U.S. Government Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change

Concept Paper

Introduction

A renewed emphasis on the application of research and evaluation to inform strategic thinking about development for low- and middle-income countries is integral to USAID’s efforts to improve health by promoting country-owned, effective and sustainable interventions. To that end USAID is leading a series of evidence summits focused on important development challenges. The aim of these summits is to provide evidence-based expert recommendations on how to achieve some of the world's most difficult development goals, for example, reducing maternal mortality, caring for children living outside families or supporting community health workers. The intended users of the information derived from the Evidence Summit are low- and middle-income country governments, USG policy and program decision makers, researchers, and other multilateral stakeholders. Because development challenges are complex, intrinsically multidisciplinary, and therefore informed by diverse data inputs and expertise, these summits engage a broad coalition of expert contributors from across the USG, academia, development agencies, low- and middle-income governments, and civil society organizations in these countries. Expected outcomes from each global health summit include: clarity on evidence to inform policies, programs, and practice; identification of knowledge gaps to inform a research agenda; publication and dissemination of findings and recommendations; and evidence-to-action follow-up to ensure application of learning and active pursuit of critical knowledge gaps.

This Evidence Summit focuses on the challenge of achieving the social and behavior changes needed to end preventable child deaths and improve under five development. As a global community, we have made staggering progress in the reduction of child mortality. Over the last 50 years, child mortality has been reduced by 70%. However, in rich and poor countries alike, the poorest and most disadvantaged children continue to miss out on life-saving, affordable interventions. In 2012 more than 7 million children – most of them in sub-Saharan Africa and South Asia - will die from mostly preventable causes before they reach their 5th birthday. In lower- and middle-income countries, an estimated 200 million children under five years of age – more than 30 percent of the world’s children – fail to reach their developmental potential, limiting their future ability to contribute to their communities and families or obtain gainful employment.

Based on the current rates of progress, many countries will not achieve Millennium Development Goals 4 and 5 to reduce child mortality and improve maternal health. The Child Survival Call to Action1

1 Child Survival Call to Action Ending Preventable Child Deaths Summary Roadmap, 2012. http://5thbday.usaid.gov/pages/ResponseSub/roadmap.pdf

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provides a roadmap for bringing an end to preventable child death. The accomplishment of this goal requires population-level behavior changes that impact maternal and child health that depend on healthy timing and spacing of pregnancy, the utilization of services, nutritional choices, and accessing and practicing preventive health care. Changing the behavior of health service providers also is a key element to a sustainable improvement in public health and the adoption of existing and new health care practices. Adherence to medications, best practices for prenatal care, following recommendations for immunizations, and the use of bed nets are still other examples of areas where knowing better how and why behaviors change would reap enormous rewards.

Early childhood health and developmental protections, which link the young child’s cognitive, social/emotional, language, and motor development with stable and supportive caregiving, help break cycles of poverty and inequality, particularly among the most vulnerable children. Although not the only time to provide developmental support, return on investment for human capital growth is greatest in children’s early years. Failure to address adversity at this time leads to lifelong deficiencies. Toxic stress, ill health, and chronic under-nutrition leave children vulnerable to many risks, impair cognitive function, stunt physical growth, and reduce lifetime earning potential. When children experience responsive relationships, including a secure attachment with a permanent primary caregiver, and an environment rich with stimulation, they are more likely to thrive and grow up to be productive adults.

In light of the mounting evidence of the long-term effects of severe adversity in early childhood, comprehensive strategies that incorporate promotion of secure and stimulating relationships, safeguarding against malnutrition during the critical 1,000 days between pregnancy and age two, and other life-saving health services are essential to the future success of communities and nations.

Globally, USAID, other health and development agencies, and the governments and civil society agencies in LMIC countries have a wide range of field research and implementation experiences on effective interventions for social and behavior change leading to improved public health outcomes. In addition, existing research evidence, some of which has been carried out in high-income countries, has identified many effective interventions for changing individual behaviors, including health communication and social marketing, performance-based incentives, new polices favoring healthy behaviors, increasing health literacy, and reducing mother-to-child transmission of HIV, among many others.

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The Summit will lead to expert recommendations based on the evidence to inform policy and practice for achieving population level shifts in behavior for improving child survival and child development. It will also identify the knowledge gaps that will inform a research agenda. Immediate follow-on activities will include: 1) the establishment of programming principles and/or technical strategies for country-led programs in low- and middle-income countries (LMIC) to achieve population-level behavior change for child survival; and 2) an evidence-to-action strategy to guide application of learning and actively address critical knowledge gaps in country- and donor-funded initiatives. Scientific journal publications will be one of the mechanisms for communicating these outcomes.

The overarching goal of the summit is to determine which evidence-based interventions and strategies are required to support a sustainable shift in health-related behaviors in populations in lower- and middle-income countries to reduce under-five morbidity and mortality. The summit will address this topic through expert consultation and a review of the evidence pertaining to specific focal questions. Expected outcomes of the evidence summit are recommendations on policy, practice, and research that will inform a strategy to embed behavioral change into child survival and development activities to enhance effectiveness, impact and sustainability.

Focal Questions

The focal questions are designed to collectively inform the field on effective behavioral change activities for child survival and development within the families and communities as well as social and health systems contexts to achieve sustainable population-level social and behavioral change. The focal questions also address critical gender issues and engage the perspectives from groups experiencing stigma, discrimination, and isolation/exclusion. These questions were informed, in part, by a scoping exercise undertaken by the organizing core group (appendix):

1. What are the effective and sustainable interventions to promote and support behavior changes required for and by families, mothers and other caregivers to accelerate reductions in under-five mortality and optimize healthy and protective child development to age five?

2. What are the effective means to facilitate and empower communities to organize and advocate for interventions to achieve behavior and social changes that are needed to accelerate reductions in under-five mortality and optimize healthy and protective child development to age five?

3. What types of sustainable health systems and policy supports are effective in producing behavior and social changes for and by primary caregivers, families, and communities that are needed to accelerate reductions in under-five mortality and optimize healthy child development to age five?

4. What are the effective and sustainable interventions that focus on gender dynamics as a means to promote and support behavior and social change that is needed to accelerate reductions in under-five mortality and optimize healthy and protective child development to age five?

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5. What are the effective and sustainable interventions that address stigma and discrimination as a means to promote and support behavior and social change that is needed to accelerate reductions in under-five mortality and optimize healthy and protective child development to age five?

6. What are the effective and sustainable interventions that utilize advances in science and technology to promote and support behavior and social changes that are needed to accelerate reductions in under-five mortality and optimize healthy child development to age five?

Organization of the Evidence Summit Process

In order to find the evidence that is needed to answer these focal questions, a systematic literature search will be conducted of the biomedical and social and behavioral sciences journals. The primary focus will be on finding reports of controlled studies or well-designed program evaluations that provide outcome data, as well as a comparator. An emphasis will be placed on finding studies that were conducted in, or are highly relevant to, the challenges faced in LMIC. A special effort will be made to identify and translate non-English language documents that are thought to be relevant to the questions. Another goal of this search will be to obtain evidence not only on the efficacy of various interventions in restricted research settings, but also on their effectiveness when applied in different settings or at a larger scale. Information will also be sought on the sustainability and potential for country ownership of programs and policies.

Experts representing the science and practice communities will be enlisted to work on Evidence Review Teams (ERTs) to assess the relevance and quality of the evidence that was obtained through the search process. Through a Call for Evidence process, ERT members will also be invited to identify other important documents that they feel can inform their work to address the focal questions.

We will establish six ERTs, one each assigned to address focal questions 1 to 6. ERTs for focal questions 1 to 5 will also consider the topic of focal question 6, i.e. interventions that utilize advances in science and technology (such as behavioral economics, health literacy, mobile/digital technologies, social network theory, neurobehavioral development, etc.), as they pertain to their core question. Each ERT will be comprised of about 20 experts. They will have the responsibility of deciding which evidence they use and to make recommendations based upon the evidence. Since not all questions may have sufficient high quality and relevant research to make evidence-based recommendations, it is acknowledged that experience-based exert opinion will be brought into the equation for committee recommendations. We will seek to have transparency in making clear the relative weight of scientific evidence and expert opinion for those recommendations that pertain to policy, program practice, and research gaps.

There will be several events that comprise the Evidence Summit process. While experts are being identified and recruited and the evidence is being gathered and reviewed, the Core Group will organize various meetings to be held prior to the Summit. We currently envision two regional country consultations to be held in Ethiopia and India to focus on evidence-to-action plans for implementing recommendations made by the Evidence Summit and a pre-summit meeting to be held either in

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Washington DC or New York in early 2013. In the pre-summit meeting, teams will hold face-to-face discussions on the status of their work and organize themselves to complete the task of compiling evidence-synthesis documents and recommendation before the Summit. The summit is tentatively scheduled for late spring 2013.

Draft Timeline for Evidence Summit

July 19, 2012: Final report from constituency scoping survey

July 26: Final core group decision on Summit topic. Initial testing for key words search begins

August 2: Identification of experts begins; subgroup works with KMS on evidence search

September 17: Final version of concept paper completed

October 12: Initial literature search completed

October 19: Invitations and copy of concept paper sent to experts

October 24: Initial screening and relevance assessment of literature completed

October 31: Leadership for ERTs confirmed

October 20-November 9: Experts assigned to ERTs

November 7: Second screening for assignment of documents to Evidence Review Teams completed

November 8-17: Call for evidence issued to ERT members

End of November to December: Regional consultations coinciding with Call to Action meetings in India

and Ethiopia (tentative and to be confirmed)

November 17-January 5, 2013: Third screening completed by ERT members

Early-Mid January: Pre-summit

Mid-January through March: Evidence review process underway; Critical study reports submitted to

quality review

April 2013: Evidence Summit

April 30: Summit feedback provided to ERTs

April 30: Evidence to action plan completed

Mid-May: Revised papers due

June 30: Internal review process completed and papers submitted for publication

Going forward: Implementation of other elements of the evidence to action plan

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APPENDIX

The appendix provides more detailed information on the considerations that formed the basis for the selection of the Focal Questions. It also provides help in gathering the evidence by identifying some of the key terms and concepts that the Core Group discussed in preparing this Concept Paper.

Population Behavior Changes and Child Survival

In a recent analysis published in Lancet1, Liu and colleagues estimate the leading causes of child mortality before age 5 (Figure 1). Of 7.6 million deaths in children younger than 5 years in 2010, 64.0% were attributable to infectious causes and 40.3% occurred in neonates. Preterm birth complications (14.1%), intrapartum-related complications (9.4%), and sepsis or meningitis (5.2%) were the leading causes of neonatal death. In older children, pneumonia (14.1%), diarrhea (9.9%), and malaria (7.4%) predominated. Other causes of neonatal mortality included congenital abnormalities, tetanus, and diarrhea. Other causes of 1-5 year old mortality included injury, meningitis, AIDS, and measles.

Figure 1: Causes of death in children under 5 years of age. Those in white and yellow represent neonatal causes; those in color represent causes of death in 1-5 years olds. [Taken from Li et al. (2012)]

To address these causes of child mortality, the Child Survival Call to Action stresses the importance of a continuum of care to benefit mothers and children, beginning with the pre-pregnancy and antenatal

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period, childbirth, and the postnatal period through infancy and childhood (Figure 2). Inspection of the broad range of interventions shows that the vast majority involve a significant element of social and behavior change. Even for those interventions involving medical care, the Call to Action acknowledges that creating access to and demand for these services is a necessary first step.

Figure 2. Continuum of Care model (taken from the Child Survival Call to Action).

Tremendous effort has gone into determining the Continuum of Care model and understanding the impact of these evidence-based interventions on child morbidity and mortality, as well as to studying trends in child mortality over time. In order to fulfill the world’s commitment to the Child Survival Call to Action, increased attention is needed to understand effective social and behavior change to promote healthy behavior and ensure proper uptake of essential services.

With this in mind, the summit will review the literature to examine how social and behavior change strategies associated with the major interventions for child survival and healthy development at multiple ecological levels can contribute to child health. To focus the scope of this exercise, the summit is concentrating on eight high-impact intervention areas that have published evidence demonstrating their efficacy. These include:

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1. Newborn health interventions that focus on simple, effective delivery methods, include an emphasis on Essential Newborn Care practices including breastfeeding and keeping newborns warm, and help babies suffering from asphyxia during birth.

2. Pneumonia and Diarrhea interventions including immunization to prevent sickness, improving sanitation and hygiene to prevent children from getting sick, and treating those kids who are sick.

3. Malaria interventions including the provision of long lasting insecticide treated nets, increasing indoor residual spraying to under-served populations, and treating kids who are sick.

4. Addressing malnutrition by ensuring proper nutrition during the 1,000 days between a woman's pregnancy and her child's second birthday, targeting micronutrient supplementation including Vitamin A, and supporting optimal breastfeeding.

5. Working with partners to make childhood immunization services available and affordable for all.

6. Preventing mother-to-child transmission of HIV by accelerating the scale-up of more effective treatment to reduce transmission.

7. Family Planning interventions including educating women on the benefits of healthy timing and spacing of pregnancy, ensuring contraception is accessible, and targeting resources where they are most needed.

8. Promoting developmental protection, which links the young child’s cognitive, social/emotional, language, and motor development with stable and supportive caregiving and healthy attachment.

Development efforts to change behaviors for public health impact traditionally have focused on individual change, specific populations, and/or shorter, more focused campaigns. Currently, no overarching strategy or “standards” exist for achieving sustainable, population-level change across different health areas that is cohesive and employs all of the appropriate social and behavior change tools available. Although current efforts have produced substantial benefits in improving child survival and healthy and protective development, a diffused approach can result in a fragmented response, not the integrated and coordinated approach that would take advantage of the synergy that could be achieved across the various behavior change tools and approaches. In addition, evidence about sustainable, population-level behavior change for child survival often is “siloed” within the health problem area (e.g., infant mortality) or risk factor area (malaria, pneumonia, diarrhea, measles, HIV/AIDS, etc.) for which the interventions were designed or within the types of interventions that are used. Finally, looking across types of interventions and the various health problem areas can lead to more cost-effective strategies.

Of particular interest for this Summit is how behavior change interventions can be/might be applied to multiple behavioral goals collectively. Up to now, behavior change efforts have been mostly compartmentalized within subsectors such as family planning, HIV, malaria prevention, etc. And too

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often, behavior change within a subsector is small, fragmented, isolated, and without the critical mass of behavioral expertise and resources. Doing behavior change across the sector is consistent with the “Ten promises to our Children” that emerged from Call to Action. We will be asking ERTs to address the evidence that exists for a compound impact from multiple initiatives.

Behavior Change and Child Development

The development that occurs during the first years of life is critically important to well-being. During this period, the brain has maximum plasticity, and each experience shapes its growth. Exposure to chronic adversity in early life leads to toxic levels of stress and permanent changes to brain architecture. This has damaging effects on learning, behavior, and physical and mental health and ultimately limits future opportunities and perpetuates the cycle of poverty.

Major advances in neuroscience, molecular biology, genomics, psychology, and other fields now help us to understand better how significant adversity early in life gets into the body and has lifelong, damaging effects on learning and behavior and both physical and mental health. Early interventions in the first two to three years of life are profoundly important and can reduce the number and severity of adverse experiences and strengthen relationships that protect young children from the harmful effects of toxic stress.

Protective and permanent family care and positive attachment experiences have beneficial immediate and long-term effects. Investments in early child care and developmental protection can mitigate the deleterious impact of poverty, social inequality, gender biases, and disability discrimination, ultimately resulting in long-lasting gains.

Seeking Country Input for Priority Setting

In order to ensure an effective Summit on social and behavior change it was necessary to identify specific priorities that resonate with both overall contemporary development thinking and the present state of play in the behavior and social change field. Such resonance is crucial for the vitally important “evidence-to-action” outcome of the Summit. Towards this end, an online survey was completed by 97 people (out of 167 invitations) representing a broad range of public health issues, types of organizations, work roles, and 22 countries of residence. All had broad experience in global health. Based on recommendations from the Core Group membership, 167 people with significant expertise in this field were asked to complete a brief priorities survey.

The questions agreed upon for the survey were:

Related to the health and development issues that are the focus for your work, can you please identify the major challenges to effective action for each of the following themes:

Individual behaviors from the health area in which you work Social norms from the health area in which you work Social context from the health area in which you work Systems and policies from the health area in which you work

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Public engagement from the health area in which you work Other structural factors from the health area in which you work

In relation to the challenges that you described, please highlight any positive and promising changes that might benefit your development work.

Opportunity 1: Opportunity 2:

Do you think that new digital technologies offer opportunities to address challenges related to individual behaviors, social norms, and health systems? If so, can you please give your reasons and concrete examples.

From the data submitted by respondents the following analysis steps were undertaken:

a. A word cloud was generated for the responses to each of the questions. This gave an initial insight into the key themes to emerge for each question.

b. Starting with those themes some groupings of predominant themes were identified.

c. Each individual comment was assigned to a relevant theme and provided a score of 1.

d. By tallying the scores for each theme we developed data for the construction of pie charts that demonstrated the main priority themes for each question.

e. We then took the priority themes to emerge across all questions, developed groupings, and tallied the collective scores.

The full data gathered is available, with the privacy of the respondents protected.

From that data the following priorities emerged:

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Figure 3: Priority themes to emerge from country input to summit topic selection

From that overall analysis a set of specific recommendations were identified as the possible priorities for the Evidence Summit. Those priorities are:

Working with communities and other specific publics to support them advocating, prioritizing, and making key decisions concerning their health needs and actions

Developing the critical analysis and healthy choice skills and perceptions required by individuals to improve their own health status

Gender-based dynamics as they affect health status Expanding open discussion on required health services and action, with a broader range of

perspectives engaged, particularly from groups experiencing stigma, discrimination, and isolation/exclusion

Change processes within health systems to improve levels of respect, response, relevance, and preventive strategies…

… one key element for the evidence collection and critical review as part of all 5 foci above was the added value and impact of social networking and shared knowledge technologies.

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Interventions for Behavior and Social Change

It is recognized that sustainable population-level social and behavior change requires a wide range of coordinated interventions at many layers of society. A summit that bridges this array of behavior change interventions and approaches can help countries and developers as they seek to produce large-scale change. In analyzing the evidence of impact of these interventions on child survival, grouping these interventions based on their objectives and focus will make the analysis more practical. A potential classification would include:

Interventions that have sought to raise awareness and knowledge of new methods of improving child survival (breastfeeding, hand washing, water filtration, use of mosquito nets, etc.)—the primary objective for these set of interventions has been to make these methods known;

Interventions that have addressed adherence to treatment regimens and/or use of the existing methods—these have been used when there was proven evidence that the treatment in question would improve the odds of child survival (e.g., vaccination, ORS, Zinc supplements);

Interventions that have sought to promote care seeking and use of health services such as antenatal clinics to enable families to prevent or interrupt childhood illnesses and make better health decisions;

Intervention that have focused on the improvement of provider behavior(s) to optimize patient-provider interactions;

Interventions that have addressed policy and community norms—focusing on political will, policy development, and resource allocation behavior. The objectives of communication interventions at these larger levels (which are often referred to as "advocacy" interventions) have been to bring about changes in policies. These interventions have sought to improve child health by creating an enabling environment. Each of these behavioral interventions has influenced actions of individual families and small groups or the actions of larger groups such as communities, states, or nations.

Further analysis will also be needed on the impact and effectiveness, including cost per person reached by communication and other approaches that have been deployed to promote these social and behavior change interventions. A potential list would include:

Media (mass, social, interpersonal, and folk) includes the use of all types of broadcasting, electronic, and print communication for broad or selected audiences. Advances in such technologies as social networking offer new opportunities for communication about health behaviors.

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Community mobilization involves utilizing a wide variety of tools to enable one-on-one and community-level communication and instruction to achieve desired social and behavior change and use of maternal and child health services.

Educational Programs include such things as school-based prevention programs, job aids, teaching aids, curriculum revisions to include new health-related information, and other organized instruction provided to a wide range of different audiences.

Opinion leadership changes are often critical to the diffusion of innovation.

Economic Incentives to reduce cost or pay for performance that have application in changing service utilization and other behaviors at a population level.

Policy/Legislation change is often needed to structure or restructure the way health services are provided.

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1Li Liu, Hope L Johnson, Simon Cousens, Jamie Perin, Susana Scott, Joy E Lawn, Igor Rudan, Harry Campbell, Richard Cibulskis, Mengying Li, Colin Mathers, Robert E Black for the Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet, 379, 251-261.