Population-Level Behavior Change to Enhance Child Survival and Development in Low- and Middle-Income Countries

Below is The Communication Initiative summary of this paper from Elizabeth Fox and Rafael Obregon. To access the full paper in the Journal of Health Communication, please click here.

"[R]ather than being a question of whether social and behavior change interventions can drive improvements in health outcomes, the key is to ensure that these interventions consistently measure up to the rigor, quality, and investments needed to facilitate the desired change. This is the challenge for multiple stakeholders involved in global, regional and country level efforts to ending preventable deaths and ensuring that all children survive, thrive and develop to realize their full potential."

In recognition of the fact that improving child survival "requires promotion of healthy behaviors as well as efforts to addressing social exclusion, discrimination and a range of social and behavioral determinants that cut across the life cycle", from June 3-4 2013, the United States Agency for International Development (USAID), in collaboration with the United Nations Children's Fund (UNICEF), hosted the Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change in Washington, DC, United States (US). "The overarching goal of the summit was to determine which evidence-based interventions and strategies support a sustainable shift in health-related behaviors in populations in lower- and middle-income countries to reduce under-5 morbidity and mortality." (Other collaborating partners included the National Institute of Mental Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Centers for Disease Control and Prevention, The Communication Initiative, and the American Psychological Association.) The summary below is of an editorial that is part of a special issue of the Journal of Health Communication emerging from the Evidence Summit.

In this editorial, Evidence Summit participants Fox and Obregón begin by describing the landscape that has informed the "tradition of applying high standards of evidence to the review of health communication and behavior change programs" in the context of child survival. For instance, they reference A Promise Renewed, a global movement to end preventable child deaths (see also Related Summaries, below). A Promise Renewed brings together public, private, and civil society actors committed to advocacy and action for maternal, newborn, and child survival. In addition, Fox and Obregón note that, in September 2010, UNICEF released Narrowing the Gaps to Meet the Goals, which emphasises the need to focus on equity to address multiple disparities and deprivations that exclude significant segments of the population from accessing health and social services and put their children at a greater risk of death.

Fox and Obregón provide some overall reflections on the Summit and its purpose, as the following excerpt from their editorial illustrates:

"On the basis of the extensive literature that supports such the importance of behaviors such as healthy timing and spacing of pregnancy, breastfeeding, seeking immunization, handwashing etc., we are taking it as given that obtaining population-level changes in these behaviors will have positive impacts on health. The summit focused instead on the important next step, what is the evidence for interventions designed to produce behavior change around these interventions at the individual, community and health systems/policy levels, including efforts to address gender inequality, stigma, and discrimination.

Many interventions examined were designed to improve knowledge and attitudes while others more directly targeted behaviors themselves. The logic in targeting knowledge and attitudes is the assumption that changes there are important intermediate outcomes and can ultimately impact behavior change. Because changes in knowledge and attitudes can occur without evidence of behavior change, however, we emphasized studies of interventions with behavior change or health outcomes. In many studies, we found that changes in health outcomes were the primary outcome measure and that the behavior changes assumed to mediate the effects of the intervention were not measured.

In the past, sometimes as a result of the lack of funding, or capacity, or other pressures, funders and implementers of behavior change and health communication programs have not always carried out evaluative or impact research to gauge the impact of programs....Without data, planners cannot know what parts did or did not work, what were the most efficacious mix of interventions, or what interventions were most appropriate.

Meanwhile, gaps between knowledge and behavior, misinformation and misconceptions, and low levels of adoption of basic health behaviors by large sectors of the population continue to bedevil public health programs throughout the world...

Behavior change programs increasingly are being held to the same standards of evidence of impact as other development investments and interventions....

...It is key to ensure that the evidence of what works is integrated into national and subnational public health programs and used to tighten and focus interventions and practices for population level behavior change around the world. Along the way, global and regional advocacy to make sure that social and behavior change interventions are based on evidence and supported with adequate human and financial resources to achieve the greatest impact will remain a critical component of global and national efforts....[R]ather than being a question of whether social and behavior change interventions can drive improvements in health outcomes, the key is to ensure that these interventions consistently measure up to the rigor, quality, and investments needed to facilitate the desired change. This is the challenge for multiple stakeholders involved in global, regional and country level efforts to ending preventable deaths and ensuring that all children survive, thrive and develop to realize their full potential."