Re-aligning social and behavior change to address structural determinants of health and improve health equity.

While social and behavior change (SBC) programs have a history of addressing multiple social determinants of health (SDH), those interventions have sought primarily to influence the behaviors of individuals, groups, and communities, often overlooking underlying social and political causes of health inequities and the multiple ways SBC could address them. The SDH include (i) 'structural mechanisms,' or the social and political contexts that produce and sustain social stratification via socioeconomic position (SEP), which comprise social class, income, education, race/ethnicity, gender, and/or marginalization, and (ii) 'intermediary determinants,' including psychosocial factors, behaviors, and the health system itself. Currently, SBC programs consistently address intermediary determinants, but rarely design approaches to affect structural determinants. To strengthen SBC programming, it will be necessary to: develop/expand social determinants competency; engage with groups most disadvantaged by SDH using an intersectional lens; advocate for, and respond to, funding for SBC programming that addresses both structural and intermediary determinants; collaborate with partners across sectors; measure and evaluate the efficacy of SDH interventions; develop and apply measurement benchmarks aligned with long-term change processes; and demonstrate how health equity approaches align with multilevel health and development priorities and goals. Political will, donor commitment, implementers' actions, and community engagement working in concert to shape actionable goals for social change that benefit underserved or unserved populations can reduce inequities in health practices and outcomes. As partners in reimagining SBC and shifting the paradigm, SBC practitioners have important roles to play; this paper speaks explicitly to their needs, concerns, and opportunities.