Evidence Synthesis: Health Systems and Policy Supports Producing Behavior and Social Changes Needed to Accelerate Reductions in the Mortality and Optimize Healthy Development of Children under Five Years of Age in Low and Middle Income Countries

"Healthy behaviors are maximized when environments and policies support healthful choices, and individuals are motivated and educated to make those choices."

In 2013, the United States Agency for International Development (USAID) convened a team of experts to conduct a systematic review of the evidence on a range of topics in recognition of the fact that governments, donors, and others need evidence to inform efficacious, effective, and sustainable policies, strategies, and programmes to achieve the Millennium Development Goals (MDGs) related to child survival and child development. The purpose of this paper is to describe why health systems and policy supports (Evidence Review Team 3 - ERT3) are important to reach these goals and how the evidence was selected and evaluated, as well as to spark discussion and formulation of recommendations for practice, policy, and research needs.

Two hundred twenty-nine manuscripts were advanced for quality review. Areas of review included:

1. Issues associated with healthy child development and survival:
   • Healthy timing and spacing of pregnancy/antenatal care
   • Prevention of mother-to-child transmission (PMTCT) of HIV/AIDS
   • Neonatal survival and health
   • Healthy early child development (ECD)/good parenting skills and family environment
2. Health practices and diseases associated with child survival
   • Nutrition/micronutrients, including vitamin A/breastfeeding
   • Prevention and treatment of diarrhoea/pneumonia/acute respiratory infections (handwashing, etc.)
   • Malaria prevention and treatment
   • Childhood immunisation

Policy or systems interventions able to produce behaviour change reviewed included media (mass media, social media, etc.), 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 other interventions.

In summary, the evaluation found that "[h]ealth systems and health policy supports are effective in producing behavior and social changes...to accelerate reductions in the mortality and optimize the development of children under five years of age yielded a series of interventions with the strongest evidence favoring integration within and among systems, training and establishing and monitoring guidelines to implement evidence based practices, and identifying the needs and practices of communities and health workers to strengthen supply and demand models, consistent monitoring and evaluation. Besides support for integrated ecological approaches, strong evidence was found for specific interventions such as prevention and control of nosocomial infections, Baby Friendly Hospital Initiatives and 'First 1,000 days' programs, nutritional assessment and food fortification, increasing the variety and quality of nutrient dense foods, regular home visitations, adoption of formal and community-based pre-schools, and the use of planning resources such as the computerized Lives Saved Tool. Promising practices with supporting evidence in some regions and whose dissemination to other regions needs further study include economic incentives and conditional cash transfers, and the use of new media."

To cite only a few examples:

• Training personnel to apply evidence-based protocols to improve care delivery has produced a strong impact on neonatal survival and health.
• Home visitations by trained community lay workers plus supervision by a child development professional led to significant improvement in cognitive development across studies and populations in Jamaica and Bangladesh, except when home visits were monthly or less.
• Community interpersonal communication is effective in increasing the uptake of malaria prevention and treatment. For instance, training mothers and supplying community health workers (CHWs) with antimalarial drugs in Burkina Faso led to an increase in health-seeking behaviour from 21% to 54% and an increase in provision of appropriate treatment from 25% to 46%.
• In the area of childhood immunisations, it is noted that the best approach is an integrated one - involving (among other things) media campaigns (one paper reviewed by the ERT3 found that, in the Russian Federation, there was a 20-80% increase in diphtheria vaccination due to one such campaign) and new media (e.g., SMS (text messaging) vaccination appointment reminders).

Recommendations for policy and practice include:

1. Organise primary care systems to provide services at different levels of complexity, with free or low cost access, a strong community component, education, technical support for CHWs (volunteer or paid), and triaging systems to detect and transfer higher-risk cases to a health centre of higher complexity.
2. Ensure systematic quality management at district, facility, and community levels using more holistic models of health systems support.
3. Strengthen interpersonal communication on the part of health professionals, trained local health workers, and/or mothers who promote the use of treatments (e.g., antimalarials) and prevention techniques. These individuals tend to be trusted sources by the community and are often trained or informally receive messages from a health professional to encourage the desired behaviours.
4. Integrate and/or link services to improve referral and use.
5. Offer formal trainings, including follow-ups using text messages, to foster health professionals' performance and compliance with national guidelines.
6. Train personnel to apply evidence-based protocols to improve health care delivery.
7. Conduct trainings and educational interventions, including a follow-up component as well as evaluations that assess the behaviour changes that occur after these trainings.
8. Focus on social networks, community leaders, multiple levels of community stakeholders, collective behaviours, and social norms.
9. Develop a comprehensive health systems approach that builds technical and healthcare delivery capacity and improves access to disease prevention strategies and evidence-based standards of care and treatment.
10. Create strong health systems with good data collection that also incorporate robust monitoring and evaluation activities that track population-level needs, detect services that are ineffective, and identify implementation concerns.
11. When crafting national policies, seek technical guidance from key authoritative agencies, such as the World Health Organization (WHO).
12. Ensure that health worker interventions, such as trainings, are accompanied by holistic health systems support for the intended interventions (e.g., supervision, drugs/supplies, etc.)

With regard to research, ERT3 notes that most evidence is for particular interventions, with scant description of the health systems and policy supports required, let alone their sustainability. This may require translating evidence-based interventions into constituent health systems supports and required policies, using a health systems model such as the WHO Building Blocks, or another conceptual or theory-of-change model. ERT3 also finds that health systems supports and policies required for population behaviour change are poorly characterised in research papers. Finally, there is a need to evaluate national programmes based on behaviour change outcomes, not just knowledge-based outcomes.

Click here for the 47-page report in PDF format.