Caregiver Behavior Change for Child Survival and Development in Low- and Middle-Income Countries: An Examination of the Evidence

In June of 2012, representatives from more than 80 countries promulgated a Child Survival Call to Action, which called for reducing child mortality to 20 or fewer child deaths per 1,000 live births in every country by 2035. To address the problem of ending preventable child deaths, the U.S. Agency for International Development and the United Nations Children’s Fund convened, on June 3–4, 2013, an Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change. Six evidence review teams were established on different topics related to child survival and healthy development to identify the relevant evidence-based interventions and to prepare reports. This article was developed by the evidence review team responsible for identifying the research literature on caregiver change for child survival and development. This article is organized into childhood developmental periods and cross-cutting issues that affect child survival and healthy early development across all these periods. On the basis of this review, the authors present evidence-based recommendations for programs focused on caregivers to increase child survival and promote healthy development. Last, promising directions for future research to change caregivers’ behaviors are given

Caregiver Behavior Change for Child Survival and Development in Low- and Middle-Income Countries: An Examination of the Evidence

In June of 2012, representatives from more than 80 countries promulgated a Child Survival Call to Action, which called for reducing child mortality to 20 or fewer child deaths per 1,000 live births in every country by 2035. To address the problem of ending preventable child deaths, the U.S. Agency for International Development and the United Nations Children’s Fund convened, on June 3–4, 2013, an Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change. Six evidence review teams were established on different topics related to child survival and healthy development to identify the relevant evidence-based interventions and to prepare reports. This article was developed by the evidence review team responsible for identifying the research literature on caregiver change for child survival and development. This article is organized into childhood developmental periods and cross-cutting issues that affect child survival and healthy early development across all these periods. On the basis of this review, the authors present evidence-based recommendations for programs focused on caregivers to increase child survival and promote healthy development. Last, promising directions for future research to change caregivers’ behaviors are given

Designing an Intervention Study

Traditionally, an intervention has been construed as a set of activities on the part of an “intervenor” to bring about changes in the behavior of target individuals or groups. There are three major paradigms for behavior change: (1) mechanistic (e.g., Skinnerian models); (2) organismic (e.g., Piagetian, Freudian models); and (3) contextual (e.g., family systems, cultural models). With the recent advent of contextual-ism, theories of behavior change have been expanded to include cultural factors that influence behavior. Social learning theory, which has been widely used in HIV prevention research, has been subsumed under a contextual paradigm

Designing an Intervention

Traditionally, an intervention has been construed as a set of activities on the part of an “intervenor” to bring about changes in the behavior of target individuals or groups. There are three major paradigms for behavior change: mechanistic, organismic and contextual. With the recent advent of contextualism, theories of behavior change have been expanded to include cultural factors that influence behavior. For example, social learning theory, which has been widely used in HIV prevention research, has been subsumed under a contextual paradigm. This chapter provides guidance on the steps in designing an intervention research study. In addition to discussing the complexities involved at each step, important methodological issues, discussed in more detail in other chapters in this book, are also raised. This chapter raises some of the complex issues involved in conducting intervention research, such as recognition of the extent to which research is designed to reflect reality, it may lose some rigor and may compromise the validity of the findings. This is a field in which there is a delicate balance between rigor and public health significance

Measurement of the Role of Families in Prevention and Adaptation to HIV/AIDS

HIV is a family disease. Family research in HIV is challenging because of complexities of family measurement, the range of family constellations across cultures, and the issues specific to HIV-affected families. A Consortium of NIMH-funded investigators is conducting HIV research on families—defined as networks of mutual commitments. A procedure for identifying the “family” is proposed. This article reviews assessment strategies from two research traditions, both of which have been greatly concerned with social context: family assessment tradition—family membership, parenting, and interactional dynamics; HIV/AIDS research tradition—HIV-relevant constructs generalized to minority families. Initially, a systematic procedure for defining family membership is provided. Constructs and measures derived from the family assessment tradition are described, including self-report and observational procedures. Constructs and measures of relevance to family research that originated in the HIV/AIDS research tradition are described: HIV knowledge, stigma, disclosure, and social support. Constructs presented derive from the Consortium's research on the role of families in prevention and adaptation to HIV/AIDS. Most of the research conducted by the Consortium has taken place with inner-city, minority, heterosexual families. By informing the selection of constructs and measures relevant to investigating the role of families in HIV prevention, and adaptation to living with HIV/AIDS, it is the Consortium's intention to enhance the quality and quantity of research at the intersection of families and HIV/AIDS

Alternatives to the Randomized Controlled Trial

Public health researchers are addressing new research questions (e.g., effects of environmental tobacco smoke, Hurricane Katrina) for which the randomized controlled trial (RCT) may not be a feasible option

National Institute of Mental Health Multisite Eban HIV/STD Prevention Intervention for African American HIV Serodiscordant Couples: a cluster randomized trial.

BackgroundHuman immunodeficiency virus (HIV) has disproportionately affected African Americans. Couple-level interventions may be a promising intervention strategy.MethodsTo determine if a behavioral intervention can reduce HIV/sexually transmitted disease (STD) risk behaviors among African American HIV serodiscordant couples, a cluster randomized controlled trial (Eban) was conducted in Atlanta, Georgia; Los Angeles, California; New York, New York; and Philadelphia, Pennsylvania; with African American HIV serodiscordant heterosexual couples who were eligible if both partners were at least 18 years old and reported unprotected intercourse in the previous 90 days and awareness of each other's serostatus. One thousand seventy participants were enrolled (mean age, 43 years; 40% of male participants were HIV positive). Couples were randomized to 1 of 2 interventions: couple-focused Eban HIV/STD risk-reduction intervention or attention-matched individual-focused health promotion comparison. The primary outcomes were the proportion of condom-protected intercourse acts and cumulative incidence of STDs (chlamydia, gonorrhea, or trichomonas). Data were collected preintervention and postintervention, and at 6- and 12-month follow-ups.ResultsData were analyzed for 535 randomized couples: 260 in the intervention group and 275 in the comparison group; 81.9% were retained at the 12-month follow-up. Generalized estimating equation analyses revealed that the proportion of condom-protected intercourse acts was larger among couples in the intervention group (0.77) than in the comparison group (0.47; risk ratio, 1.24; 95% confidence interval [CI], 1.09 to 1.41; P = .006) when adjusted for the baseline criterion measure. The adjusted percentage of couples using condoms consistently was higher in the intervention group (63%) than in the comparison group (48%; risk ratio, 1.45; 95% CI, 1.24 to 1.70; P < .001). The adjusted mean number of (log)unprotected intercourse acts was lower in the intervention group than in the comparison group (mean difference, -1.52; 95% CI, -2.07 to -0.98; P < .001). The cumulative STD incidence over the 12-month follow-up did not differ between couples in the intervention and comparison groups. The overall HIV seroconversion at the 12-month follow-up was 5 (2 in the intervention group, 3 in the comparison group) of 535 individuals, which translates to 935 per 100,000 population.ConclusionTo our knowledge, this is the first randomized controlled intervention trial to report significant reductions in HIV/STD risk behaviors among African American HIV serodiscordant couples.Trial registrationclinicaltrials.gov Identifier: NCT00644163