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A Toolkit for Evaluating the Impact of HIV/AIDS Programming on Children in Africa
1. A Toolkit for
Evaluating the
Impact of HIV/AIDS
Programming on
Children in Africa
Jenifer Chapman, PhD
MEASURE Evaluation/Futures
Group
2. Stepping back for a minute
HIV/AIDS Programming = President’s Plan for
AIDS RELIEF (PEFPAR)
Interagency effort
Introduced by President Bush in 2003
Largest Commitment in history by any nation
to combat a single disease
Reauthorized in 2008 for $48 billion
3. PEPFAR I and II
First phase of PEPFAR (2003-2008) focus on
emergency response—program reviews, simple
evaluations, operations research
Second phase of PEPFAR (2009-2013) focus on
sustainability, better attribution, program
outcomes and impact
4. PEPFAR Mission & Goal (OVC)
Mission: To mitigate the social, emotional and
economic impacts of HIV/AIDS on children and to
reduce their risk and vulnerability while
increasing their resilience
A goal: To care for 5 million orphans and
vulnerable children
10% funding earmark for OVC
5. What is an “OVC”?
A child infected or affected by HIV
And what does that really mean?
PEPFAR 1 vs. PEPFAR 2
And how do we “care” for them?
6. Guidance!
6+1 areas of
programming
Health, Education,
PSS, Protection,
Food & Nutrition,
Shelter & Care, HES
8. OVC Programs, under PEPFAR, aim to:
Improve the wellbeing of children and families
Strengthen families as primary caregivers of children
Support the capacity of communities to create
protective, caring environments
Build the capacity of social service systems to protect
the most vulnerable
9. Implementation
Community-based programs
Focus: case management (social work)
Home-visiting by community based volunteers
(beneficiaries are targeted)
Community-wide interventions (HES, Kids Clubs)
6+1 domains of programming (health, PSS, etc.)
Referral networks
10. Evaluating PEPFAR’s contribution
Reviews of the OVC portfolio found that despite
great investment, we know little about impact and
“what works”
11. Not so long ago…
Few evaluations conducted at program level
Outcomes monitoring at case management level
(good, but led to problems in evaluation practice)
Studies carried out were challenged:
Tool misuse, low data quality, inadequate
measurement and poor choice of constructs, no
comparability of measures, unethical practices
Poor availability of information for decision making
The State of Evaluation Practice was:
13. The purpose
Standardize population-level child and caregiver wellbeing data beyond what is available from routine
surveys
Produce actionable data to inform programs and
enable mid-course corrections
Enable comparative assessments of child and
caregiver well-being and household economic status
across a diverse set of interventions and regions
14. But what do we measure?
Developing country
context
15.
16. Focus on PEPFAR OVC programs
Indicators need to reflect
& be amenable to change
by PEPFAR program
intervention
HH interventions led by
home visitors
Community interventions
Low direct funding per
target, focus on linkages
Often inadequate
services in vicinity
17. Who are these tools for?
Local and international
research institutions
and other implementing
organizations with
evaluation agenda
USAID Forward –
supporting local
researchers
18. So, where to start…
Two step, participatory process:
Build consensus around core impact indicators for
PEPFAR-funded OVC programs
Develop OVC program evaluation (survey) tools
19. Distilling the core indicators
Our starting point: 6+1 domains of PEPFAR OVC
programming
Step 1: Extensive literature search
Step 2: Gaps (HES, PSS) filled through targeted
research
Result: >600 child/HH wellbeing
questions/indicators
Step 3: Analysis against 8 criteria
Result: shorter list of questions for discussion
19
20. Inclusion criteria
1. Measures impact/outcomes
2. Amenable to change from program interventions
3. Relevant across a wide range of interventions
4.
5.
6.
7.
8.
20
Contributes to a holistic vision of child wellbeing
Verifiable through another source
Easy to implement
Relevant across different regions / countries
Relevant or easily adapted across age and sex
21. Finalizing the core indicators
External working group: solicited review from 49
stakeholders
Finalized core set of 12 child and 3 household
measures
21
22. Developing the tools
Tools drafted with
strong stakeholder input
Draft tools piloted in
Zambia and Nigeria
Cognitive interviews to
test key concepts (e.g.
social support)
Household pre-test of
full tools, procedures
23. Structure and content
1. Caregiver questionnaire (including questions on
household)
2. Child questionnaire (ages 0-9 years),
administered to caregiver
3. Child questionnaire (ages 10-17), administered
to child with parental consent & child assent
24.
25.
26. Caregiver questionnaire
Sections
Core questions
Section 1: Household
schedule
•
•
Household schedule* (10)
Changes in household
composition (4)
Section 2: Background
Information on Caregiver
and Household
•
•
•
•
Demographic information* (7)
Work* (3)
Access to money (3)
Shelter (1)
•
Section 3: Food Security
•
Household food security (6)
•
Section 4: Caregiver Wellbeing and Attitudes
•
•
•
General health (2)
Caregiver support (4)
Parental self-efficacy (1)
•
Basic HIV/AIDS knowledge* (7)
HIV testing* (3)
Attitudes to condom educ (1)
•
Section 5: HIV/AIDS Testing, •
Knowledge, Attitudes
•
•
Section 6: Access to HIV
Prevention, Care & Support
*DHS, bold=core indicator
•
Household access to services
(1)
Optional modules
•
•
Household Economic Status
(forthcoming)
Progress out of Poverty
Index or similar (country
specific)
Dietary Diversity (1)
Perceptions and experience
of child discipline, violent
discipline (forthcoming)
Gender roles and
decisionmaking power* (9)
HIV/AIDS attitudes* (4)
27. Child questionnaire (ages 0-9)
Sections
Core questions
Optional modules
Section 1: Child Health and
Welfare
•
•
•
•
•
•
•
•
•
Confirm demographics (5)
General health & disability (4)
Birth certificate (2)
Vaccinations (11)
Fever (<5 years)* (1)
Diarrhea (<5 years)* (1)
Experience of neglect (2)
Slept under mosquito net* (1)
HIV testing experience* (2)
•
•
•
Section 2: Education and
Work
•
Section 3: Food
Consumption
Section 4: Access to HIV
Prevention, Care & Support
•
School attendance*,
progression/repeats, drop-outs,
missed school days (5+ years) (9)
Work for wages (2)
Early childhood stimulation (2)
Food consumption (2+ years) (8)
•
Child access to services (1)
Section 5: Anthropometric
Measures (of Children)
•
Weight*, Height*, MUAC
•
•
*DHS, bold=core indicator
•
Fever: extended* (4)
Diarrhea: extended* (3)
Health for children
living with HIV/AIDS
(forthcoming)
Dietary diversity (1)
28. Child questionnaire (ages 10-17)
Sections
Core questions
Section 1: Background
Information on Child
Section 2: Diary
Section 3: Education
•
•
•
•
Section 4: Chores & Work
•
•
•
•
•
•
•
Confirm demographics* (5)
Identity of caregiver (1)
Daily log (6)
School attendance*,
progression/repeats, dropouts (9)
Chores (3)
Work (7)
Food consumption (8)
Alcohol consumption (3)
Birth certificate (2)
General health & disability (3)
General support (4)
•
•
Basic HIV/AIDS knowledge* (7) •
HIV testing * (3)
•
Section 8: Sexual Experience
Section 9: Access to HIV
•
Prevention, Care & Support
Section 10: Anthropometric
•
Measures: Weight and Height
•
Section 5: Food & Alcohol
Consumption
Section 6: Health, Support &
Protection
Section 7: HIV Testing,
Knowledge, and Attitudes
Child access to services (1)
Weight, Height, MUAC
Optional modules
•
Dietary diversity (1)
•
Health for children living with
HIV/AIDS (forthcoming)
Perceptions/experience of
violence (forthcoming)
Child development knowledge (6)
HIV/AIDS attitudes and beliefs (4)
•
Sexual behavior (13-17 yrs) (5)
29. Lessons from piloting
Access to money
Social support (and PSS generally)
The importance of validating translations and
pre-testing
Addressing child headed households
30. You said a toolkit?
Tools & Manual
Template protocol with
consent/assent forms
Methodological guidance
Data analysis guide
Data collector training
manual and materials
31. Now….
Evaluation and data use are high on the agenda
We have standardized tools/measures and
guidance for evaluating OVC
programs/interventions with global buy-in
Tools misuse is being corrected
More information available for decision making
The State of Evaluation Practice is:
32. Where can I find out more?
Go to our website:
http://www.cpc.unc.edu/measure/
our-work/ovc
Keep in touch on ChildStatusNet:
http://childstatus.net/
Email:
Jenifer Chapman:
jchapman@futuresgroup.com
Janet Shriberg: jshriberg@usaid.gov
33. The research presented here has been supported by the
President’s Emergency Plan for AIDS Relief (PEPFAR)
through the United States Agency for International
Development (USAID) under the terms of MEASURE
Evaluation cooperative agreement GHA-A-00-08-0000300. Views expressed are not necessarily those of
PEPFAR, USAID or the United States government.
MEASURE Evaluation is implemented by the Carolina
Population Center at the University of North Carolina at
Chapel Hill in partnership with Futures Group, ICF
International, John Snow, Inc., Management Sciences for
Health, and Tulane University.
{"27":"I wouldn’t read through these if only 15 mins\n","28":"I wouldn’t read through these if only 15 mins\n","7":"PURPOSE OF SLIDE: To show a diagram of the social-ecological model emphasizing the different levels that OVC programming can impact to improve child and family wellbeing.\nNOTES:\nThe PEPFAR approach to children in the epidemic is based on a social-ecological model that considers the child, family, community and country contexts and recognizes the unique yet interdependent contributions of actors at all levels of society to the well-being of children affected by HIV/AIDS. \n \nThis version is an AIDS-sensitive version that considers the ultimate goal at each level of society in achieving an AIDS free generation.\n \nIt also seeks to emphasize that Families are the first line of support and defense for children. And that Even in the most resource-deprived settings, families and communities have critically important strengths. This should be recognized by programs and built upon to achieve the best outcomes for vulnerable children affected by AIDS. \n","2":"PEPFAR, originally introduced in 2003 by then-President George W. Bush, remains the largest commitment in history by any nation to combat a single disease. In 2008, PEPFAR was reauthorized for $48 billion over five years (2009 to 2013), with the goals of preventing 12 million new infections; treating 3 million people living with AIDS and caring for 12 million people, including 5 million orphans and vulnerable children. The Reauthorization Act seeks to transition the U.S. response from an emergency approach to a focus on sustainability, including health system strengthening and partnership building. The legislation allows the program to serve as a platform for expanded responses to a broader range of global health needs. The Act also supports the availability and accessibility of female condoms. \n \n","30":"I could elaborate on any of these if time allows\n","8":"PEPFAR and OVC\n-10% earmark for children made vulnerable by HIV and AIDS\n-falls under Care and Support \n--focuses on the social and emotional consequences and important responses to epidemic\n--updated our guidance in 2012: based in ecological model and care and protection for children emphasizing\nStrengthen families as primary caregivers of children;\nSupport the capacity of communities to create protective and caring environments;\nBuild the capacity of social service systems to protect the most vulnerable; and\nAllocate resources for children according to need in the context of HIV/AIDS by integration with the broader PEPFAR platform and response\n","3":"In the first phase of PEPFAR, activities were more of an emergency nature with the goal of using available interventions to reduce mortality and alleviate suffering from HIV disease as quickly and effectively as possible. \nMany lessons have been learned through examination of programs, including simple evaluations and operations research. \n \nAs would be expected in an emergency context state-of-the-art monitoring, evaluation, and research methodologies were not fully integrated or systematically performed.\nIn its second phase of PEPFAR-, emphasis on sustainability, programs must demonstrate value and impact to be prioritized within complex and resource-constrained environments. \nNow there is a greater demand to causally attribute outcomes to programs. Better attribution can be used to inform midcourse corrections in the scale-up of new interventions or to re- evaluate investments in programs for which impact is less clear.\n","9":"Change model\n","26":"I wouldn’t read through these if only 15 mins\n"}