U.S. Government Evidence Summit on Enhancing Child Survival and Development in Lower- and
Middle-Income Countries by Achieving Population-Level Behavior Change
Concept Paper
Introduction
A renewed emphasis on the application of research and evaluation to inform strategic thinking about
development for low- and middle-income countries is integral to USAID’s efforts to improve health by
promoting country-owned, effective and sustainable interventions. To that end USAID is leading a
series of evidence summits focused on important development challenges. The aim of these summits is
to provide evidence-based expert recommendations on how to achieve some of the world's most
difficult development goals, for example, reducing maternal mortality, caring for children living outside
families or supporting community health workers. The intended users of the information derived from
the Evidence Summit are low- and middle-income country governments, USG policy and program
decision makers, researchers, and other multilateral stakeholders. Because development challenges are
complex, intrinsically multidisciplinary, and therefore informed by diverse data inputs and expertise,
these summits engage a broad coalition of expert contributors from across the USG, academia,
development agencies, low- and middle-income governments, and civil society organizations in these
countries. Expected outcomes from each global health summit include: clarity on evidence to inform
policies, programs, and practice; identification of knowledge gaps to inform a research agenda;
publication and dissemination of findings and recommendations; and evidence-to-action follow-up to
ensure application of learning and active pursuit of critical knowledge gaps.
This Evidence Summit focuses on the challenge of achieving the social and behavior changes needed to
end preventable child deaths and improve under five development. As a global community, we have
made staggering progress in the reduction of child mortality. Over the last 50 years, child mortality has
been reduced by 70%. However, in rich and poor countries alike, the poorest and most disadvantaged
children continue to miss out on life-saving, affordable interventions. In 2012 more than 7 million
children – most of them in sub-Saharan Africa and South Asia - will die from mostly preventable causes
before they reach their 5th birthday. In lower- and middle-income countries, an estimated 200 million
children under five years of age – more than 30 percent of the world’s children – fail to reach their
developmental potential, limiting their future ability to contribute to their communities and families or
obtain gainful employment.
Based on the current rates of progress, many countries will not achieve Millennium Development Goals
1
4 and 5 to reduce child mortality and improve maternal health. The Child Survival Call to Action1
provides a roadmap for bringing an end to preventable child death. The accomplishment of this goal
requires population-level behavior changes that impact maternal and child health that depend on
healthy timing and spacing of pregnancy, the utilization of services, nutritional choices, and accessing
and practicing preventive health care. Changing the behavior of health service providers also is a key
element to a sustainable improvement in public health and the adoption of existing and new health care
practices. Adherence to medications, best practices for prenatal care, following recommendations for
immunizations, and the use of bed nets are still other examples of areas where knowing better how and
why behaviors change would reap enormous rewards.
Early childhood health and developmental protections, which link the young child’s cognitive,
social/emotional, language, and motor development with stable and supportive caregiving, help break
cycles of poverty and inequality, particularly among the most vulnerable children. Although not the only
time to provide developmental support, return on investment for human capital growth is greatest in
children’s early years. Failure to
address adversity at this time leads
to lifelong deficiencies. Toxic stress,
ill health, and chronic undernutrition leave children vulnerable
to many risks, impair cognitive
function, stunt physical growth, and
reduce lifetime earning potential.
When children experience
responsive relationships, including a
secure attachment with a
permanent primary caregiver, and
an environment rich with
stimulation, they are more likely to
thrive and grow up to be productive
adults.
In light of the mounting evidence of the long-term effects of severe adversity in early childhood,
comprehensive strategies that incorporate promotion of secure and stimulating relationships,
safeguarding against malnutrition during the critical 1,000 days between pregnancy and age two, and
other life-saving health services are essential to the future success of communities and nations.
Globally, USAID, other health and development agencies, and the governments and civil society agencies
in LMIC countries have a wide range of field research and implementation experiences on effective
interventions for social and behavior change leading to improved public health outcomes. In addition,
existing research evidence, some of which has been carried out in high-income countries, has identified
1
Child Survival Call to Action Ending Preventable Child Deaths Summary Roadmap, 2012.
http://5thbday.usaid.gov/pages/ResponseSub/roadmap.pdf
2
many effective interventions for changing individual behaviors, including health communication and
social marketing, performance-based incentives, new polices favoring healthy behaviors, increasing
health literacy, and reducing mother-to-child transmission of HIV, among many others.
The Summit will lead to expert recommendations based on the evidence to inform policy and practice
for achieving population level shifts in behavior for improving child survival and child development. It
will also identify the knowledge gaps that will inform a research agenda. Immediate follow-on activities
will include: 1) the establishment of programming principles and/or technical strategies for country-led
programs in low- and middle-income countries (LMIC) to achieve population-level behavior change for
child survival; and 2) an evidence-to-action strategy to guide application of learning and actively address
critical knowledge gaps in country- and donor-funded initiatives. Scientific journal publications will be
one of the mechanisms for communicating these outcomes.
The overarching goal of the summit is to determine which evidence-based interventions and strategies
are required to support a sustainable shift in health-related behaviors in populations in lower- and
middle-income countries to reduce under-five morbidity and mortality. The summit will address this
topic through expert consultation and a review of the evidence pertaining to specific focal questions.
Expected outcomes of the evidence summit are recommendations on policy, practice, and research that
will inform a strategy to embed behavioral change into child survival and development activities to
enhance effectiveness, impact and sustainability.
Focal Questions
The focal questions are designed to collectively inform the field on effective behavioral change activities
for child survival and development within the families and communities as well as social and health
systems contexts to achieve sustainable population-level social and behavioral change. The focal
questions also address critical gender issues and engage the perspectives from groups experiencing
stigma, discrimination, and isolation/exclusion. These questions were informed, in part, by a scoping
exercise undertaken by the organizing core group (appendix):
1. 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-five
mortality and optimize healthy and protective child development to age five?
2. What are the effective means to facilitate and empower communities to organize and advocate
for interventions to achieve behavior and social changes that are needed to accelerate
reductions in under-five mortality and optimize healthy and protective child development to age
five?
3. What types of sustainable health systems and policy supports are effective in producing
behavior and social changes for and by primary caregivers, families, and communities that are
needed to accelerate reductions in under-five mortality and optimize healthy child development
to age five?
3
4. What are the effective and sustainable interventions that focus on gender dynamics as a means
to promote and support behavior and social change that is needed to accelerate reductions in
under-five mortality and optimize healthy and protective child development to age five?
5. What are the effective and sustainable interventions that address stigma and discrimination as a
means to promote and support behavior and social change that is needed to accelerate
reductions in under-five mortality and optimize healthy and protective child development to age
five?
6. What are the effective and sustainable interventions that utilize advances in science and
technology to promote and support behavior and social changes that are needed to accelerate
reductions in under-five mortality and optimize healthy child development to age five?
Organization of the Evidence Summit Process
In order to find the evidence that is needed to answer these focal questions, a systematic literature
search will be conducted of the biomedical and social and behavioral sciences journals. The primary
focus will be on finding reports of controlled studies or well-designed program evaluations that provide
outcome data, as well as a comparator. An emphasis will be placed on finding studies that were
conducted in, or are highly relevant to, the challenges faced in LMIC. A special effort will be made to
identify and translate non-English language documents that are thought to be relevant to the questions.
Another goal of this search will be to obtain evidence not only on the efficacy of various interventions in
restricted research settings, but also on their effectiveness when applied in different settings or at a
larger scale. Information will also be sought on the sustainability and potential for country ownership of
programs and policies.
Experts representing the science and practice communities will be enlisted to work on Evidence Review
Teams (ERTs) to assess the relevance and quality of the evidence that was obtained through the search
process. Through a Call for Evidence process, ERT members will also be invited to identify other
important documents that they feel can inform their work to address the focal questions.
We will establish six ERTs, one each assigned to address focal questions 1 to 6. ERTs for focal questions
1 to 5 will also consider the topic of focal question 6, i.e. interventions that utilize advances in science
and technology (such as behavioral economics, health literacy, mobile/digital technologies, social
network theory, neurobehavioral development, etc.), as they pertain to their core question. Each ERT
will be comprised of about 20 experts. They will have the responsibility of deciding which evidence they
use and to make recommendations based upon the evidence. Since not all questions may have
sufficient high quality and relevant research to make evidence-based recommendations, it is
acknowledged that experience-based exert opinion will be brought into the equation for committee
recommendations. We will seek to have transparency in making clear the relative weight of scientific
evidence and expert opinion for those recommendations that pertain to policy, program practice, and
research gaps.
4
There will be several events that comprise the Evidence Summit process. While experts are being
identified and recruited and the evidence is being gathered and reviewed, the Core Group will organize
various meetings to be held prior to the Summit. We currently envision two regional country
consultations to be held in Ethiopia and India to focus on evidence-to-action plans for implementing
recommendations made by the Evidence Summit and a pre-summit meeting to be held either in
Washington DC or New York in early 2013. In the pre-summit meeting, teams will hold face-to-face
discussions on the status of their work and organize themselves to complete the task of compiling
evidence-synthesis documents and recommendation before the Summit. The summit is tentatively
scheduled for late spring 2013.
Draft Timeline for Evidence Summit
July 19, 2012: Final report from constituency scoping survey
July 26: Final core group decision on Summit topic. Initial testing for key words search begins
August 2: Identification of experts begins; subgroup works with KMS on evidence search
September 17: Final version of concept paper completed
October 12: Initial literature search completed
October 19: Invitations and copy of concept paper sent to experts
October 24: Initial screening and relevance assessment of literature completed
October 31: Leadership for ERTs confirmed
October 20-November 9: Experts assigned to ERTs
November 7: Second screening for assignment of documents to Evidence Review Teams completed
November 8-17: Call for evidence issued to ERT members
End of November to December: Regional consultations coinciding with Call to Action meetings in India
and Ethiopia (tentative and to be confirmed)
November 17-January 5, 2013: Third screening completed by ERT members
Early-Mid January: Pre-summit
Mid-January through March: Evidence review process underway; Critical study reports submitted to
quality review
April 2013: Evidence Summit
April 30: Summit feedback provided to ERTs
April 30: Evidence to action plan completed
Mid-May: Revised papers due
June 30: Internal review process completed and papers submitted for publication
Going forward: Implementation of other elements of the evidence to action plan
5
APPENDIX
The appendix provides more detailed information on the considerations that formed the basis for the
selection of the Focal Questions. It also provides help in gathering the evidence by identifying some of
the key terms and concepts that the Core Group discussed in preparing this Concept Paper.
Population Behavior Changes and Child Survival
In a recent analysis published in Lancet1, Liu and colleagues estimate the leading causes of child
mortality before age 5 (Figure 1). Of 7.6 million deaths in children younger than 5 years in 2010, 64.0%
were attributable to infectious causes and 40.3% occurred in neonates. Preterm birth complications
(14.1%), intrapartum-related complications (9.4%), and sepsis or meningitis (5.2%) were the leading
causes of neonatal death. In older children, pneumonia (14.1%), diarrhea (9.9%), and malaria (7.4%)
predominated. Other causes of neonatal mortality included congenital abnormalities, tetanus, and
diarrhea. Other causes of 1-5 year old mortality included injury, meningitis, AIDS, and measles.
Figure 1: Causes of death in children under 5 years of age. Those in white and yellow represent
neonatal causes; those in color represent causes of death in 1-5 years olds. [Taken from Li et al. (2012)]
To address these causes of child mortality, the Child Survival Call to Action stresses the importance of a
continuum of care to benefit mothers and children, beginning with the pre-pregnancy and antenatal
6
period, childbirth, and the postnatal period through infancy and childhood (Figure 2). Inspection of the
broad range of interventions shows that the vast majority involve a significant element of social and
behavior change. Even for those interventions involving medical care, the Call to Action acknowledges
that creating access to and demand for these services is a necessary first
step.
Figure 2. Continuum of Care model (taken from the Child Survival Call to Action).
Tremendous effort has gone into determining the Continuum of Care model and understanding the
impact of these evidence-based interventions on child morbidity and mortality, as well as to studying
trends in child mortality over time. In order to fulfill the world’s commitment to the Child Survival Call
to Action, increased attention is needed to understand effective social and behavior change to promote
healthy behavior and ensure proper uptake of essential services.
With this in mind, the summit will review the literature to examine how social and behavior change
strategies associated with the major interventions for child survival and healthy development at
multiple ecological levels can contribute to child health. To focus the scope of this exercise, the summit
7
is concentrating on eight high-impact intervention areas that have published evidence demonstrating
their efficacy. These include:
1. Newborn health interventions that focus on simple, effective delivery methods, include an
emphasis on Essential Newborn Care practices including breastfeeding and keeping newborns
warm, and help babies suffering from asphyxia during birth.
2. Pneumonia and Diarrhea interventions including immunization to prevent sickness, improving
sanitation and hygiene to prevent children from getting sick, and treating those kids who are
sick.
3. Malaria interventions including the provision of long lasting insecticide treated nets, increasing
indoor residual spraying to under-served populations, and treating kids who are sick.
4. Addressing malnutrition by ensuring proper nutrition during the 1,000 days between a woman's
pregnancy and her child's second birthday, targeting micronutrient supplementation including
Vitamin A, and supporting optimal breastfeeding.
5. Working with partners to make childhood immunization services available and affordable for all.
6. Preventing mother-to-child transmission of HIV by accelerating the scale-up of more effective
treatment to reduce transmission.
7. Family Planning interventions including educating women on the benefits of healthy timing and
spacing of pregnancy, ensuring contraception is accessible, and targeting resources where they
are most needed.
8. Promoting developmental protection, which links the young child’s cognitive, social/emotional,
language, and motor development with stable and supportive caregiving and healthy
attachment.
Development efforts to change behaviors for public health impact traditionally have focused on
individual change, specific populations, and/or shorter, more focused campaigns. Currently, no
overarching strategy or “standards” exist for achieving sustainable, population-level change across
different health areas that is cohesive and employs all of the appropriate social and behavior change
tools available. Although current efforts have produced substantial benefits in improving child survival
and healthy and protective development, a diffused approach can result in a fragmented response, not
the integrated and coordinated approach that would take advantage of the synergy that could be
achieved across the various behavior change tools and approaches. In addition, evidence about
sustainable, population-level behavior change for child survival often is “siloed” within the health
problem area (e.g., infant mortality) or risk factor area (malaria, pneumonia, diarrhea, measles,
HIV/AIDS, etc.) for which the interventions were designed or within the types of interventions that are
used. Finally, looking across types of interventions and the various health problem areas can lead to
more cost-effective strategies.
8
Of particular interest for this Summit is how behavior change interventions can be/might be applied to
multiple behavioral goals collectively. Up to now, behavior change efforts have been mostly
compartmentalized within subsectors such as family planning, HIV, malaria prevention, etc. And too
often, behavior change within a subsector is small, fragmented, isolated, and without the critical mass of
behavioral expertise and resources. Doing behavior change across the sector is consistent with the “Ten
promises to our Children” that emerged from Call to Action. We will be asking ERTs to address the
evidence that exists for a compound impact from multiple initiatives.
Behavior Change and Child Development
The development that occurs during the first years of life is critically important to well-being. During
this period, the brain has maximum plasticity, and each experience shapes its growth. Exposure to
chronic adversity in early life leads to toxic levels of stress and permanent changes to brain architecture.
This has damaging effects on learning, behavior, and physical and mental health and ultimately limits
future opportunities and perpetuates the cycle of poverty.
Major advances in neuroscience, molecular biology, genomics, psychology, and other fields now help us
to understand better how significant adversity early in life gets into the body and has lifelong, damaging
effects on learning and behavior and both physical and mental health. Early interventions in the first
two to three years of life are profoundly important and can reduce the number and severity of adverse
experiences and strengthen relationships that protect young children from the harmful effects of toxic
stress.
Protective and permanent family care and positive attachment experiences have beneficial immediate
and long-term effects. Investments in early child care and developmental protection can mitigate the
deleterious impact of poverty, social inequality, gender biases, and disability discrimination, ultimately
resulting in long-lasting gains.
Seeking Country Input for Priority Setting
In order to ensure an effective Summit on social and behavior change it was necessary to identify
specific priorities that resonate with both overall contemporary development thinking and the present
state of play in the behavior and social change field. Such resonance is crucial for the vitally important
“evidence-to-action” outcome of the Summit. Towards this end, an online survey was completed by 97
people (out of 167 invitations) representing a broad range of public health issues, types of organizations,
work roles, and 22 countries of residence. All had broad experience in global health. Based on
recommendations from the Core Group membership, 167 people with significant expertise in this field
were asked to complete a brief priorities survey.
The questions agreed upon for the survey were:
Related to the health and development issues that are the focus for your work, can you please identify
the major challenges to effective action for each of the following themes:

Individual behaviors from the health area in which you work
9





Social norms from the health area in which you work
Social context from the health area in which you work
Systems and policies from the health area in which you work
Public engagement from the health area in which you work
Other structural factors from the health area in which you work
In relation to the challenges that you described, please highlight any positive and promising changes that
might benefit your development work.


Opportunity 1:
Opportunity 2:
Do you think that new digital technologies offer opportunities to address challenges related to individual
behaviors, social norms, and health systems? If so, can you please give your reasons and concrete
examples.
From the data submitted by respondents the following analysis steps were undertaken:
a. A word cloud was generated for the responses to each of the questions. This gave an initial
insight into the key themes to emerge for each question.
b. Starting with those themes some groupings of predominant themes were identified.
c. Each individual comment was assigned to a relevant theme and provided a score of 1.
d. By tallying the scores for each theme we developed data for the construction of pie charts that
demonstrated the main priority themes for each question.
e. We then took the priority themes to emerge across all questions, developed groupings, and
tallied the collective scores.
The full data gathered is available, with the privacy of the respondents protected.
From that data the following priorities emerged:
10
Figure 3: Priority themes to emerge from country input to summit topic selection
From that overall analysis a set of specific recommendations were identified as the possible priorities for
the Evidence Summit. Those priorities are:





Working with communities and other specific publics to support them advocating, prioritizing,
and making key decisions concerning their health needs and actions
Developing the critical analysis and healthy choice skills and perceptions required by individuals
to improve their own health status
Gender-based dynamics as they affect health status
Expanding open discussion on required health services and action, with a broader range of
perspectives engaged, particularly from groups experiencing stigma, discrimination, and
isolation/exclusion
Change processes within health systems to improve levels of respect, response, relevance, and
preventive strategies…
… one key element for the evidence collection and critical review as part of all 5 foci above was the
added value and impact of social networking and shared knowledge technologies.
11
Interventions for Behavior and Social Change
It is recognized that sustainable population-level social and behavior change requires a wide range of
coordinated interventions at many layers of society. A summit that bridges this array of behavior
change interventions and approaches can help countries and developers as they seek to produce largescale change. In analyzing the evidence of impact of these interventions on child survival, grouping
these interventions based on their objectives and focus will make the analysis more practical. A
potential classification would include:

Interventions that have sought to raise awareness and knowledge of new methods of improving
child survival (breastfeeding, hand washing, water filtration, use of mosquito nets, etc.)—the
primary objective for these set of interventions has been to make these methods known;

Interventions that have addressed adherence to treatment regimens and/or use of the existing
methods—these have been used when there was proven evidence that the treatment in
question would improve the odds of child survival (e.g., vaccination, ORS, Zinc supplements);

Interventions that have sought to promote care seeking and use of health services such as
antenatal clinics to enable families to prevent or interrupt childhood illnesses and make better
health decisions;

Intervention that have focused on the improvement of provider behavior(s) to optimize patientprovider interactions;

Interventions that have addressed policy and community norms—focusing on political will,
policy development, and resource allocation behavior. The objectives of communication
interventions at these larger levels (which are often referred to as "advocacy" interventions)
have been to bring about changes in policies. These interventions have sought to improve child
health by creating an enabling environment. Each of these behavioral interventions has
influenced actions of individual families and small groups or the actions of larger groups such as
communities, states, or nations.
Further analysis will also be needed on the impact and effectiveness, including cost per person reached
by communication and other approaches that have been deployed to promote these social and behavior
change interventions. A potential list would include:

Media (mass, social, interpersonal, and folk) includes the use of all types of broadcasting,
electronic, and print communication for broad or selected audiences. Advances in such
technologies as social networking offer new opportunities for communication about health
behaviors.
12

Community mobilization involves utilizing a wide variety of tools to enable one-on-one and
community-level communication and instruction to achieve desired social and behavior change
and use of maternal and child health services.

Educational Programs include such things as school-based prevention programs, job aids,
teaching aids, curriculum revisions to include new health-related information, and other
organized instruction provided to a wide range of different audiences.

Opinion leadership changes are often critical to the diffusion of innovation.

Economic Incentives to reduce cost or pay for performance that have application in changing
service utilization and other behaviors at a population level.

Policy/Legislation change is often needed to structure or restructure the way health services are
provided.
1
Li Liu, Hope L Johnson, Simon Cousens, Jamie Perin, Susana Scott, Joy E Lawn, Igor Rudan, Harry Campbell, Richard Cibulskis,
Mengying Li, Colin Mathers, Robert E Black for the Child Health Epidemiology Reference Group of WHO and UNICEF. Global,
regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet,
379, 251-261.
13