SENIOR DIRECTOR'S COLUMN
Behavioral health interventions: So much data and so little evidence
By Merry Bullock, Senior Director, APA Office of International Affairs
In mid-February, about 60 people gathered at the UNICEF house in New York City to prepare for a June meeting titled “U.S. Government Evidence Summit on Enhancing Child Survival & Development for Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change.” This gathering included communication experts, field workers, USAID staff and consultants, U.N. consultants, public health experts and some psychologists. Sponsored by USAID, the goal of the June summit will be to provide evidence on which interventions are most effective in changing behavior important to child health, survival and well being. It is part of USAID’s concerted efforts to provide evidence-based, global health strategies.
The February preparation meeting used “evidence review teams” — groups of experts whose task is to find, review and summarize the literature on behavioral health interventions in those areas most crucial to ensuring child survival: prevention of infectious disease (e.g., malaria, diarrhea, HIV), promotion of nutrition (breastfeeding), immunization and healthy development. The meeting was the culmination of almost a year of planning at USAID. Psychology’s involvement was facilitated by the leadership of Robert Balster, PhD, a Professor of Psychopharmacology at Virginia Commonwealth University. Balster was a 2012 recipient of the Jefferson Science Fellowship — a prestigious program where senior research scientists are assigned to U.S. State Department offices to provide scientific expertise on international policy issues. Balster’s placement was at USAID, where he collaborated with USAID Global Health colleagues to develop a summit on evidence for population-level behavioral change strategies. This summit offers a stunning opportunity for psychology to contribute to a policy arena that would seem natural, but that has not been part of mainstream psychology research or education.
It also illustrates how expanding psychology’s self-definition can open important opportunities. For example, the most crucial challenges to child survival are health issues: nutrition, malaria, diarrhea, immunization and infectious disease. Psychology as a discipline has only recently (in any organized sense) begun to identify itself as a health profession, rather than just a mental health profession. Defining psychology as a health profession makes it easier to collaborate with those disciplines that have traditionally addressed health behavior change (e.g., communications, nursing, anthropology and public health), and to bring a strong psychosocial perspective to global health (e.g., family and community have a direct health impact) and sophisticated sets of tools for measuring and modeling behavior.
Participation in activities like the upcoming USAID summit also offers psychology an opportunity to showcase its engagement in policy-rich areas. Despite decades of acknowledging the importance of making research and theories relevant to societal challenges, psychology research — even applied research — is not strongly visible in international policy decisions, even though as a discipline we have the methodological expertise and experimental savvy to provide relevant information.
What can we do to change this? Two challenges are paramount. First, we need to be able to provide solid measures that can be applied worldwide as part of country-level data gathering so that behavioral outcomes will be as prevalent and easy to collect as physiological ones. Health outcomes such as mortality or infection rate are relatively easy to compute. Psychology needs to agree on behavioral health outcomes for healthy development, for well-being, for youth resilience and the like. Second, we need to value and invest in evaluation studies and meta-analysis for behavioral interventions — to be able to ask “what works best” with the same rigor that we investigate single interventions, behavioral phenomena or causal mechanisms.
We reviewed the substantial literature on health interventions in low- and middle-income countries to find evidence for intervention effectiveness. This will allow us to move beyond knowing which interventions can make a difference to knowing which of many effective interventions are sustainable, scalable and applicable on a large scale population level. What we found was that few studies provided sufficient detail on protocols, definitions or populations to compare against a common metric. There was indeed, as one colleague quipped, “so much data and so little evidence.” The call for evidence and the evidence summit will help articulate further the specific kinds of evidence that are needed for effective policy.
This evidence summit and its predecessors are part of the USAID Global Health call to action. This initiative is also an important call to action for psychology and other disciplines invested in behavior and psychosocial context to provide tools to guide policy that are methodologically sound, culturally relevant and behaviorally grounded. If you are looking for high impact, high importance areas for important effort, this is a good beginning.