Social Approval Community Engagement

Social Approval Community Engagement (SACE) is a highly effective, evidence-based approach which has successfully mobilised rural communities in support of health improvements and created an enabling environment for women and girls’ empowerment.

The approach is designed to be implemented at scale. It has been adapted for use in fragile and post-conflict settings and has been implemented in northern Nigeria and Zambia.


SACE is based on a flexible methodology which can be adapted to suit different contexts. This approach is rooted in an analysis of social context, and of the knowledge, access and affordability barriers that prevent communities from accessing essential health care and other resources and opportunities.

SACE builds local capacity, usually of community volunteers, to facilitate a participatory change process at community level. A community discussion group methodology engages community members in a reflection and analysis of their situation and encourages actions (e.g. establishment of community transport of savings schemes) to address these challenges.

SACE has a number of distinctive features:

  • Ordinary members of the community are trained to facilitate change using a training methodology built around the needs of adult learners operating in low literacy contexts.
  • In order to generate community-wide social approval for behaviour change, volunteers work methodically through communities to reach every part.
  • The content of training addresses the priority problems identifed by communities and used methods for communicating information that are familiar and lcoally appropriate.
  • A system of mentoring and coaching support is provided to help communities make the transition from increased awareness to sustained behaviour change.
  • Considerable emphasis is placed on reaching the least-supported women, who tend to have the poorest access to health services and to suffer the highest burden of ill-health.


SACE was implemeted in four northern Nigerian states between 2008 and 2014 as part of the PRRINN-MNCH programme. This was the largest and longest-lasting demand-side maternal newborn and child health effort ever seen in northern Nigeria, reaching 72 local government authorities and covering a population of 7.64 million. Key results from three PRRINN-MNCH states were:

  • Antenatal care use rates increased from 25% to 51%
  • Skilled birth attendance rates increased form 11% to 27%
  • Children receiving DPT3 vacccine increased from 5% to 42%

Schemes established by communities to address delays in health care access helped to avert many potential maternal and newborn deaths: 20,000 women with a maternal complication were supported by community emergency transport schemes; and Naira 39 million (GBP £157,000) was saved by intervention communities to support women in maternal emergencies; 9,000 women (52% of reported maternal complications) were assisted by these schemes.

In Zambia, SACE was implemented in six districts between 2010 and 2013 as part of the MAMaZ programme. Key results included:

  • Delivery with a skilled health worker increased from 43% to 70%
  • Propostion of pregnant women aware of need to attend antenatal care in their first trimester increased from 47% to 71%
  • Proportion of these women attending at least four ANC visits increased from 30% to 43%
  • Use of modern contraception increased from 21% to 33%


SACE is an evidence-based approach which strengthens community health systems and stimulates significant and long-lasting behaviour change. SACE lends iteslef to being implemented at scale. Recent evidence from Zambia suggests that the approach builds sustainable capacity at community level and generates long-lasting social capital and cohesion.

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