Evidence and Gap Map Report: Social and Behavior Change Communication (SBCC) Interventions for Strengthening HIV Prevention and Research among Adolescent Girls and Young Women (AGYW) in Low- and Middle-Income Countries (LMICs)

"Interest in socio-behavioural interventions to support demand and uptake of HIV services is on the rise. Therefore, the evidence of their effectiveness needs to be systematically mapped to enable informed decision-making by sponsors, researchers, policymakers and public health experts."

Converging social, cultural, and economic factors affect how adolescent girls and young women (AGYW), aged 15-24 years, understand, negotiate, and access information and biomedical treatment related to HIV. Social and behaviour change communication (SBCC) interventions not only help address aspects of underlying socio-behavioural barriers that drive the HIV epidemic, but they also play a critical role in expanding knowledge of and access to quality health services, health equity, and participation in research. They also assist in addressing gendered health disparities throughout the continuum of care. This evidence and gap map (EGM) report characterises the evidence base on SBCC interventions for strengthening HIV prevention and research among AGYW in low- and middle-income countries (LMICs) and outlines possibilities for future research and programme design.

This EGM is based on a search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes aimed at engaging AGYW in LMICs in HIV prevention and research that were published in the English language from January 2000 to April 2021. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. The EGM includes 458 studies: 43 systematic reviews and 415 impact evaluations. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

The interventions included in these studies were categorised across four broad intervention themes: mass media, community-based, interpersonal, and information communication and technology (ICT)/digital-media-based interventions. They were further sub-categorised into 15 intervention categories. Included studies looked at 23 unique behavioural and health outcomes, such as knowledge attitude and skills, relationship dynamics, household dynamics, healthcare services, and health outcomes and research engagement.

Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Most of the interventions were delivered by peers, healthcare providers, and educators, largely in school-based settings, and in many cases are part of sex education curricula. Despite increased digital penetration, use of media- and technology-driven interventions are relatively less studied. Similarly, the EGM highlights that evidence for gamified learning interventions, both in physical and digital arenas, is underexplored. "Given the blurring line between digital and physical spaces, it is important to understand changing media ecologies of AGYW networks and meet them where they are. It is important to be cognizant, however, that while the potential reach of these tools makes these valuable methods of engaging these diverse population, growing concerns around gendered access, issues of privacy, confidentiality, and cyber security warrant the need for more evidence to be generated to better understand and utilize these media forms in appropriate and ethical ways."

Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviours and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household-dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

The EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behaviour change and is less robust for outcomes situated within the intent-action and the action-habit-formation spectrum of the behaviour change continuum. Most of the evidence was concentrated on increasing awareness/knowledge and building risk perception around sexual and reproductive health (SRH) domains; however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors, such as strengthening social and community norms, relationships, and household dynamics, that determine individual thought and action such as negotiation and life skills was less often found in the literature studied.

The researchers note that few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments, including key influencers such as young men, partners, families, religious leaders, and community elders. There is a need for better-quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome.

Other implications of the EGM for research, practice, and policy include:

• Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). "Given the high burden of HIV in the Sub-Saharan Africa region, evidence concentration is understandable. However, other regions with a significant burden of HIV remain less studied, necessitating a more inclusive programming and evidence generation effort that is responsive to the regionally diverse needs of AGYW."
• "[A]n ecosystem-based approach that involves other influencers from their family/community, etc. [beyond peers, educators, and healthcare providers], and creates 'safe spaces' for AGYW to openly share and discuss such intimate details of their life can be valuable."
• "SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this [type of intervention] remains poorly evidenced and calls for investigation and investment."