The Effect of SBCC on the Service Delivery Gap in Maternal and Child Health within Public Health Facilities in Gulele sub city, Addis Ababa
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Date
2026-11-30
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Addis Ababa University
Abstract
Background: The use of maternal and child health services remains a long-standing challenge in Ethiopia. Only 43% of women had four or more antenatal care visits, 50% had skilled birth
attendance and 34% received postnatal care. Social and Behavior Change Communication (SBCC) interventions have been utilized as marketing-oriented strategies to combat demand-side barriers and improve health seeking behaviors. However, there is limited evidence on how SBCC influences the service delivery gap; the gap between client expectations and actual serviperceptions, especially in urban public health settings. Objective: This study examined the effect of Social and Behavior Change Communication (SBCC) on the service delivery gap in maternal and child health (MCH) services within public health facilities in Gulele Sub-City, Addis Ababa, Ethiopia. Methods: A convergent parallel mixed methods cross-sectional design was employed. Quantitative data were collected from 160 clients of MCH through exit interviews using a modified SERVQUAL instrument measuring expectations, perceptions and gap scores across five dimensions (Tangibles, Reliability, Responsiveness, Assurance and Empathy). Qualitative data were collected through 12 in-depth interviews with mothers and 6 key informant interviews with health center managers and providers. Descriptive statistics, correlation analysis, simple and multiple linear regression, and thematic analysis were used to analyze the data. Seven hypotheses were tested using the integrated theoretical framework of Social Cognitive Theory, Theory of Planned Behavior, Expectancy-Disconfirmation Theory and SERVQUAL model.
Results: The expectations of the clients were consistently high for all the SERVQUAL dimensions (mean scores: 4.65 – 4.86) and perceptions were considerably low (mean scores: 2.56 – 2.97) resulting in substantial negative service quality gaps for all dimensions. The total gap index was –2.05 (SD = 0.35) with the largest gap of Reliability (–2.18), followed by Responsiveness (
8 2.17) and Empathy (–2.09). The majority of respondents (96.9%) were in the high gap category. The exposure to SBCC was moderate (mean index = 3.38, SD = 0.68) and 91.9% of the
respondents had moderate exposure levels. Satisfaction levels were low (26.9% satisfied; 64.4% neutral satisfied) and behavioral intentions were weak (PNC return: 19.4%; recommendation: 31.9%). Qualitative findings indicated that SBCC messages generated heightened expectations that the health system could not meet, resulting in negative disconfirmation, emotional distress and behavioral consequences including switching clinics and considering home delivery. Hypothesis testing showed that H₂ (negative gap across all SERVQUAL dimensions) was fully supported; H₁ (SBCC → expectations), H₆a (education → expectations and gap) and H₆b (income → expectations) were partially supported; and H₄ (gap → satisfaction), H₅ (gap →
behavioral intentions) and H₇ (mediation effect) were not supported. Conclusions: SBCC is effective in raising the awareness and expectations of MCH clients, but it inadvertently createsunrealistic expectations that the current service delivery system cannot meet, resulting in a large and multidimensional service quality gap. These “neutral” satisfaction ratings hide active dissatisfaction and quiet defection as clients switch facilities or contemplate home delivery. SBCC alone is not enough to close the gap in service delivery. There is a need for integratedinterventions that address communication and service delivery capacity. Socio demographic factors, particularly education, income and parity, have important impact on SBCC
exposure, expectations and magnitude of service quality gaps. Recommendations: SBCC messages should be consistent with actual service delivery capacity, include realistic disclaimers onservice limitations and communicate real-time service availability. Health centers need to address the empathy gap by investing in client-centered training, grievance redressal systems, improving the reliability of the supply chain, and redesigning patient flow to minimize waiting times. A “promise-keeping” marketing approach should be adopted with SBCC combined with strengthening service delivery. Policy makers should invest in human resources to address gaps in responsiveness, proportionate budget allocation for service delivery in addition to SBCC and establish cross-sectoral quality improvement taskforces
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Social and Behavior Change Communication (SBCC), Service Delivery Gap, Maternal and Child Health (MCH), SERVQUAL, Expectancy-Disconfirmation Theory, Client Expectations, Service Quality, Gulele Sub-City, Ethiopia