John P. Elder
Willo Pequegnat
Saifuddin Ahmed
Gretchen Bachman
Merry Bullock
Waldemar A. Carlo
Venkatraman Chandra-Mouli
Nathan A. Fox
Sara Harkness
Gillian Huebner
Joan Lombardi
Velma McBride Murry
Allisyn Moran
Maureen Norton
Jennifer Mulik
Will Parks
Helen H. Raikes
Joseph Smyser
Caroline Sugg
Michael Sweat
Publication Date
September 1, 2014

San Diego State University (Elder, Smyser); National Institute of Mental Health (Pequegnat); Johns Hopkins Bloomberg School of Public Health (Ahmed); United States Agency for International Development (Bachman, Huebner, Moran, Norton); American Psychological Association (Bullock); University of Alabama at Birmingham (Carlo); World Health Organization (Chandra-Mouli); University of Maryland (Fox); University of Connecticut (Harkness); Bernard van Leer Foundation (Lombardi); Vanderbilt University (Murry); PACT (Mulik); United Nations Children's Fund (Parks); University of Nebraska (Raikes); British Broadcasting Company (Sugg); Medical University of South Carolina (Sweat)

"While evidence-based behavior change interventions targeting caregivers are necessary, adopting prevention programs piecemeal is not sufficient to achieve the goals of the Child Survival Call to Action. There are multiple social ecological approaches that provide a framework in which to embed the evidence-based prevention programs at different levels..."

This is one finding from an exploration of the research literature on caregiver change for child survival and development conducted by one of the evidence review teams (ERTs) participating in the June 3-4 2013 Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change. It was hosted by the United States Agency for International Development (USAID), in collaboration with the United Nations Children's Fund (UNICEF) and 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 part of a special issue of the Journal of Health Communication that is a product of the Evidence Summit.

For context, the authors explain that, in June of 2012, more than 80 countries represented by governmental officials and partners from the private sector, civil society, and faith-based organisations gathered for the Child Survival Call to Action (See also Related Summaries, below). Convened by the governments of Ethiopia, India, and the United States in collaboration with UNICEF, this high-level forum resulted in a challenge to the world to reduce child mortality to 20 or fewer child deaths per 1,000 live births in every country by 2035.

This article was inspired by the question, posed to this ERT prior to the Evidence Summit: "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-5 mortality and optimize healthy and protective child development to age 5?" It is organised into childhood developmental periods followed by cross-cutting issues that affect child survival and healthy development across all these periods. On the basis of this review, evidence-based recommendations for programmes focused on caregivers to increase child survival and promote healthy development are presented. Last, promising directions for future research to change caregivers' behaviours are presented. Throughout the article, it is understood that "[p]arenting is one type of caregiving to a child in a caring relationship and is not limited to biological parents. This article addresses interventions at the level of the caregiver who can be a parent, foster parent, relative, or someone who assumes the parental role."

To respond to that question, members of this ERT undertook a systematic search of the published literature, nominations of documents in response to the call for evidence (i.e., potentially relevant papers identified by other Evidence Summit participants), and a targeted web search to identify primary documents.

An excerpt from the article follows (with references removed - please see the full document):

"We have reviewed a large body of research showing that there are effective behavior change interventions targeting caregivers that can enhance child survival and early development. Looking primarily at the extensive literature on healthy timing and spacing of pregnancy, we see that effective interventions are focused on implementing multidisciplinary, goal-oriented programs that included the following components: (a) multiple caregiver contacts in homes, health care settings, schools, or community meeting places during the antenatal and early childhood periods...;(b) multidisciplinary caregiver teams, including case management by social workers, with trained nurses, trained paraprofessionals, and volunteers...;(c) home visits by caregivers, often over a 2-year postpartum period ...; (d) motivating caregiver behavior, sometimes referred to as mentoring...;(e) use of standardized curricula and protocols...; (f) goal-orientation interventions...; (g) employment/career planning...; (h) health, and/or fertility education...; and (i) achievable parenting goals.

Interventions for parent education and support can lead to improvements in children's cognitive and psychosocial development, where a greater benefit may be observed for more disadvantaged younger children. These programs should be based on systematic curricula and training for both health care workers and parents, and use active strategies such as practice or coaching. Effect sizes were larger for interventions that included programs for both parents and children rather than for parents alone.

Preschool can be an important point of intervention for vulnerable children, particularly if it is of higher quality and intensity. Promising but not definitive evidence for the benefits of cash transfer programs to the family were evident. Last, other early education experiences through media (e.g., Sesame Street) were found to promote children's readiness for school.

Parenting programs which combine home-visiting and community-based interventions and provide counseling to parents and caregivers on early stimulation (play and communication) behaviors along with child health and feeding practices are the most common programs that can be scaled up. Evidence from Bangladesh, Brazil, Chile, Colombia, Jamaica, and Peru parenting programs are among the most promising ones. They provide methods that can be adapted to other countries and settings.

Both mass media campaigns and one-on-one and group interventions can dramatically increase handwashing of caregivers. These are scalable and cost-effective and can create awareness of the importance of correct and consistent handwashing. They can also increase health-seeking behavior if the child is exhibiting symptoms of illness. To be successful, evidence-based interventions must be adapted to the culture, especially in framing a positive message.

Although many of the behavioral and biomedical interventions discussed in this article have demonstrated evidence of efficacy, they need to be continually implemented. Every year, a new cohort of mothers/caretakers and their children enter[s] the health care system. Studies need to be conducted to tailor the evidence-based interventions for these new mothers/caretakers and children and to integrate new treatments that have come online...."

Our assessment is that we do not lack effective behavior change tools, but that these tools have not been widely enough used and prioritized within global health. We have tried to identify some of the most salient components of effective interventions in our review. There is strong support for scaling up interventions to promote healthy timing and spacing of pregnancy. These include interventions to increase the use of family planning and preventing pregnancy before age 18 and waiting at least 24 months after a live birth before attempting a pregnancy. In addition, there is evidence that education, counseling, and community involvement are all effective interventions to promote neonatal survival and health. We found evidence supporting the Partnership for Maternal, Newborn and Child Health (2011) list of essential interventions for reproductive, maternal, newborn and children targeting parental and caregiver behaviors. For neonatal care, home visits by community-based health workers can develop caregiver skills to identify complications with newborns, provide first line treatment, and make informed decisions on referral for facility-based care. Many studies also show that there are effective interventions to promote the quantity and quality of breastfeeding behaviors through a combination of counseling, home visits, group sessions, and changes in policy, sometimes supported by print and mass media. The findings from trials also support the importance of skin-to-skin care (Kangaroo Mother Care) for increasing neonate survival and there are effective, low-cost interventions to increase this behavior, which have the potential to be scaled up. There is growing evidence that the promotion of insecticide-treated nets, through community events, health care workers visiting homes combined with policy changes that make bed nets widely available, can be accomplished. We also conclude that behavior change interventions that target caregiver knowledge about oral rehydration therapy can enhance its utilization. Priority should be given to early childhood programs for caregivers because this is the most effective and cost-effective period. The number of contacts between parents and health care workers should be frequent (a minimum of twice a month) and should provide sufficient time to allow the caregiver to practice the new skills. Interventions with caregivers should target improvement in a range of functioning in young children from eating more food, improving cognitive development, language skills, and social emotional-development to readiness for school. Quality early child development programs for caregivers should be given priority because they can contribute to overcoming inequalities and the perpetuation of economic disparities.

...More implementation studies that scale up evidence-based interventions need to be conducted to identify what factors are associated with successful countrywide programs that increase child survival and healthy development. As a first step, evidence-based interventions that were scaled up but did not work should be assessed to identify the barriers and facilitators of scaling up. We found few studies of behavior change interventions designed to increase caregiver recognition of symptoms of illness or to increase early engagement of health professions early in disease progression.

Another step in scaling up is to adapt and test evidence-based interventions for health care workers that can be delivered to caretakers to ensure child survival and healthy development. Related to this is the development of user-friendly manuals based on research protocols that health care workers can implement with caregivers. Another promising direction is to study the role of frequency of contact, length, quality of relationship between caregiver and intervener on the effectiveness of the prevention program in child survival and healthy development which affects the cost-effectiveness of studies and their sustainability in developing countries.

Another area where progress could be made is to develop behavior change programs for caregivers for interventions that are known to be effective but where uptake has been low (e.g., oral rehydration therapy, immunizations, delay of marriage, prevention of pregnancy before age 18 years, and family planning). For example, some interventions have shown to be effective in delaying early marriage and early pregnancy in adolescents, but they have been applied in research studies and in small scale and time limited projects. Implementation research is needed in different contexts to test best approaches to expand the coverage of these interventions while maintaining quality. While cash transfer programs have provided some evidence of addressing the basic causes of poor child development, more research needs to be conducted to determine which kinds of programs are effective in supporting child's health care, education, and cognitive development. Media is an underinvestigated strategy for improving child survival and healthy development in children by offering programs for improving child rearing skills for caregivers and programs for improving language and child development in preschool children (e.g., Sesame Street). Media can be instrumental in changing community norms which leads to community mobilization that changes countrywide policies. More research needs to be conducted on culturally-appropriate messages to caretakers about child rearing strategies and practices that enhance child survival and healthy development and methods for delivering those messages (e.g., handouts in clinics, educational media, soap operas)."


Journal of Health Communication: Special Issue: Population-Level Behavior Change to Enhance Child Survival and Development in Low- and Middle-Income Countries: A Review of the Evidence, Volume 19, Supplement 1, 2014, pages 25-66.Image credit: Health Communication Capacity (H3C)