Evidence Synthesis - Evidence Review Team 1: (Supporting Children and Caregivers)

"Research has demonstrated that it is important to intervene early with parents, enhance child-parent attachment and communication, and teach parents age-appropriate skills in raising children."

In an effort to develop effective public health measures to prevent mortality and morbidity and to optimise child development among children under five, in 2013, the United States Agency for International Development (USAID) convened several teams of experts to conduct a systematic review of the evidence. One team, Evidence Review Team 1 (ERT1), stresses in this report that, while evidence-based preventive interventions are necessary, adopting prevention programmes piecemeal is not sufficient to impact children's survival and development. There are multiple ecological approaches that provide a framework in which to embed the evidence-based prevention programmes identified in this review and hence to mobilise different systems to have the greatest impact on children and families. For example, an integrated programme to improve health in children under five may involve the microsystem of the family as well as the mesosystem of communications between the parents and local health care workers, whose resources are ultimately determined by policies and programmes of the state (macrosystems).

The analysis was based on a systematic review of this literature to assess the evidence around behaviour change interventions for women, families, and caregivers to improve child survival and child development. Each article was reviewed by a member of ERT1 to assess the empirical quality of the evaluation design. The team divided its themes into 7 categories: 1) healthy timing and spacing of pregnancy, 2) newborn health, 3) child development, 4) nutrition, 5) immunisation, 6) handwashing, and 7) malaria control.

Various communication-related findings emerge from ERT1's review process. For instance, they identified one programme report of a broad-based communication intervention to educate young couples and families about the importance of delaying the first birth until the mother is at least 18. Launched in 2001 by an international family planning and reproductive health non-governmental organisation (NGO), this programme worked with 30 local NGOs in Bihar India. In 2008, using a non-randomised, experimental design, the programme staff evaluated the programme's impact on early childbearing. Among other findings, the analysis found that the median age at marriage of females in the intervention group was 2.6 years higher (22.0 vs. 19.4) than the comparison group (p <0.001). Project staff then used a RAPID model to estimate the project's potential mortality impact. They found that a reduced total fertility rate and delayed childbearing in the state of Bihar could lead to an estimated 60,000 fewer maternal deaths and reduction in the infant mortality rate by three-quarters over the next 20 years (from 62 to 15 deaths per 1000 live births); this would be the equivalent of 1.9 million fewer infant deaths over the period from 2005 to 2025. ERT1 also discusses 2 reports of communication programmes designed to encourage pregnancy spacing. Almost all studies found a positive effect of the intervention on contraceptive use. In a study conducted in Pakistan, home visits by Lady Health Workers during pregnancy and the postnatal period using locally embroidered communication tools resulted in increased rates of colostrum feeding as well as maintenance of exclusive breastfeed up to the first 4 months of life. Communication approaches - including mass media - are described as integral to multi-component immunisation programmes, which include mass campaigns or child health days.

In conclusion, ERT1 finds that, across the 7 health areas, "programs that emphasize both parents and children, are well supervised, and concurrently address multiple levels of the socioecological model and use multiple channels of communication produce superior results - and save lives....Programmatically, direct behavior change efforts delivered by face-to-face by trained workers through home visiting programs or in other community settings over an extended period of time and involving multiple aspects of health and development appear to be most likely to produce positive outcomes. Most of these interventions train the parents who are the ones that deliver the intervention to the children seizing on opportune moments to protect and train their children. Direct demonstrations of complex behaviors (e.g. proper mosquito net hanging, ORS [oral rehydration salt] mixing, correct handwashing) are especially appropriate for face-to-face interventions."

The report ends with a series of questions that emerged from the review process. For example, "[w]hat intervention experiences are not accessible through formal literature reviews? The current effort used state-of-the-science search engines with the participation of dozens of experts from around the world. However, none of us would pretend that we are fully aware of effective programs that have either been published only in the non-peer reviewed 'gray literature' or others that have not been described in print at all....On-line publication in new outlets would allow for broad sharing of evaluations, even if they are not predicated on randomized designs."

Looking ahead, ERT1 states that the broader use of "new media" - cell phone and web-based technologies - will be of particular interest. "Parents and other caregivers increasingly access these media in even economically poor regions, and when they cannot, at least health workers, teachers and other change agents can make use of them...in promoting the development and saving lives of young children."

Click here for the 48-page report in PDF format.