Improving child health globally through evidence-based programs George Diana Sharpe Perinatal Lectureship University o

1. Improving child health globally through evidence-based programsGeorge & Diana Sharpe Perinatal LectureshipUniversity of Texas at AustinSchool of Nursing Kirk Dearden – 27 February 2009

3. Structure… Evidence to improve programming Before programs begin During program implementation Innovative strategies to improve child survival After program completion

4. Our focus… Who? Children < 5 y old in developing countries Girls, marginalized, poverty-stricken What? Programs implemented by community-based NGOs Less on MOH activities Impact? On health systems, policies and populations

5. Our focus… What evidence? Before programs begin… Epidemiological evidence Formative research (usually qualitative) During program implementation Monitoring and evaluation After programs end Rigorous assessments of program impact (usually quantitative)

6. Speaking of evidence… A quiz to start things off! Which country in each pair has twice the under-five mortality rate as the other? Ethiopia vs. Sierra Leone Mali vs. Benin Cambodia vs. Niger

7. Speaking of evidence… Twice the under-five mortality rate Ethiopia vs. Sierra Leone Mali vs. Benin Cambodia vs. Niger

8. Speaking of evidence… Twice the total number of deaths to children <5 y old India vs. Nigeria Pakistan vs. Afghanistan Indonesia vs. Iraq

9. Speaking of evidence… Twice the total number of deaths to children <5 y old India vs. Nigeria Pakistan vs. Afghanistan Indonesia vs. Iraq

10. Our focus… Quiz points to the need to understand where the numbers of deaths are greatest What evidence? Before programs begin… Epidemiological evidence Formative research (usually qualitative)

11. The epidemiological evidence We MUST know the underlying epidemiology of child morbidity and mortality prior to initiating programs and policies designed to help children survive and thrive Sometimes we don’t attempt to get this evidence Sometimes we are thorough in obtaining this evidence But evidence used poorly to champion a single, specific cause Or used effectively to bring attention to a neglected topic Deborah Maine/Allen Rosenfield: Maternal mortality Lancet series on neo-natal survival

12. Epidemiology of child survival Who What When Where Why

13. Epidemiology of child survival Who 10 million children < 5 y of age Poor and females at much greater risk

14. Epidemiology of child survival What Neonatal disorders: 33% Diarrhea: 22% Pneumonia: 21% Malaria: 9% Other causes: 9% AIDS: 3% Measles: 1% Undernutrition: 60% of all deaths to children < 5 y old

15. Major causes of death, children < 5 y

16. Epidemiology of child survival When 40% of all under-five deaths: first 28 d of life 2/3rds of all IMR in first 28 d 2/3rds of all NMR in first week 2/3rds of all deaths in first week occur in the first d Most deterioration in nutritional status occurs in first 18 m of life

17. An example of using evidence effectively: Weight-for-age Z-score by age and region, Save the Children, 1986-1997

18. Epidemiology of child survival Where Half of all deaths in just 6 countries India, Nigeria, China, Pakistan, DR Congo, Ethiopia 90% of all deaths to children < 5 y old occur in 42 countries

19. Epidemiology of child survival Where Half of all deaths: India, Nigeria, China, Pakistan, DR Congo, Ethiopia 90% of all deaths to children < 5 y old occur in 42 countries

20. Epidemiology of child survival Why At a fundamental level, children die because those who have been entrusted to care for them: Parents Family Health care providers Program planners and implementers Policy makers Donors Don’t practice “optimal behaviors”

21. Epidemiology of child survival In most cases the technology to address these challenges exists What we don’t know is why, for example: Some mothers fail to exclusively breastfeed Some health care providers discourage exclusive breastfeeding Breastfeeding is not a priority for the MOH and for donors

22. The most effective preventive and treatment services and their impact The following preventive interventions would do the most to reduce U5MR Breastfeeding 13% Insecticide treated materials 7% Complementary feeding 6% Zinc 6% Treatment interventions ORT 15% Antibiotics for sepsis 6% Antibiotics for pneumonia 6% Antimalarials 5%

23. What happens when we don’t use epidemiological evidence to guide programs? Fail to address the greatest causes of morbidity and mortality Ignore country- and region-specific disease patterns e.g., malaria in Africa Misdirect scarce resources

24. Our focus… What evidence? Before programs begin… Epidemiological evidence Formative research (usually qualitative)

25. What happens when we don’t conduct formative research? Programs targeted at the wrong populations No community buy-in Poor understanding of the facilitators and barriers to engaging in optimal behaviors Inappropriate/ineffective programs

26. An example of a program that didn’t use formative research Peru – no needs assessment, no clear understanding of the underlying epidemiological profile Misunderstanding of what was needed Community largely uninvolved Focus on a very small town ? public health impact? Potential for public health impact is doubtful despite massive resources

27. An example of successful use of formative research Multivitamins for Women of Reproductive Age in Bolivia

28. Background Hypothesis: social marketing improves women’s awareness and consumption of multiple vitamin and mineral supplements, especially among low-income women Design: formative research and baseline and final surveys

29. Intervention Formative research to inform micronutrient product and marketing strategy Product name Location of manufacture Appearance Cost Packaging Advertising including appropriate media

30. Intervention Commercial distributors and medical staff to work with doctors and pharmacists Department-wide events for gov’t, NGO and other leaders 6 months of media advertising Poster, dangling product shots 148,000 brochures distributed thru pharmacies 900 TV spots

31. Percent of Women Who Had Ever Taken Multiple Supplements, by Years of Formal Schooling

32. Structure… Evidence to improve programming During program implementation Innovative strategies to improve child survival

33. Structure… Evidence to improve programming During program implementation Monitoring and evaluation critical Sometimes we incorrectly conclude that a program is ineffective when in fact, the program wasn’t implemented as designed Example: Positive Deviance Initiative in Vietnam

34. Structure… Evidence to improve programming During program implementation Innovative strategies to improve child survival

36. Behavior Change Strategies Policy Advocacy including the use of data-driven models to inform decisions REDUCE: Maternal health ALIVE: Neonatal mortality PROFILES: infant nutrition Simulated models to estimate the relative advantages of exclusive breastfeeding over replacement feeding and vice versa IMR < 25/1000 live births: exclusive replacement feeding

37. Behavior Change Strategies Health care providers Assessments of existing policies, health care provider knowledge Changes to national guidelines JHU: reproductive health Pre-service and in-service reform and training Vietnam: training in breastfeeding for clinicians

38. Behavior Change Strategies Norms of surrounding society Information, education and communications (IEC) strategies including social marketing VitalDía in Bolivia

39. Behavior Change Strategies Secondary target audience Inclusion of husbands and in-laws The Grandmother Project Positive Deviance Other efforts

40. Behavior Change Strategies Primary target audience 3 strategies Negotiation ORPA Positive Deviance ALL involve collection of data to inform programming

41. Negotiation Negotiation ASK RECOMMEND AGREE REMIND APPOINTMENT

42. Example of Negotiation: reduction of indoor air pollution ASK the mother about current use of the stove to identify any problems RECOMMEND options to the mother and help her to select one she can try AGREEMENT on a behavior that the mother will try REMIND mother of optimal practice and help overcome obstacles Make an APPOINTMENT for a follow-up visit

43. What might you recommend? Unblock/properly seal chimney Make sure door has hinges Repair holes and missing/broken plates Keep at least 2 windows/doors open during burning Open long enough to ventilate house Keep child away from stove/outside during ignition, morning hours, and burning Put out fire when burning is finished

44. ORPA Observe Reflect Personalize Act Case study from West Africa (feeding sick children) Feeding as much or more during and after illness Feeding patiently Feeding special foods (enriched broth, fish soup, mashed banana or other fruit)

45. How are Negotiation and ORPA different from “education?” Give individuals options Individuals choose options that are most feasible/do-able given their own culture, social environment, etc. Put the health promoter and the individual on an equal footing Require two-way communication intense listening by the health promoter followed by tailor made recommendations Require reflection

46. PD/Hearth

47. PD/Hearth

48. PD/Hearth

49. PD/Hearth

50. PD in Vietnam Some children from poor houses well-nourished. How did they do it? Answers vary by setting but include crabs, shrimps and greens from rice paddies PD hearth involves Discovering local solutions (evidence-based) Sharing those solutions Designing hearth sessions for malnourished children 2 weeks, 6 days per week Parents of malnourished children practice the practice Example: contributing a handful of PD foods as the price of admission to a hearth session PD/Hearth requires evidence: anthropometry before and after 2-week session

51. PD/Hearth Turn to neighbor and identify one PD outcome and risk factor She/he does the same Outcome: inner city youth who get a college education Risk: poor schools in inner city (or parental disinterest or lack of resources or…) We’ll share 2 or 3 examples in plenary

52. What are the benefits of applying a PD framework to development? PD behaviors are affordable, acceptable, and sustainable already practiced by those at-risk, do not conflict with local culture, and they work PD introduces a generic model for local problem-solving PD provides solutions today to challenges that cannot await long-term development Focus on “what’s right”: not prescriptive, “top down,” or donor-driven Easier to sustain without on-going external resources

53. What are the limitations of using PD? limited generalizability of findings labor- and cost intensive potential for scale uncertain

54. What is the impact of PD? PD study in Vietnam…disappointing results. However… Trinh MacIntosh study on sustainability was quite encouraging

55. Positive Deviance and Neonatal Health: A Case Study from Pakistan How do you find PDs? Situation analysis to discover norms Community/clinic investigation to find PDs Positive Deviant Inquiries; uncommon behaviors among: Surviving asphyxiated newborns Thriving LBW babies Surviving newborns who had danger signs Normal newborns

56. Marsh, Pakistan Both groups, weak practice of: Clean delivery Thermal control Immediate/exclusive breastfeeding Fathers’ involvement

57. Marsh, Pakistan PD behaviors (Afghani refugees): Mother prepared own delivery kit Mother given diet of chicken and eggs before/after birth Mother-in-law washed hands with soap before and after cutting cord Room kept warm at all times Dai used mouth-to-nose resuscitation

58. Our focus… Evidence to improve programming Before programs begin During program implementation Innovative strategies to improve child survival After program completion

59. A variety of sources that examine the impact of specific interventions… Lancet series on: child survival maternal health neonatal health Adolescents Undernutrition Alma Ata, etc. Perry H, Freeman (2008). How effective is community-based primary health care in improving the health of children? a review of the evidence. Report to the Expert Review Panel, the World Health Organization, UNICEF, and the World Bank

60. UNICEF: more than enough information to act

61. Community-based Primary Health Care any activity which directly or indirectly has a positive influence on health, and does not take place exclusively in a health center or hospital

62. A review of the evidence…

63. Extensive evidence that interventions are effective and should receive priority Immunizations for mothers and children (TT for mothers and measles for children Supplemental vitamin A Exclusive breastfeeding during the first 6 months of life and continued breastfeeding thereafter Hygiene, safe water, and sanitation Oral rehydration therapy and zinc supplementation for children with diarrhea Handwashing

64. Extensive evidence Clean deliveries when births are at home and where hygiene is poor Home-based neonatal care (immediate/exclusive breastfeeding, cleanliness and prevention of hypothermia) Community-based treatment of childhood pneumonia Insecticide-treated bednets Detection and treatment of syphilis in pregnant women, and Iodine supplementation

65. Efficacious interventions that need more evaluation in routine settings Community-based treatment of malaria Community-based rehabilitation of malnourished children through Positive Deviance/Hearth or through ready-to-use dry therapeutic foods Prophylactic supplemental zinc Complementary feeding from 6-9 months of age; Prenatal calcium for prevention of pre-eclampsia and eclampsia Intermittent preventive treatment of malaria during pregnancy Detection and treatment of asymptomatic bacteriuria

66. Need more evaluation Application of a topical antiseptic to the umbilical cord of neonates Skin cleansing of newborns with a topical antiseptic soon after birth Improved airway management and resuscitation in neonates by trained community health workers Detection and treatment of neonatal sepsis by trained community health workers Improved cooking stoves through improved stoves (to reduce childhood pneumonia) Participatory women’s groups for empowerment and education about maternal and neonatal health issues Non-health interventions, including micro-credit and conditional cash transfers to women Improved socio-political environments which support maternal and child health and allow access to high-quality basic services

67. Do not appear to have a beneficial effect on the health of children Supplementary feeding programs in non-emergency situations De-worming medication for children (on growth or on cognition/school performance)

68. Haven’t had sufficiently rigorous evaluations Growth monitoring? Antenatal care Large-scale integrated programs to reduce stunting and wasting Birthing homes

69. Adverse effects Iron supplementation in malaria-endemic areas Micronutrient mix of iron, other minerals including zinc, and riboflavin

70. Successful programs…what do they have in common? Perry and Freeman: the most successful integrated programs with a sustained and documented impact on child health: Jamkhed Comprehensive Health Project in Jamkhed, India SEARCH (Society for Education, Action and Research in Community Health) in Gadchiroli, India Matlab MCH-FP field site in Bangladesh, and Hospital Albert Schweitzer in Haiti Common characteristics in operation for 20-50 years published, documented mortality impacts, and BRAC also worthy of attention but no published mortality impact

71. Common characteristics

72. What’s missing Geographic: Info on program effectiveness outside S Asia, especially Sub-saharan Africa Content: Urban health Health systems…not simply health programs Methods: Formative research Small-scale research to test elements of successful program strategies Operations research needed…effective relative to what? All: Honest assessment of what does and doesn’t work Tendency toward PR means that there are few unsuccessful experiences documented

73. The way forward… Program planners: Implement effective packages first on a pilot basis then at scale Donors: “Divest” of requirements that every project—large or small—track progress on a host of indicators Provide broader support to integrated packages described by Perry and Freeman

74. The way forward… Program evaluators: Rigorously assess packages to judge effectiveness/make adjustments to programs as the scale expands Develop innovative methods for assessing impact Assess packages of interventions in routine field settings at scale over long time periods Bhutta et al. (2005) reviewed 740 studies of the effectiveness of community-based interventions for improving perinatal and neonatal health outcomes only 10 carried out in routine field settings that could be considered effectiveness trials Haws et al. (2007) looked at packages to improve neonatal health no studies at scale in routine settings

75. The way forward… Program evaluators: More info needed on program context and extent to which programs are implemented as planned PD in Vietnam is one example More cost-effectiveness studies More community empowerment studies More on service delivery mechanisms including Behavior Change Communications strategies Which approaches work best? In which contexts?

76. The way forward… If we are to effectively address child survival, we need an evidence base Prior to beginning programs Must answer what, when, where, how and why? Must examine feasibility (formative research) During program implementation After program completion Rigorous testing of the most promising strategies—during pilot phase and at scale—is absolutely essential No justification for allowing 10 million children to die every year Our obligation as practitioners of public health is to ensure that the programs and policies we implement do the most to help children survive and thrive

77. Thank you!