Linking knowledge with action when engagement is out of reach: three contextual features of effective public health communication.

Scholars and practitioners often promote direct engagement between policymakers, health workers and researchers as a strategy for overcoming barriers to utilizing scientific knowledge in health policy. However, in many settings public health officials rarely have opportunities to interact with researchers, which is a problem further exacerbated by the coronavirus disease 2019 pandemic. One prominent theory argues that policy actors will trust and utilize research findings when they perceive them to be salient, credible and legitimate. We draw on this theory to examine the conditions facilitating greater uptake of new knowledge among health officials when engagement is out of reach and they are instead exposed to new ideas through written mass communication. Using data from a survey experiment with about 260 health workers and administrators in Honduras, we find that messages from a technocratic sender based on statistical evidence improved perceptions of salience, credibility and legitimacy (SCL). Additionally, perceptions of SCL are three contextual features that operate as joint mediators between knowledge and action, and several individual characteristics also influence whether officials trust research findings enough to apply them when formulating and implementing health policies. This research can help inform the design of context-sensitive knowledge translation and exchange strategies to advance the goals of evidence-based public health, particularly in settings where direct engagement is difficult to achieve.

Organizations matter in local governance: evidence from health sector decentralization in Honduras.

Health systems strengthening is at the forefront of the global health agenda. Many health systems in low-resource settings face profound challenges, and robust causal evidence on the effects of health systems reforms is lacking. Decentralization has been one of the most prominent reforms, and after more than 50 years of implementation and hundreds of studies, we still know little about whether these policies improve, harm or are inconsequential for the performance of health systems in less-developed countries. A persistent problem in existing studies is the inability to isolate the effect of decentralization on health outcomes, struggling with heterogeneous meanings of decentralization and missing counterfactuals. We address these shortcomings with a quasi-experimental, longitudinal research design that takes advantage of a unique staggered reform process in Honduras. Using three waves of household survey data over 10 years for a matched sample of 65 municipalities in Honduras, we estimated difference-in-difference models comparing changes in outcomes over time between local health systems that were decentralized using one of three types of organizations [municipal governments, associations of mayors or non-governmental organization (NGOs)] and those that remained centrally administered. We find evidence of overall improvements between 2005 and 2016 in several service delivery-related outcomes, and additional improvements in decentralized municipalities governed by NGOs. NGO-led municipalities saw a 15% decrease in home delivery relative to centralized municipalities in 2016, a 12.5% increase in MCH facility delivery and a 7% increase in the use of a skilled birth attendant. There were no detectable positive treatment effects for vaccination, and a slight decline in the weight-for-length z-scores in NGO municipalities, but we find no systematic evidence of decentralization negatively impacting any maternal and child health outcomes. These findings highlight the importance of considering implementation context, namely organization type, when assessing the effects of decentralization reform.

Community trust and household health: A spatially-based approach with evidence from rural Honduras.

What is the relationship between community trust and household health? Scholars working to understand the effects of trust and social capital on human health tend to focus on individual characteristics or social environments, frequently without integrating these two dimensions. In light of this, the present paper makes contributions in both conceptualization and measurement. First, I develop a spatially-based approach for operationalizing community trust as the product of individual orientation and social environment. This approach highlights the need for a household to trust its neighbors and for those neighbors to reciprocate trust in order to constitute the psychological and material mechanisms critical for linking social context to individual health. Second, I illustrate the utility of this measure by evaluating the relationship between community trust and self-rated health status using an original population census survey from 2009 to 2010 for two municipalities in western Honduras (approximately 2800 households with a response rate of 94.9%). I implement spatial regression analysis and show that there is a positive and substantively meaningful relationship between community trust and household health; households that are trusting and surrounded by similarly trusting neighbors report better health status, while those in uncertain or mutually distrusting environments report worse health. The theory and results presented here suggest an important link between trust and social capital at the community level, which is particularly salient for rural regions in developing countries where health resources are scarce and community-based interventions are common.

Childhood immunization rates in rural Intibucá, Honduras: an analysis of a local database tool and community health center records for assessing and improving vaccine coverage.

BACKGROUND: Vaccines are highly effective at preventing infectious diseases in children, and prevention is especially important in resource-limited countries where treatment is difficult to access. In Honduras, the World Health Organization (WHO) reports very high immunization rates in children. To determine whether or not these estimates accurately depict the immunization coverage in non-urban regions of the country, we compared the WHO data to immunization rates obtained from a local database tool and community health center records in rural Intibucá, Honduras. METHODS: We used data from two sources to comprehensively evaluate immunization rates in the area: 1) census data from a local database and 2) immunization data collected at health centers. We compared these rates using logistic regression, and we compared them to publicly available WHO-reported estimates using confidence interval inclusion. RESULTS: We found that mean immunization rates for each vaccine were high (range 84.4 to 98.8 percent), but rates recorded at the health centers were significantly higher than those reported from the census data (p ≤ 0.001). Combining the results from both databases, the mean rates of four out of five vaccines were less than WHO-reported rates (p <0.05). Overall immunization rates were significantly different between townships (p=0.03). The rates by individual vaccine were similar across townships (p >0.05), except for diphtheria/tetanus/pertussis vaccine (p=0.02) and oral polio vaccine (p <0.01). CONCLUSIONS: Immunization rates in Honduras were high across data sources, though most of the rates recorded in rural Honduras were less than WHO-reported rates. Despite geographical difficulties and barriers to access, the local database and Honduran community health workers have developed a thorough system for ensuring that children receive their immunizations on time. The successful integration of community health workers and a database within the Honduran decentralized health system may serve as a model for other immunization programs in resource-limited countries where health care is less accessible.