Luis F. Vélez
Mary Sanitato
Donna Barry
Martin Alilio
Franklin Apfel
Gloria Coe
Amparo Garcia
Michelle Kaufman
Jonathan Klein
Vesna Kutlesic
Lisa Meadowcroft
Wendy Nilsen
Gael O'Sullivan
Stefan Peterson
Daniel Raiten
Susan Vorkoper
Publication Date
September 1, 2014

DePelchin Children's Center (Vélez); United States Agency for International Development (Sanitato, Alilio, Coe); Center for American Progress (Barry); World Health Communication Associates (Apfel); U.S. Forest Service (Garcia); Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health (Kaufman); American Academy of Pediatrics (Klein); National Institutes of Health (Kutlesic); AMREF (Meadowcroft); National Institutes of Health (Nilsen); ABT Associates (O'Sullivan, Raiten, Vorkoper); Karolinska Institute (Peterson)

"Evidence-based behavior change interventions addressing health systems must be identified and disseminated to improve child health outcomes."

This is one finding from an exploration of the research literature on social and behaviour changes that are facilitated by interventions targeting health systems and health policies. The review was conducted by one of the evidence review teams (ERTs) participaing 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. This gathering 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.

The members of this ERT, authors of this article, explain that "[t]he quality of service delivery and health workforce development are the most visible aspects of the health system that affect behavior - for example, the quality of service delivery can influence the behavior of the client or patient. Likewise, the health workforce, especially the knowledge, attitudes, and behaviors of providers, has an impact on the behaviors of the clients or patients. The impact of the other building blocks are less obvious, but also can be important, for example the way information is processed and shared and the ways medical products, vaccines and technologies are priced, regulated, distributed or promoted. Health financing and performance based incentives have a clear impact on patient or client behavior since cost of services (e.g., price or subsidies) affects their demand and use. Leadership and governance can also affect behaviors, for instance in the way program delivery is negotiated and implemented based on the characteristics and needs of the community or on policies determined by international funders or at the ministerial level."

Studies of the efficacy of such interventions were identified from systematic searches of the published literature. Two hundred twenty-nine of the initially identified references were judged to be relevant and were further reviewed for the quality and strength of the evidence. Studies were eligible if an intervention addressed policy or health systems interventions, measured relevant behavioral or health outcomes (e.g., nutrition, childhood immunisation, and/or malaria prevention and treatment), used at least a moderate quality research design, and were implemented in low- or middle-income countries. Policy or systems interventions able to produce behaviour change reviewed included media (e.g., mass media, social media), community mobilisation, educational programmes (for caregivers, communities, or providers), social marketing, opinion leadership, economic incentives (for both caregiver and provider), health systems strengthening/policy/legislation, and others.

Specific examples are provided. For instance, on the demand side, research cited here has found that social mobilisation and public education initiatives as part of "a comprehensive education and information package including the training of doctors and Expanded Program on Immunization staff can lead to a significant increase in public and provider knowledge, attitudes and practices and support smooth integration of a new vaccine into the Expanded Program on Immunization." For example, a campaign in the Bihar State in India, called Muskaan Ek Abhiyan led to a 16-26% greater vaccination uptake than in the control areas. The main strategies of the Muskaan campaign included, for instance: increasing access to immunisation sessions; enhancing inter-sectoral coordination between the Departments of Health and Women and Child Development; training trainers, with alternate vaccinators to counter the shortages; facilitating the involvement of community-based women's groups in awareness generation; strengthening of monitoring and supervision mechanisms, and; providing performance-based incentives to service providers.

Several other examples of research cited in the article relate to efforts to raise awareness and knowledge of different methods to improve malaria prevention and treatment. Reviewing the research, the ERT found that community interpersonal communication is effective in increasing the uptake of malaria prevention and treatment. For instance, a study in Burkina Faso involved training a core group of mothers and supplying CHWs with antimalarial drugs specially packed in age-specific bags and containing a full dose of treatment. The proportion of mothers seeking help from anyone in the village (primarily a CHW) for their child's malaria episode increased from 21% at baseline to 54% at the end of the study. In addition, use of chloroquine and paracetamol for treatment rose from 25% to 46%.

Based on the findings of this exploration, including the above-cited and many other studies, the researchers present recommendations for policy, practice, and research based on data across the following areas:

  • Health service delivery - "Research has shown that evidence-based policies and well-organized health systems can contribute to positive health and development outcomes for children younger than 5 years of age when (a) health services are offered at different levels of complexity (e.g., early detection, triage, and linkage to the appropriate service), (b) access is free or low cost, (c) a strong community component is included, and (d) education and technical support is provided for CHWs (volunteer or paid)."
  • Health workforce - "The studies strongly support the provision of training, technical support and monitoring for health professionals, paid CHWs and volunteers towards improving caregiver behavior related to antenatal care, immunization rates, postnatal birth control, malnutrition, and the prevention, detection of warning signs, basic early treatment, and timely and appropriate referral in cases of acute respiratory infection, diarrhea, and malaria." Furthermore, "[t]raining personnel to apply evidence-based protocols, paired with follow-up (e.g., using text messages), and monitoring the use of such protocols effectively promote behaviors that improve child survival and healthy development."
  • Health financing and governance and leadership - "The data show that systematic quality management has important effects at district, facility and community levels. Using more holistic models of health systems support is recommended for accelerating behavior change at the different levels."
  • Research - recommendations include:
    1. "Most existing research has examined the effectiveness for particular health interventions, with scant description of the health systems and policy supports required. In addition, there is little research on factors needed to sustain effective programs. To address this gap, researchers may need to translate evidence-based interventions into constituent health systems supports and required policies, using a health systems model such as the World Health Organization Building Blocks, or another conceptual or theory-of-change model.
    2. Additional research is needed to identify health systems supports and policies required to sustain behavior change at a population level that lead to improved public health outcomes.
    3. There is a need to evaluate national programs based on behavior change outcomes, and not just knowledge-based outcomes.
    4. Implementation research is needed to more fully appreciate both the opportunities and barriers to scaling up effective, cost-efficient interventions and to gauge their long-term impact."

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 89-121. Image credit: Mark Tuschman, Kenya