1. Knowledge Practice and Coverage (KPC) Revision Process June 3, 2014 Jennifer Winestock Luna

2. Agenda  Brief overview of tool  Importance of revision  The process  Specific modules  Resources

3. KPC – What is it?  Rapid Small Sample Household Survey that:  Contains modules so that surveys can be customized to technical areas of a program  Useful for designing surveys for integrated health programs

4. Overview: Characteristics  Easy to implement  Developed to collect standardized information from a variety of technical areas  Traditionally, targets mothers of children 0-23 months  Modules: questionnaires, indicators, tab plans, instructions  Implementers select modules relevant to technical areas  Within each module select questions & indicators relevant to interventions

5. Overview: Technical Areas - Modules  Sick Child - (ARI, CDD, Malaria, CCM)  Malaria (stand-alone)  Immunization  Maternal Newborn Care  Pregnancy Spacing and Family Planning  Breast Feeding IYCF  Water &Sanitation

6. Overview: Knowledge Practice and Coverage Survey (KPC)  Developed by JHU / CSSP 1990  Based on 30x7 cluster methodology used by EPI  Rapid survey methodology; small sample sizes  Household selection done in the field  Computer simulations conducted validated EPI methodology  Developed for CSHGP, used by grantees since 1991  Collected at baseline, midterm, and final  Intervals 2-3 years

7. Overview: Purpose Implementers  Understand health situation at local level  Program area or district  Measure progress toward results  Input for decision making, especially local level USAID  Allows USAID to measure the contribution of a portfolio of projects to improved health  i.e. portfolio of CSHGP grants 

8. KPC - Characteristics  Two standard sampling methodologies  30x10 cluster sample of 300 (coverage for entire project area) May increase sample size for operations research; may need parallel sampling  LQAS sample of 95 (coverage for entire project area) or 19/supervision area to determine areas that need additional attention Recommended for monitoring, but not for operations research

9. Timeline for implementing KPC  Normal time from planning to discussion of results is 30 days of full work.  Includes questionnaire development, field work, data entry/ analysis, developing action plan, (report writing)  Helen Keller International Baseline Niger -21 days  14 days for questionnaire design, sampling frame, cluster selection and logistics planning  2 days training in country  5 days field work (September 2005)

10. Importance of the revision  Technical areas advanced; new/updated indicators  i.e. new vaccines, respectful maternity care  Revision supported by CSHGP; tool has wider use  PVOs already use outside of CSHGP  USAID emphasis on:  District level planning; Monitoring and Evaluation  Implementation science  MACS can use this tool in country programs

11. The Revision Process Team effort, led by MCHIP PVO/NGO support  MCHIP technical: FP, Immunization, Child, Maternal, MIP  SNL, newborn indicator working group;  MEASURE Evaluation – Malaria  CORE working groups: Malaria, Community Child Health  USAID: OPRH, PMI, Maternal, Newborn, Child, Immunization, CSHGP

12. The Process: Basic Steps 1.Review of indicators from other sources:  DHS, MICs  Measure Evaluation  CCM task force  PMI  LiST Tool  SNL

13. The Process: Basic Steps Simultaneously 2. Consulted experts MCHIP, MEASURE Evaluation; CORE Group, USAID, others 3. TA to CSGHP grantees to integrate most recent state-of-art indicators into baselines Conducted Dec. 2012 – Apr. 2013 4. Revised modules

14. The Process: Basic Steps Simultaneously 5. USAID reviews, comments, and approves MCHIP adjusts modules 6. Modules posted on MCHIP PVO/NGO support website Later posted on MACS website

15. The Process: Where we are now (June 3, 2014) Approved by USAID and Posted: Malaria (stand-alone); Pregnancy Spacing and Family Planning; MNC; Immunization; Sick Child - (ARI, CDD, Malaria) Work at early stage: IYCF, WASH http://www.mchipngo.net/controllers/link.cfc?method=tools_mande

16. The Process: Where we are now (June 3, 2014) IYCF: Meetings with nutrition teams at USAID and MCHIP completed Comparative indicator table compiled Module update in process WASH Communication with USAID/WASH; Discussion with MCHIP/WASH Comparative indicator table developed Next: Set up meeting with FHI360 – Orlando Hernandez; Update module

17. Infant and Young Child Feeding (IYCF)  Based on WHO IYCF guidance document  USAID, WHO, IFPRI, Fanta, UCDAVIS UNICEF  Adapted for rapid small sample survey (KPC)  Indicators selected as appropriate for small sample sizes  i.e. limited age disaggregation to maintain validity with small overall sample

18. Overall changes  Standardized outline and format  Questionnaire consistent with DHS standard template  Excel  Consistent format conventions i.e. Statements in all capital letters are interviewer instructions not to be read aloud to the mother

19. Overall changes  Notes for Program Managers section added  Outlines contextual items that must be determined before designing survey What are names of different types of health service providers; What is the vaccination schedule, which vaccines are included?  Other data section added  Acknowledges, some information better obtained from other sources: Qualitative, HFA, routine health Updated suggested qualitative research topics

20. Key points – Sick Child: Malaria, Suspected Pneumonia, Control of Diarrhea  Incorporates iCCM indicators, including from CCM task force  Contains instructions for contextual information to obtain prior to developing questionnaire, i.e. Which interventions are being implemented (malaria, diarrhea, pneumonia)? What are national CCM policies; CHW diagnosis/treatment?  What is current (or planned) situation regarding RDTs? Are RDTs approved? Is supply reliable?

21. Challenges  Among/within countries variation: roll-out iCCM & RDT  Must consider context for questionnaire and interpretation of results  Satisfying information needs of different vertical areas requires compromise for survey to be feasible  1 ITN for every 2 people requires net roster, not always practical  Controversy in Malaria community regarding mother’s recall of finger/heel stick and if results of test received

22. Challenges  Developing combined indicators for fever; fast/ difficult breathing; and diarrhea complicated  Fever and fast/difficult breathing should be seen by a health provider (i.e. CCM trained CHW), but non-severe diarrhea can be managed in home  Limited experience using some indicators, i.e.  % children 0-59 months with fast, difficult breathing 2 wks preceding survey; advice/r treatment sought from CCM- trained CHW as first source of care

23. Key points – Sick Child: Malaria, Suspected Pneumonia, Control of Diarrhea  Limited experience with using some indicators, i.e.  Percentage of children age 0-59 months with fast or difficult breathing in the two weeks preceding the survey for whom advice or treatment was sought from a CCM- trained CHW as the first source of care  Use of malaria diagnostic testing: Percentage of children age 0-59 months with fever in the two weeks preceding the survey who had a finger or heel stick (i.e. mRDT)

24. Key points – Malaria stand-alone  Includes indicator/ questions from sick child module  Incorporation of malaria in pregnancy  Expanded LLIN use; net roster option Challenges:  Malaria programs now recommend universal net coverage (not just children 0-59 months and pregnant women)  If net use is a focus, program must use a net roster, time consuming

25. Key points – Malaria stand-alone MIP: IPTi; Malaria Case Management in Pregnancy Challenges:  WHO now recommends 3 doses IPTi; however programs struggle for 2  Module recommends breakdown: 1, 2, 3, 4+ doses  As malaria incidence decreases, IPTi is replaced by case management in pregnancy  No agreement on measurement in HH surveys; RHMIS do not record separately for pregnant women  Disagreement determining positive cases through HH surveys; impossible to measure appropriate treatment

26. Key points – Malaria stand-alone MIP: IPTi; Malaria Case Management in Pregnancy  Module includes one indicator on appropriate care seeking for fever during pregnancy  Appropriate care-seeking for fever during last pregnancy: Percentage of mothers of children age 0- 23 months who had fever during pregnancy with the youngest child, who sought care from an appropriate provider

27. Key points – Immunization Challenges  Introduction of new and underutilized vaccines  More than 1 vaccine in same anatomical site, at same time; complicates maternal recall  Changes in vaccine schedules  No standard schedule for all countries  Important to have:  Separate indicators for card verified coverage and maternal recall  Indicators for coverage of valid doses

28. Key points – Immunization: Introduction of new and underutilized vaccines  DTP vaccine replaced with pentavalent  Diphtheria, pertussis (whooping cough), tetanus, hepatitis B and Haemophilus influenzae type b (Hib)  Pneumococcal Conjugate Vaccine (PCV);  Given as three injections in thigh, usually at same time as pentavalent vaccine (given in other thigh)  Rotavirus vaccine given orally  Rotarix® requires 2 doses; Rotateq® requires 3.  OPV also given orally

29. Key points – Immunization: Introduction of new and underutilized vaccines  Hepatitis B birth dose  Regionally important vaccines  Yellow fever parts of Africa  Japanese encephalitis parts of Asia

30. Key points – Immunization: valid dose  Card verified  Correct timing of first dose, interval between doses, i.e.  Polio 1, PCV 1, Rotavirus 1 not before 42 days after birth  Polio 2 & 3, Penta 2 & 3, PCV 2 & 3, Rotavirus 2 & 3 not before 28 days after previous dose  Birth dose hepatitis B; valid within 24 hours after birth  Birth dose OPV; valid first 2 weeks of life

31. Key points – Immunization Module has:  Detailed description of information to obtain from national and local-level immunization officials  Allows survey to be adapted to local situation  Questions for collecting both card verified and maternal recall of vaccinations  A chart for calculating valid doses

32. Key Points – Maternal Newborn Care Addition of:  Content of ANC, PNC (previously just # of ANC and timing of PNC); i.e.  ANC – i.e. Counseling for birth planning, Blood Pressure taken  PNC – % of children who had at least two signal functions checked within 2 days of birth Signal functions: Examine cord; Counsel on newborn danger signs; Assess newborn temperature; Counsel on/observe breastfeeding; Weigh baby

33. Key Points – Maternal Newborn Care Addition of: Includes:  MIP: IPTi; Malaria case management in pregnancy  Respectful Maternity Care; i.e.  % of mothers who had a support person or birth companion during labor and/or delivery  Misoprostol: received, used  Indicators of SNL led Newborn indicator working group

34. Key Points: Pregnancy Spacing and Family Planning  Focuses on knowledge, practices related to Family Planning (FP) and Healthy Timing and Pregnancy Spacing (HTPS).  HTPS is an approach to help women/ families delay, space, or limit pregnancies to achieve healthiest outcomes for women, newborns, infants, and children  HTPS works within the context of free, informed contraceptive choice; takes into account fertility intentions and desired family size.

35. Key Points: Pregnancy Spacing and Family Planning - Highlights  Measurement of healthy timing practices:  Adequate birth spacing; Births before age 18; Births in women over 34; Pregnancies in high parity women  Community distribution of methods  Post-Partum Family Planning  Integration of Maternal, Infant, Young Child Nutrition (MIYCN) and FP

36. People involved in updating process - 58 LastFirst BenaventeLuis CrewsMeredith EckertErin BazantEva BeyeneEndale BlanchardHolly BoswellClaire BrunieAurelie CharuratElaine ChoiMisun LastFirst CooperChelsea CurrieSheena DagnonJean Fortuné S. DaryOmar Desai Hobson Reeti DialloNene DibabaAsrat ElliotLeah Farnsworth Katherine FavinMike

37. People involved in updating process LastFirst FieldsRebecca GallowayRae GrahamVictoria GryboskiKristina GuentherTanya HassanMohammed N IvonovitchElizabeth JacobsTroy KakLily KasungamiDyness LastFirst KavleJustine KureshyNazo MacDonaldTrish MfornyamChristopher MongaTanvi MooreZhuzhi MoranAllisyn MorrowMelanie NortonMaureen OthepaMichel

38. People involved in updating process LastFirst ProsnitzDebra RawlinsBarbara RomanElaine Rosales Alfonso ShenAngela SitrinDeborah StantonMary Ellen SteinglassRobert Talens Alan TripathiVandana LastFirst TsumaLaban UccelloAmy UnfriedKirsten Van HulleSuzanne VorkoperSusan WilsonLucy Winestock LunaJennifer ZinzindohouePascal

39. Resources http://www.mchipngo.net/controllers/link.cfc?method=tools_mande http://www.mchipngo.net/controllers/link.cfc?method=tools_mande  KPC modules:  Questionnaires; tabulation plans; indicator definitions; instructions; consent forms  KPC Trainer of survey trainers (TOAST)  The Rapid Household Survey Handbook

40. Resources  Lot Quality Assurance Sampling (LQAS)  LQAS Trainer’s Guide  Assessing Community Health Programs: Using LQAS for Baseline Surveys and Regular Monitoring Participants Module  LQAS Protocol for Parallel Sampling  LQAS Frequently asked Questions

41. If you want more information, please contact me Thank you Jennifer.WinestockLuna@icfi.com