Approaches to Improve Malaria Outcomes_Debra Prosnitz_4.25.13


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  • Since 1985, CSHGP has been supporting PVO/NGO programs to implement integrated packages of interventions through cross-cutting strategies, increasing coverage and strengthening impact.This report is a preliminary analysis of select CSHGP projects, examining the comparability of quantitative data and availability and depth of qualitative data, to determine whether outcomes and impact of behavior change communication strategies and messages can be systematically assessed across the larger portfolio of projects.
  • Grantees conduct standardized population-based baseline and endline surveys called Knowledge Practices and Coverage (KPC) Surveys. KPC is a small population-based survey that collects data from mothers of children under two years of age, and typically use parallel sampling as necessary to collect sufficient information on children 0-5 months, 0-11 months and 12-23 months, and on children who experienced an illness (fever, difficult breathing or diarrhea) in the past two weeks.Usually a 30 cluster survey; sometimes use LQASRapid Core Assessment Tool on Child Health (CATCH), Key Indicators, and KPC modules which all address various technical areas: The Rapid CATCH is a set of standard indicators that all grantees are required to collect at baseline and endline, regardless of their project intervention mix, in order to understand the overall maternal, newborn and child health (MNCH) situation in their project area before and after implementation. These indicators are a subset of those found in the KPC modules.
  • Inclusion criteria:were implemented in the last 10 years (2001 – 2011) in PMI countrieshad at least 10% level of effort (LOE) dedicated to malaria. A total of 34 projects met the inclusion criteria. 5 were selected for the preliminary analysis (Phase I) and provide a snapshot sampling of the different types of CSHGP project award categories (Standard, Cost Extension, Expanded Impact, and New Partner) as well as regions represented by PMI countries (East Africa, West Africa, Southern Africa, and the Greater Mekong Sub-Region).
  • * But 88.2% slept under any netDHS indicator: Percentage of children under five years of age who slept under an insecticide-treated net the night before the survey** Mozambique DHS baseline indicator: Percentage of children under five years of age who slept under a bed net (treated or untreated) the night before the surveyMake the point that Kenya, Liberia, and Senegal had significant increases over national and regional averages.
  • (Note: Information on diagnosed vs. presumptive treatment is not available)Make point that Kenya, Mozambique and Senegal had significant increases over national and regional averages.
  • *including MTI Liberia, the first to implement the Care Group approach in Liberia, later scaled up in a different county by a UNICEF-funded project.Reference BC comparison table, and say something about approaches (e.g. 3 of the projects used Care Groups)
  • *part of the challenge with materials is that projects generally have to use MOH materials, though they often participate in the development/revision/testing of materials. **e.g. CRS FE noted that women’s groups in Cambodia can be harnessed to address issues beyond health, such as education and gender equity
  • Interpersonal contact data, particularly linked with outcome data, will enable us to better understand what kind of BCC is most effective, and makes the greatest impact
  • Approaches to Improve Malaria Outcomes_Debra Prosnitz_4.25.13

    1. 1. A Review of the Approaches to Improve MalariaOutcomes through Changing Knowledge,Attitudes, and Behavior in USAID’s ChildSurvival and Health Grants ProgramPhase I: Preliminary Review ResultsDebra Prosnitz, Kirsten Unfried, Jennifer YourkavitchApril 25, 2013
    2. 2. Introduction PMI requested MCHIP conduct a review of USAID’sCSHGP projects to examine malaria BCC to improve netuse, case management, IPTp, adherence to diagnosticresults, and care seeking. Until FY 13, PVO/NGOs implementing CSHGP projectsdeveloped DIPs and submitted evaluation reports thatdescribe behavior change strategies. All projects report data on key outcome indicators, inputs,and outputsCSHGP Project Reports can be accessed at:
    3. 3. Behave FrameworkDesigning for Behavior Change curriculum is available at: and SupportingGroups Behavior Key Factors ActivitiesPregnant women Take IPT Barriers: low knowledge of thebenefits of IPT; low perception ofthe severity of malaria for selfand unborn child; ANC visits notperceived as needed; distanceto health facilityFacilitators: desire foruncomplicated pregnancy andhealthy babyRadio messages, dramagroups, support materials;Indicators: % pregnant women receiving IPTFamily members Encourage pregnant women toreceive IPT.Barriers: low knowledge aboutIPT and its benefits; andacceptance of ANC and IPTFacilitators: desire for healthyoutcome of pregnancyRadio messages; dramagroups, support materialsIndicators: % women reporting family supportHealth workers Counsel pregnant women aboutIPT in a friendly andknowledgeable mannerBarriers: lack of time; lack ofknowledge; lack of supplyFacilitators: desire to perform jobwell; desire to improve outcomesCounseling training for healthworkers and TBAs with jobaids, improved reporting tools(including reporting thathighlights supply issues);improved supportivesupervisionIndicators: % records indicating counseling regarding IPT or IPT distribution% health workers that can correctly state information about IPT
    4. 4. Methodology1) Review of quantitative data collected byprojects (KPC) to assess improvements inmalaria indicators over time and comparisonwith DHS trends; and2) Document review (FE reports) to assessbehavior change communication strategiesand tools, interpersonal contact, andnumbers of people trained and reached withmalaria messages.
    5. 5. Included ProjectsLiberia (2006-2010)Medical Teams International (MTI)(New Partner – 20% Malaria LOE)Grand Cape Mount CountyPop. 138,138Senegal (2002-2006)ChildFund International (CFI)(Cost Extention – 15% MalariaLOE)3 districts in Thies RegionPop. 184, 259Kenya (2004-2009)Plan International USA(Standard – 25% Malaria LOE)Kilifi DistrictPop. 257,522Mozambique (2004-2009)World Relief(Expanded Impact – 20% MalariaLOE)5 districts in Gaza ProvincePop. 247,002Cambodia (2001-2006)Catholic Relief Services (CRS)(Standard – 30% Malaria LOE)4 districts in Battambang ProvincePop. 177,834
    6. 6. ResultsChild ITN Use: Percentage of children 0-23 months who slept under an insecticide-treated bed net the previous nightPVO Data National DHS Data Regional DHS DataPVO CountryBaselineValue(%)EndlineValue(%)Change(%)AverageAnnualChange(%)BaselineValue(%)EndlineValue(%)Change(%)AverageAnnualChange(%)BaselineValue(%)EndlineValue(%)Change(%)AverageAnnualChange(%)CRS Cambodia84.3(80.3 -88.3)87.9(82.8 -93.0)3.6 0.7 n/a 4.2* n/a n/a n/a 3.9 n/a n/aPlan Kenya21(17 - 25)76.7(71.0 -82.4)55.7 11.1 6.0 46.7 40.7 7.4 8.5 56.9 48.4 8.8MTI Liberia17.7(13.5 -22.5)69.3(63.8 -74.5)51.6 12.9 n/a 26.4 n/a n/a n/a 32.2 n/a n/aWR Mozambique8.1(3.7 -12.5)20.0(14.0 -26.0)11.9 2.4 9.7** 17.5 7.8 1.0 22.2** n/a n/a n/aCFI Senegal50(44.3 -55.7)97.4(95.0 -99.8)47.4 11.9 7.2 29.2 22 6.3 5.4 29.9 24.5 7.0
    7. 7. Child Fever Treatment: Percentage of children 0-23 months with a febrile episode thatended during the last two weeks who were treated with an effective anti-malarial drugwithin 24 hours after the fever beganPVO Data National DHS Data Regional DHS DataPVO CountryBaselineValue(%)EndlineValue(%)Change(%)AverageAnnualChange(%)BaselineValue (%)EndlineValue(%)Change(%)AverageAnnualChange(%)BaselineValue (%)EndlineValue(%)Change(%)AverageAnnualChange(%)CRS Cambodia n/a n/a n/a n/a n/a 0.2 n/a n/a n/a n/a n/a n/aPlan Kenya18(n/a)67.5(58.9 - 76.1)49.5 9.9 10.8 11.7 0.9 0.2 18.7 8.7 -10 -1.8MTI Liberia3.6(1.0 - 8.9)32.5(24.3 - 40.7)28.9 7.2 n/a 37.6 n/a n/a n/a 40.8 n/a n/aWR Mozambique17.4(7.3 - 27.5)62.1(47.1 - 77.0)44.7 8.9 8.3 22.2 13.9 1.7 11.4 n/a n/a n/aCFI Senegal64(n/a)82.4(n/a)18.4 4.6 12.2 4.2 -8 -2.3 7.2 1.7 -5.5 -1.6
    8. 8. Results: Summary of BCC Strategies Projects had significant involvement and input into development ofnational strategies and tools. CRS Cambodia was involved in C-IMCI working group to develop BCCcurriculum for Village Health Volunteers Behavior Change strategies implemented by some projects have beenreplicated in other contexts by other partners and NGOs WR Mozambique developed and implemented the Care Group approach, a model thathas been adopted and adapted by multiple NGOs in many different contexts* None of the projects conducted studies that explicitly comparedcommunication channels or methods that address malaria, thoughPDME processes examined BCC approaches, and projects adjustedimplementation accordingly PLAN Kenya conducted a special study on the Care Group approach; CRS Cambodiaidentified gaps in overall BCC approach and hired a BCC expert to revise the strategy
    9. 9. Conclusions: Gaps and Common Challenges Malaria in pregnancy not specifically addressed, though may beincluded in promotion of ANC uptake Creation of demand in a context of limited supplies How to adequately address low perceived risk during low malariatransmission seasons, leading to low ITN use among those who ownITNs IEC materials could be better designed for use in illiterate populations* Need to involve community structures more holistically, beyond fillinggaps in government health services** Strategies to mobilize and educate the migrant population should bestrengthened Inadequate sustainability planning, particularly as related to motivationand supervision of community-based agents
    10. 10. Recommendations More detailed definitions of communitymobilization strategies More detailed reporting on what messages arepromoted in different intervention packages (e.g.ANC promotion and IPTp) Systematic collection and reporting on type andfrequency of interpersonal contacts (quantitativemeasures) and quality of contacts
    11. 11. Thank You!World Relief, Mozambique