of communication channels to reach the intended audiences.

Use Behavior Change Theory to Inform an SBCC Strategy

What is SBCC

This video explains SBCC in under four minutes.



For more information on all aspects of SBCC, the Health COMpass is a great place to start. The website includes everything from SBCC information and resources to actual tools and project examples from around the world.


Behavior change theories can help us understand why people act the way they do and why and how behaviors change. SBCC theories can help guide SBCC program design and help you focus on what or who to address in your program.

Most behavior change theories include similar behavioral determinants, or factors that impact how or whether one thinks about a behavior (see Table 2). Research around a health problem’s root cause can help identify which determinant(s) most strongly influence a behavior among a particular audience, and therefore how to focus your program design. Once the specific behavioral determinants are identified, program messages and activities can be tailored to properly address them.



When evaluating an SBCC activity or intervention, it is important to measure change in the behavioral determinants of interest, and not simply changes in knowledge and attitudes.

Table 2. Common Behavior Change Theory Components


Motivation is an individual’s desire to perform a promoted behavior.

Attitude An individual's  evaluation or thoughts about the promoted behavior.

For example: Whether a woman thinks using FP to delay or limit births and avoid AMA or HP pregnancies is “right” or “good.”

Belief An individual’s perception about the promoted behavior, which may or may not be based on fact.

For example: If an AMA or HP woman believes using an FP method will cause health problems.

Intention An individual’s future plan or desire to perform the promoted behavior.

For example: If a pregnant woman plans to start using an FP method in a few months, after she gives birth, to prevent future pregnancy.

Locus of Control The idea that an individual believes that his or her health is 1) under the control of other people or circumstances, such as fate or God, or 2) under the individual’s direct control.

For example: If a woman believes that God determines how many children she will have, she would not be motivated to use FP to avoid AMA or HP pregnancy.

Outcome Expectations An individual’s belief or trust that a promoted behavior will result in the promoted result.

For example: If a woman believes that using a modern FP method will prevent an AMA or HP pregnancy.

Subjective Norm This refers to whether an individual feels pressured to think about the promoted behavior the same way as others in his or her social group.

For example: If an older women knows her family and friends support using FP to space births, she will be more likely to accept FP to space births.

Threat (risk) If an individual feels at risk for a problem, he or she is likely to change his/her behavior to reduce the risk. “Threat” here is made up of perceived severity (seriousness of the problem) and perceived susceptibility (how likely they are to “contract” the health problem).

For example: If a woman remembers her last delivery was difficult, thinks it is because she has had so many children already, and fears more births will be even harder and more dangerous, she will be more likely to adopt an FP method to prevent future pregnancies.

Perceived “Cost” / Willingness to Pay An individual’s belief of how much performing a behavior will “cost” them, and their readiness to “pay” this cost. Here, cost may be measured in time (away from work or family), price (monetary gain or loss), social acceptance (losing or gaining support from friends and family), or other factors.

For example: If a woman thinks her family or community will ridicule or reject her for using FP, the negative social impact may be greater to her than the benefit of avoiding an AMA or HP pregnancy.


Ability refers to an individual’s skills or capacity to perform a promoted behavior.


Correct information about the public health problem (symptoms, causes, prevention and transmission).

For example: If a woman knows and understands that being 35 or older or having five or more births makes future pregnancies risky, she has some correct knowledge about AMA and HP pregnancy.


An individual’s belief that he or she is able to implement the promoted behavior successfully, and has the skills to do so

For example: Whether an AMA woman feels that she can discuss FP with her husband.

Social Support 

An individual’s perception of how much support he or she will receive to perform the promoted behavior. An individual is more likely to perform a behavior that is supported by his or her social environment.

For example: If a woman’s husband says he wants to help her avoid an HP pregnancy, and the woman’s friends have encouraged her to use FP, she will be more likely to adopt an FP method.


Opportunity refers to an individual’s chance to perform a promoted behavior depending on environmental, institutional or structural factors.


Whether the necessary tools or products an individual needs to perform a behavior are accessible.

For example: If an HP woman wants to adopt and continue using a modern FP method, is the method available in her community?

Quality of Care/Trust in Services

Whether the necessary services an individual needs to perform a behavior are accessible.

For example: If an HP woman would like to learn about the risks of AMA and HP pregnancy, are her local service providers able and available to provide correct information and respectful counseling?

Social Norm 

A community-held belief about the promoted behavior that individuals are expected to follow. An individual is more likely to perform a promoted behavior if related positive and supportive social norms exist.

For example: If women in a community can make decisions about their own health, they are more likely to be able to control whether they can use FP.

Annex A provides more information on the theories most commonly used in FP SBCC programs and examples of how they can be applied.



For step-by-step guidance on designing an SBCC strategy, please refer to HC3’s Designing a Social and Behavior Change Communication Strategy Implementation Kit. 

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