Saving children

In many cases, experts know how to prevent child mortality. The trick is getting people to adopt those often-simple interventions.

Take hand-washing, for example. "Simply providing soap and a quick demonstration has been shown to have a nice impact on child mortality," says psychologist John Elder, PhD, a professor of health promotion and behavioral sciences at San Diego State University's Graduate School of Public Health. Multiple studies, he points out, show that proper hand-washing reduces the incidence of diarrhea, which kills 1.87 million children under 5 each year. But getting people to actually wash their hands remains a serious challenge.

How to achieve that goal was the kind of question explored at an evidence summit sponsored by the U.S. Agency for International Development (USAID) and UNICEF in conjunction with APA and other partners in Washington, D.C., in June. "Saving Children's Lives: From Evidence to Action!" focused on enhancing child survival and development in lower- and middle-income countries by achieving population-level behavior change.

Bringing together academics, technical experts, practitioners, donors and government representatives, the summit had two goals: achieving clarity on evidence to inform policies, strategies and programs and identifying gaps in the evidence as a way of shaping a future research agenda.

The summit was the brainchild of psychologist Robert L. Balster, PhD, a professor of pharmacology, toxicology, psychology and psychiatry at Virginia Commonwealth University, who serves as a science advisor to USAID after a one-year stint as a Jefferson Science Fellow there last year.

The summit was a response to UNICEF's and USAID's Child Survival Call to Action/A Promise Renewed, says Balster.

"It was driven by the knowledge that a lot of the global health issues I learned about during my time at USAID have a significant element of behavior change necessary to achieve critical public health goals," he says. "There has been a downward movement in the rates of child mortality — and it has been very encouraging that fewer children are dying in their first five years — but the trajectory is still such that it's going to take a long time to end preventable child death." Meeting that challenge is also a big priority for the U.S. government, Balster added. In President Barack Obama's 2013 State of the Union address, for example, the president affirmed that "the United States will join with our allies to eradicate such extreme poverty in the next two decades" by taking steps that include "saving the world's children from preventable deaths."

Psychologists' involvement in the summit helped expand USAID's vision of how psychology can help solve global health problems, says APA Past President Suzanne Bennett Johnson, PhD, who helped plan the event.

"Psychologists are the experts on human behavior," says Johnson. "Scientists can come up with all kinds of biomedical interventions, but if people don't use them, then they're not very effective."

The fact that APA co-sponsored the event underscores the importance of that role, says Merry Bullock, PhD, director of international affairs at APA and a member of the summit's core planning group.

"Another contribution of psychology was to encourage expanding the focus from decreasing child mortality alone to decreasing child mortality and fostering positive development — that is, not just addressing child mortality but also addressing adequate development in the first thousand days of a child's life," says Bullock.

Of course, says Bullock, psychologists working in public health, medical settings and the like are already working on interventions for HIV/AIDS, malnutrition, child development and similar areas.

"But addressing behavior change at the population level is not part of the mainstream," she says. "The issues raised in this summit — from questions of appropriate methodology for testing interventions to the development of behaviorally relevant outcome measures to cultural context effects — are all well within psychology's range of experience."

Reviewing the evidence

The summit's work began months ago, with multidisciplinary teams of experts convening to peruse the peer-reviewed and gray literature on such topics as community empowerment, sustainable health systems and policy supports, gender dynamics, and scientific and technological advances. At the summit itself, each team presented the evidence and their provisional recommendations for practice, policy and research. Participants then broke into small groups to discuss each topic and offer extensive feedback.

In the stigma and discrimination realm, for example, a team reviewed the evidence on how stigma-reduction efforts can improve child survival. One key intervention is to reduce stigma among HIV-positive pregnant women, which can reduce mother-to-child transmission of HIV by as much as a third, says psychologist Usha Nayar, PhD, former professor and deputy director of the Tata Institute of Social Sciences in Mumbai, India. Her team called for increased attention to stigma in all domains of child health, including increased investment in stigma interventions and evaluation, new standards for reporting research and more qualitative and quantitative research.

"The challenge for us is to establish clear causal models and common or comparable instruments to permit more accumulation of knowledge," Nayar said at the summit.

Following the summit, participants began the next phase — developing an "evidence-to-action" strategy to ensure that the summit's recommendations are put into practice. The evidence review teams are combing the feedback generated at the summit and producing final papers, which will eventually be published in scientific journals.

But that's just a first step, says Balster.

"It would be a mistake to think of this as just another exercise in producing journal articles," he says. "If we can get countries — mainly those in sub-Saharan Africa and South Asia, where there's a lot of preventable child mortality — to implement these effective behavior change interventions, that's going to make a huge difference."

Rebecca A. Clay is a writer in Washington, D.C.