Evidence acquisition and evaluation for a U.S. Government Evidence Summit on Protecting Children Outside Family Care

Understanding the role of mHealth and other media interventions for behavior change to enhance child survival and development in low- and middle-income countries: an evidence review

Given the high morbidity and mortality among children in low- and middle-income countries as a result of preventable causes, the U.S. government and the United Nations Children's Fund convened an Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change on June 3-4, 2013, in Washington, D.C. This article summarizes evidence for technological advances associated with population-level behavior changes necessary to advance child survival and healthy development in children under 5 years of age in low- and middle-income countries. After a rigorous evidence selection process, the authors assessed science, technology, and innovation papers that used mHealth, social/transmedia, multiplatform media, health literacy, and devices for behavior changes supporting child survival and development. Because of an insufficient number of studies on health literacy and devices that supported causal attribution of interventions to outcomes, the review focused on mHealth, social/transmedia, and multiplatform media. Overall, this review found that some mHealth interventions have sufficient evidence to make topic-specific recommendations for broader implementation, scaling, and next research steps (e.g., adherence to HIV/AIDS antiretroviral therapy, uptake and demand of maternal health service, and compliance with malaria treatment guidelines). While some media evidence demonstrates effectiveness in changing cognitive abilities, knowledge, and attitudes, evidence is minimal on behavioral endpoints linked to child survival. Population level behavior change is necessary to end preventable child deaths. Donors and low- and middle-income countries are encouraged to implement recommendations for informing practice, policy, and research decisions to fully maximize the impact potential of mHealth and multimedia for child survival and development.

Evidence acquisition and evaluation for evidence summit on population-level behavior change to enhance child survival and development in low- and middle-income countries

Recognizing the need for evidence to inform public health officials and health care workers in the U.S. government and low- and middle-income country governments on efficient, effective behavior change policies, strategies, and programs for child health and development, the U.S. government convened the Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change. This article summarizes the background and methods for the acquisition and evaluation of the evidence used to the achieve the goals of the summit that is reviewed in other articles in this special issue of the Journal of Health Communication. The process began by identifying focal questions intended to inform the U.S. and low- and middle-income governments about behavior change interventions that accelerate reductions in under-5 mortality and optimize healthy and protective child development to 5 years of age. Experts were selected representing the research and program communities, academia, relevant nongovernmental organizations, and government agencies and assembled into evidence review teams. This was followed by the systematic gathering of relevant peer-reviewed literature that would inform the focal questions. Members of the evidence review teams were invited to add relevant articles not identified in the initial literature review to complete the bibliographies. Details of the search processes and methods used for screening and quality reviews are described. The evidence review teams were asked to comply with a specific evaluation framework for recommendations on practice and policy on the basis of both expert opinion and the quality of the data reviewed.

Systems, strategies, and interventions for sustainable long-term care and protection of children with a history of living outside of family care

OBJECTIVES

This article reviews the available evidence regarding the efficacy, effectiveness, ethics, and sustainability of approaches to strengthen systems to care for and protect children living outside family care in low- and middle-income countries.

METHOD

For trafficked children, children of and on the street, children of conflict/disaster, and institutionalized children, a systems framework approach was used to organize the topic of sustainable approaches in low- and middle-income countries and addresses the following: legislation, policies, and regulations; system structures and functions (formal and informal); and continuum of care and services. The article draws on the findings of a focal group convened by the U.S. Government Evidence Summit: Protecting Children Outside of Family Care (December 12-13, 2011, Washington, DC), tasked with reviewing the literature on systems, strategies, and interventions for sustainable long-term care and protection of children with a history of living outside of family care in low- and middle-income country contexts. The specific methodology for the review is described in the commentary paper (Higgs, Zlidar, & Balster, 2012) that accompanies these papers.

RESULTS

For the most part, the evidence base in support of sustainable long-term care for the populations of interest is relatively weak, with some stronger but unreplicated studies. Some populations have been studied more thoroughly than others, and there are many gaps. Most of the existing studies identify population characteristics, needs, and consequences of a lack of systemic services to promote family-like care. There is some evidence of the effectiveness of laws and policies, as well as some evidence of service effectiveness, in improving outcomes for children outside of family care.

CONCLUSIONS

Despite the weaknesses and gaps of the existing research, there is a foundation of research for going forward, which should focus on developing and implementing systems for these most vulnerable children. The evidence reviewed indicates that child protection systems should aim for appropriate, permanent family care (including reunification, adoption, kinship care, or kafalah) for children in order to secure the best environment for a child's developmental prospects. Evidence also suggests that the quality and duration of care, including both permanent family care and alternative care, are important regardless of setting. The diversity of political, socioeconomic, historical, regional, community, and cultural contexts in which child protection systems operate need to be taken into account during programming and research design.

What strategies are appropriate for monitoring children outside of family care and evaluating the impact of the programs intended to serve them?

OBJECTIVES

To strengthen the evidence-base for policy and practice for support of children outside of family care requires effective, efficient and sustainable mechanisms for monitoring and evaluation. Toward that end, two core questions guided a systematic review of evidence: What strategies are appropriate for monitoring the needs and circumstances of children outside of family care? What strategies are suitable for evaluating the impact of the programs intended to serve such children?

METHODS

A structured document search and review process was implemented within the context of the U.S. Government Evidence Summit on Protecting Children Outside of Family Care of December 2011. Through successive review phases, initially using structured screening criteria, followed by thematic review by an expert panel, 73 documents were identified for analysis.

RESULTS

Analysis of models and strategies indicates that: (1) tools are available for assessment of children's needs, but require refining to accommodate contextual demands; (2) well-designed evaluations are able to identify the influence of assistance; (3) long-term follow-up is crucial to developing a strong evidence-base on effective strategies; and (4) insights into systems-wide monitoring mechanisms are emerging. In addition to describing key components of monitoring and evaluation strategies, findings draw attention to the evaluation of children's resiliency and protective factors, community based monitoring and the role of caregivers, as well as concerns over the stigmatization of children (through data collection methodologies encouraging the 'labeling' of children) and the importance of children's participation.

CONCLUSIONS

Fostering a stronger evidence-base to improve protection for vulnerable children requires evaluations that are integrated into program development, use context-appropriate methodologies able to assess intervention scalability and employ more longitudinal designs to explore children's trajectories. Further, future programming will benefit from systems-wide data coordination and international comparisons, research that emphasizes coping and resilience mechanisms, and children's participation in monitoring and evaluation.

What are the most effective early response strategies and interventions to assess and address the immediate needs of children outside of family care?

OBJECTIVES

Children outside of family care face increased risk of threats to their well-being, have lower educational achievement, and experience adverse developmental outcomes. While it is generally accepted that early response and intervention is critical to reducing the risk of harm for children who have been separated from their families, it is not always clear what the most effective early response strategies are for assessing and addressing their immediate needs. The purpose of this review was to identify evidence-based early response strategies and interventions for improving the outcomes of children outside of family care, including children of and on the street, institutionalized children, trafficked children, children affected by conflict and disaster, and who are exploited for their labor.

METHODS

A multi-phased, systematic evidence review was conducted on peer-reviewed and gray literature, which yielded a total of 101 documents that met the inclusion criteria and were reviewed.

RESULTS

Overall there is a weak evidence base regarding assessment and early response interventions for children living outside of family care. Few studies included careful outcome measures or comparison groups. Although few proven interventions emerged, the review identified several promising early interventions and approaches. In emergency settings, family tracing and reunification is a highly effective response in regard to separated children, whereas placing children in institutional care is problematic, with the possible exception of time-limited placements of formerly recruited children in interim care centers. Livelihood supports are promising in regard to preventing and responding to children living outside family care. Other promising interventions include psychosocial support, including the use of traditional cleansing rituals as appropriate, educational supports such as Child Friendly Spaces, the maintenance of family connectedness for children of or on the streets, the use of community-based approaches that aid social integration, and approaches that enable meaningful child participation. A recurrent theme was that to be effective, all assessments and interventions must fit the context.

CONCLUSION

A strong need exists for strengthening the evidence base regarding the effectiveness of early assessments and responses to children living outside family care and for using the evidence to guide operational policy and practice. Recommendations regarding policy, practices, and research emerged from the review process.