VarSeq 2.6.0: Advancing Pharmacogenomics and Genomic Analysis
Approaches to Improve Malaria Outcomes_Debra Prosnitz_4.25.13
1. A Review of the Approaches to Improve Malaria
Outcomes through Changing Knowledge,
Attitudes, and Behavior in USAID’s Child
Survival and Health Grants Program
Phase I: Preliminary Review Results
Debra Prosnitz, Kirsten Unfried, Jennifer Yourkavitch
April 25, 2013
2. Introduction
PMI requested MCHIP conduct a review of USAID’s
CSHGP projects to examine malaria BCC to improve net
use, case management, IPTp, adherence to diagnostic
results, and care seeking.
Until FY 13, PVO/NGOs implementing CSHGP projects
developed DIPs and submitted evaluation reports that
describe behavior change strategies.
All projects report data on key outcome indicators, inputs,
and outputs
CSHGP Project Reports can be accessed at:
http://www.mchipngo.net/controllers/link.cfc?method=project_doc_search
3. Behave Framework
Designing for Behavior Change curriculum is available at:
http://www.coregroup.org/storage/documents/Workingpapers/dbc_curriculum_final_2008.pdf
Priority and Supporting
Groups Behavior Key Factors Activities
Pregnant women Take IPT Barriers: low knowledge of the
benefits of IPT; low perception of
the severity of malaria for self
and unborn child; ANC visits not
perceived as needed; distance
to health facility
Facilitators: desire for
uncomplicated pregnancy and
healthy baby
Radio messages, drama
groups, support materials;
Indicators: % pregnant women receiving IPT
Family members Encourage pregnant women to
receive IPT.
Barriers: low knowledge about
IPT and its benefits; and
acceptance of ANC and IPT
Facilitators: desire for healthy
outcome of pregnancy
Radio messages; drama
groups, support materials
Indicators: % women reporting family support
Health workers Counsel pregnant women about
IPT in a friendly and
knowledgeable manner
Barriers: lack of time; lack of
knowledge; lack of supply
Facilitators: desire to perform job
well; desire to improve outcomes
Counseling training for health
workers and TBAs with job
aids, improved reporting tools
(including reporting that
highlights supply issues);
improved supportive
supervision
Indicators: % records indicating counseling regarding IPT or IPT distribution
% health workers that can correctly state information about IPT
4. Methodology
1) Review of quantitative data collected by
projects (KPC) to assess improvements in
malaria indicators over time and comparison
with DHS trends; and
2) Document review (FE reports) to assess
behavior change communication strategies
and tools, interpersonal contact, and
numbers of people trained and reached with
malaria messages.
5. Included Projects
Liberia (2006-2010)
Medical Teams International (MTI)
(New Partner – 20% Malaria LOE)
Grand Cape Mount County
Pop. 138,138
Senegal (2002-2006)
ChildFund International (CFI)
(Cost Extention – 15% Malaria
LOE)
3 districts in Thies Region
Pop. 184, 259
Kenya (2004-2009)
Plan International USA
(Standard – 25% Malaria LOE)
Kilifi District
Pop. 257,522
Mozambique (2004-2009)
World Relief
(Expanded Impact – 20% Malaria
LOE)
5 districts in Gaza Province
Pop. 247,002
Cambodia (2001-2006)
Catholic Relief Services (CRS)
(Standard – 30% Malaria LOE)
4 districts in Battambang Province
Pop. 177,834
6. Results
Child ITN Use: Percentage of children 0-23 months who slept under an insecticide-
treated bed net the previous night
PVO Data National DHS Data Regional DHS Data
PVO Country
Baseline
Value
(%)
Endline
Value
(%)
Change
(%)
Averag
e
Annual
Change
(%)
Baseline
Value
(%)
Endline
Value
(%)
Change
(%)
Averag
e
Annual
Change
(%)
Baseline
Value
(%)
Endline
Value
(%)
Change
(%)
Averag
e
Annual
Change
(%)
CRS Cambodia
84.3
(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/a
Plan Kenya
21
(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 8.8
MTI Liberia
17.7
(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/a
WR Mozambique
8.1
(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/a
CFI Senegal
50
(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. Child Fever Treatment: Percentage of children 0-23 months with a febrile episode that
ended during the last two weeks who were treated with an effective anti-malarial drug
within 24 hours after the fever began
PVO Data National DHS Data Regional DHS Data
PVO Country
Baseline
Value
(%)
Endline
Value
(%)
Change
(%)
Average
Annual
Change
(%)
Baseline
Value (%)
Endline
Value
(%)
Change
(%)
Average
Annual
Change
(%)
Baseline
Value (%)
Endline
Value
(%)
Change
(%)
Average
Annual
Change
(%)
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/a
Plan Kenya
18
(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 -1.8
MTI Liberia
3.6
(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/a
WR Mozambique
17.4
(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/a
CFI Senegal
64
(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. Results: Summary of BCC Strategies
Projects had significant involvement and input into development of
national strategies and tools.
CRS Cambodia was involved in C-IMCI working group to develop BCC
curriculum for Village Health Volunteers
Behavior Change strategies implemented by some projects have been
replicated in other contexts by other partners and NGOs
WR Mozambique developed and implemented the Care Group approach, a model that
has been adopted and adapted by multiple NGOs in many different contexts*
None of the projects conducted studies that explicitly compared
communication channels or methods that address malaria, though
PDME processes examined BCC approaches, and projects adjusted
implementation accordingly
PLAN Kenya conducted a special study on the Care Group approach; CRS Cambodia
identified gaps in overall BCC approach and hired a BCC expert to revise the strategy
9. Conclusions: Gaps and Common Challenges
Malaria in pregnancy not specifically addressed, though may be
included in promotion of ANC uptake
Creation of demand in a context of limited supplies
How to adequately address low perceived risk during low malaria
transmission seasons, leading to low ITN use among those who own
ITNs
IEC materials could be better designed for use in illiterate populations*
Need to involve community structures more holistically, beyond filling
gaps in government health services**
Strategies to mobilize and educate the migrant population should be
strengthened
Inadequate sustainability planning, particularly as related to motivation
and supervision of community-based agents
10. Recommendations
More detailed definitions of community
mobilization strategies
More detailed reporting on what messages are
promoted in different intervention packages (e.g.
ANC promotion and IPTp)
Systematic collection and reporting on type and
frequency of interpersonal contacts (quantitative
measures) and quality of contacts
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