1. USAID’s Child Survival and Health Grants Program Improves EBF, ORT, and Handwashing Practices Jennifer Yourkavitch, MPH; Jim Ricca, MD, MPH; Karen Fogg, MPH American Public Health Association November 9, 2009

2. Presenter Disclosures Jennifer Yourkavitch The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose 2

3. 3 Agenda  Objectives  Background  Methods and data  NGO approaches to improve coverage  Conclusions

4. 4 Objectives 1.Describe the coverage changes and estimated impact of hygiene and diarrhea prevention interventions (exclusive breastfeeding (EBF), ORT use, and hand washing) implemented by recent USAID- supported NGO projects 2.Describe the approaches used to increase coverage

5. Background  Since 1985, CSHGP has supported more than 400 projects implemented by nearly 60 different NGOs in more than 60 countries, reaching more than 143 million children under 5 and WRA  CSHGP currently supports 47projects in 27 countries, reaching more than 8.5 million children under 5 and WRA 5

6. Active Projects 6

7. Interventions  Grantees work in one or more of the following areas: immunization, infant and young child feeding, control of diarrheal disease, pneumonia case management, maternal and newborn care, vitamin A/micronutrients, malaria, and HIV/AIDS 7

8. Intervention mix over time 8

9. Methods and data  APHA theme: Water and Public Health  CSHGP interventions related to Control of Diarrheal Disease (this analysis)  EBF  Handwashing  ORT 9

10. Grantee data collection  Population-based surveys of mothers of children under 2 at baseline and project end  Standard questionnaires and indicators (KPC, CSTS+ and CORE, 2008: www.childsurvival.com )  Field guide for survey implementation; training curriculum for supervisors and interviewers  Technical support to grantees with survey preparation 10

11. Indicators used in this analysis KPC 2000  Exclusive breastfeeding (EBF): percentage of infants age 0–5 months who were exclusively breastfed in the last 24 hours  ORT use: Percent of children aged 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids (RHF)  Handwashing: Maternal hand-washing behavior: percentage of mothers of children age 0–23 months who wash their hands with soap/ash before food preparation, before feeding children, after defecation, and after attending to a child who has defecated 11

12. Methods for this analysis 1.Review and comparison of survey data (indicators) for 22 projects implemented between 2001 and 2007 2.Lives Saved Tool (LiST) analysis 3.Descriptions of project approaches to improve coverage 12

13.  EBF: median absolute improvement of 27.8%  ORT: median absolute improvement of 42.2%  Handwashing: median absolute improvement of 27.7% 13 Coverage changes (all projects)

14. Coverage Changes: EBF 14

15. Change in Oral Rehydration Therapy Use - Latest DHS Since 2000 and CSHGP Grantees 15

16. Coverage changes: Handwashing 16

17. LiST Methodology  Adapted from model developed by Bellagio Child Survival Study Group: See the 2003 Child Survival and 2005 Neonatal Survival articles in the Lancet: http://www.thelancet.com/collections/child2004  Tool for estimating U5 mortality reduction  Use of this method with CSHGP presented to APHA in 2006 and 2007 17

18. Lives Saved Estimates  EBF*: 2,886 (all projects); 22% of all LS  ORT: 1,295 (all projects); 9.9%  Handwashing: 758 (all projects; combined with POU and safe feces disposal); 5.8% of all lives saved 18

19. Total Estimated U5 Mortality Reduction (22 projects) 23% 40% of that is due to EBF, ORT, and Handwashing 19

20. NGO Approaches  Community-oriented  Household behaviors  Build capacity  In communities  Of health staff, MOH and volunteers  Concentrate on achieving “full coverage”— i.e. reaching everyone in the project area  Some examples follow: 20

21. Care Groups  Used by 2 projects in this analysis: World Relief in Cambodia and Rwanda  These projects saved an estimated 878 lives, or 6.7% of the total for this cohort 21 For more information: www.coregroup.org; search for Care Groups www.coregroup.org “The Care Group Difference: A Guide to Mobilizing Community-Based Volunteer Health Educators” by World Relief

22. VISA Mothers  Used by 2 projects: Medical Care Development International in Benin and Madagascar  Saved an estimated 1,083 lives, or 8.3% of the total for this cohort  Recruit CHVs among mothers who have successfully adopted healthy behaviors  V=visit; I=identify; S=sensitize; A=accompany  Invite 5 new mothers; mitigates effects of low retention while educating a large proportion of mothers in an area 22

23. Context-specific approaches—key features  CARE Ethiopia – trained religious leaders, mothers groups, and CHWs who gave the same messages during the same time frames (1,071 LS; 8.2% of total)  Plan Mali – community mobilization by establishing village health committees; training and supporting community health workers; and strengthening community associations that manage health services. Also partnered with Roll Back Malaria to distribute ITNs. (2,242 LS; 17% of total) 23

24. Different models of community mobilization  Commonalities among approaches  Regular, interpersonal communication (one-to-one)  Community-based information and service resources  Appropriate analysis of barriers to behavior change and of community strengths and assets  Good project management, including appropriate M&E  Optimizing partnerships (MOH, donors, NGO partners) 24

25. Conclusions  Through almost 30 years of investment in community- oriented NGO programming through the CSHGP, USAID has had a measurable impact on child mortality and morbidity, and on health-related behaviors in households.  We are still learning how best to build the evidence base to expand community-oriented NGO programming.  To achieve MDG 4, further study is urgently needed to build the evidence for community-oriented behavior change strategies. This will help build consensus among donors and host country governments for scale-up. 25

26. Acknowledgements  Co-authors and colleagues at MCHIP  NGO grantees  Robert Carty for assistance with charts 26

27. For more information  www.childsurvival.com www.childsurvival.com  Jennifer.m.yourkavitch@macrointernational.com Jennifer.m.yourkavitch@macrointernational.com  http://www.usaid.gov/our_work/global_health/ home/Funding/cs_grants/cs_index.html http://www.usaid.gov/our_work/global_health/ home/Funding/cs_grants/cs_index.html  Thanks for your attention! 27