Author: 
Silvio Waisbord
Publication Date
September 10, 2014
Affiliation: 

School of Media and Public Affairs, George Washington University

"Programs to address behaviors related to child health have been implemented in communities and countries with significant particularities and differences across the world. Interventions have selected a wide range of strategies and tactics - from peer education to media campaigns to mHealth - to tackle behavioral obstacles and contribute to improving the health of children, mothers, and caregivers."

Silvio Waisbord offers this editorial summarising findings of the Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change. The Summit was held in Washington, DC, United States (US), June 3-4 2013, evidence encapsulated in this issue of the Journal of Health Communication: International Perspectives, Volume 19, Supplement 1, 2014. 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.

Waisbord asks, "What Do We Know?....The articles confirm that child survival programs need to be based on realistic, evidence-based expectations to promote behavior change....Among other findings, better knowledge about services (from immunization to counseling), positive attitudes about specific interventions (from certain nutritional foods to bednets), self-efficacy about particular actions (e.g., breastfeeding, child feeding), positive community norms about certain practices (e.g., regular visits to antenatal care centers, HIV testing for mothers and babies), and low barriers of access to service and health technologies, are more likely to lead to positive behaviors and health indicators....

These insights yield two important lessons. First, certain interventions might be conducive to change if they are the right way to address specific behavioral obstacles. Rather than solutions driving programmatic priorities, programs need to define strategies and tactics that are based on nuanced considerations of problems as well as past successes and failures. If negative attitudes about health services deter families from seeking care in established heath systems, then, it seems sensible for communities to address existing concerns and improve perceptions. If high fees and transportation costs discourage families from getting diagnosed or using specific health technologies,then, solutions need to tackle those obstacles. Put it differently, only if we understand the relative weight of specific behavioral determinants that make healthy practices difficult or impossible can we then identify suitable courses of action based on past experiences and innovative ideas. Such problem-based thinking is needed to rectify the tendency to focus on strategies and tools. Flawless strategies and exciting tools are as good as they are adequate to address effectively the problems at stake. Second, the articles demonstrate that no behavioral challenge in child survival should be approached with a single tactic. A combination of policy, technological, communicational, and educational tactics aimed at transforming behavioral obstacles at different levels increases the prospects of effective programming....

Enthusiasm about specific ideas should be tempered by evidence and embedded in a nuanced understanding of challenges.... Consider mHealth, which has received a tremendous amount of interest in recent years, much as old technologies (from radio to grassroots video to computer centers) attracted significant attention and funding decades ago. Mobile platforms are helpful to address specific obstacles that affect child survival (e.g., health care practices of caregivers, quality of health systems), as the chapter by Higgs and colleagues (2014) demonstrates, but they may not be effective to change community distrust or mistreatment of mothers and families that undermine effective care. Peer education may help to address misperceptions about nutrition practices and encourage breastfeeding among mothers and influencers. However, if other reasons explain why newborns are undernourished are different (e.g., availability of nutritious foods, control over decisions about expenditures and foods in households, stigmatized behaviors), a different, complementary set of interventions may be needed....

What Do We Need to Know?....Certainly, there are important data gaps in the behavioral literature on child survival. Two gaps deserve particular attention: evidence about the behavioral and social impact of interventions on community, social, and policy issues, and the scale and sustainability of results....[W]e lack a similarly strong body of evidence about effective interventions to address challenges in communities, societies, and health systems. Many articles in this issue reach this conclusion and recommend further attention. No doubt, progress has been made in recent years, as shown by the articles on stigma, community engagement, health system strengthening, and gender empowerment. Yet, much remains to be done, particularly linking health policies and programs with behavioral outcomes....

On this issue, it is necessary to adopt a social change perspective that foregrounds the idea that social organizations (communities, organizations, governments) need to be collectively mobilized to address social problems. Solutions do not come only from disseminating information or changing individual attitudes or behaviors using sporadic, short-term campaigns. Rather, what is needed is to continue refining appropriate interventions to address social factors underlying the decisions of families and communities: social norms, trust and solidarity, power inequalities in households, neighborhoods, and societies, and the quality of health services particularly in poor and low-income communities....

A broad social change perspective on child survival could help address a long-standing question in the communication and behavioral literature: the information-behavior gap. This gap reflects the limitations of the old conviction that knowledge leads to behavioral changes....The problem is espousing a narrow perspective about drivers of change that ignores or downplays social determinants that weigh more heavily than individual knowledge on individual and collective decisions. A social change perspective, then, offers a different entry point into child survival. It assesses the significance of a range of social forces that affect specific health-related behaviors, and opens up a range of possible interventions.

Also, it is necessary to address research gaps related to scale and sustainability....How do we scale-up effective behavioral and social results beyond the impact of 'boutique’' interventions? How do we know that what works in one community might be implemented elsewhere? What evidence is needed to generalize results and program impact? Similar questions are relevant to the issue of sustainability: How do we know, encourage, and ensure that changes promoted by specific interventions are sustainable through time? What is the likelihood that promising interventions are sustainable?....

Addressing these gaps demands fresh thinking among all parties involved. What we know and do not know is not accidental: It is the result of prevalent theoretical frameworks and questions in academic behavioral research as well as research priorities among program funders and managers....On the one hand, researchers need to overcome empirical dispersion grounded in the wide technical and behavioral agenda of child survival and the interdisciplinary nature of the field. Studies need to identify common theoretical and research questions about social determinants of health practices. What actions effectively modify social obstacles to healthy behaviors across case studies? How do findings inform sophisticated theoretical arguments about causal pathways?

On the other hand, program funders and managers need to support flexible, comprehensive, and different approaches to impact data using various methods....

What Arguments Do We Need?....Even if the aforementioned research gaps are meticulously addressed, it is not obvious that new findings might satisfactorily respond to questions about the effect of behavioral interventions. The challenge is not the data per se. All kinds of data on effective interventions have been produced and will be produced in the future. Funders and managers, however, expect parsimonious explanations showing clear causal pathways linking interventions, behaviors, and health conditions. They do not just ask for data showing ‘‘what causes what’’ in specific cases. They expect coherent, elegant propositions that generalize and predict that certain stimuli/interventions will consistently lead to certain outcomes (and be cost-effective). The expectation is that behavioral studies need to deliver arguments that meet basic conditions of scientific research, namely validity, replicability, generalizability, and predictability....

Suffice to say that it is difficult, if not impossible, for behavioral and social studies to produce the kind of theoretical arguments that meet standard criteria that defines 'scientific' evidence in medical and public health research. As some articles show, health behavior can effectively use randomized control trials, widely considered the 'gold standard' in medical scientific research, to produce evidence. Yet, other quantitative and qualitative methodologies are equally needed to yield a complex, nuanced body of evidence demonstrating impact. Continuous engagement with funders and program managers is necessary to harmonize expectations about evidence data, enrich the methodological toolkit, and identify potential financial and technical support....

A substantive body of evidence shows that mediainterventions and interpersonal communication programs, if planned and executed correctly, change levels of knowledge about specific health behaviors, disease transmission and prevention, and so on....The key challenge is different: The social complexity of health issues at the core of child survival programs. The articles patently demonstrate the range of behaviors and sociocultural settings and challenges, as well as the multilayered social determinants affecting specific health practices....Decisions about myriad behaviors are nestled in
multiple factors: gender roles, self and collective efficacy, social norms, quality and access to health services, power structures, public trust of care providers, stigma, and so on. The weight of these determinants is not similar across communities around the world. No single variable neatly and inevitably affects specific behaviors across all instances.

Therefore, even if the literature produces persuasive and plentiful data about how specific interventions modify particular ideational factors or other determinants of health behaviors, it might not deliver the kind of concise arguments stating and predicting that particular programs will necessarily change myriad social determinants that influence child survival behaviors.

Given discrepancies between expectations, it is important to continue conversations across scientific, professional, and institutional cultures to find common language and define common expectations. Researchers need to prioritize lines of inquiry that foreground causal pathways and add to theories of behavioral and social change. It is regrettable that empirical studies do not consistently engage with existing theories of social change....

Therefore, empirical findings about child survival programs need to be embedded in common questions and cross-cutting arguments about social processes and behavioral determinants....

Organizing research in clusters of common theoretical questions exploring the links among interventions, social determinants, and health behaviors and indicators might get us closer to responding to questions such as 'what intervention leads to what behavioral change and health outcome.'

In closing, future research and programs need to cultivate a broad understanding of behavioral and social change, be driven by problem-based assessments and past experiences, support for innovative impact studies that address scale and sustainability, and promote collective efforts to refine coherent and elegant theories. of change. The articles in this issue provide plenty of insights and evidence to guide future behavioral and social research applied to child survival programming."

Source: 

Journal of Health Communication: International Perspectives, 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 216-222, accessed September 16 2014. Image credit: Core Group website