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Title: Improving child health globally through evidence-based programs George


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

2
Why the next 40 minutes matter
  • Scope of the problem is large
  • 27,000 children lt 5 y die every day
  • 16,000 of those deaths have malnutrition as an
    underlying cause
  • Solutions to the problem are well-known
  • We are most effective in improving child survival
    when our efforts are evidence-based

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 lt 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 lt5 y
    old
  • India vs. Nigeria
  • Pakistan vs. Afghanistan
  • Indonesia vs. Iraq

9
Speaking of evidence
  • Twice the total number of deaths to children lt5 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 dont 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 lt 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 lt 5
    y old

15
Major causes of death, children lt 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 lt 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 lt 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
  • Dont practice optimal behaviors

21
Epidemiology of child survival
  • In most cases the technology to address these
    challenges exists
  • What we dont 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 dont 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 dont 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 didnt 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 womens
    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 govt, 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 wasnt
    implemented as designed
  • Example Positive Deviance Initiative in Vietnam

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

35
Behavior change needs to occur at a variety of
levels
Advocacy for policy change
Policy
Training, advocacy
Health Care Providers - Services Provision
Groups to change community norms
Norms of Surrounding Society
Secondary Target Audience
Groups to create support
Primary Target Audience
Individual Behavior Change
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 lt 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)
  • Well 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 whats 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 Vietnamdisappointing 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 womens 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
Havent 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 programswhat 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
Whats missing
  • Geographic
  • Info on program effectiveness outside S Asia,
    especially Sub-saharan Africa
  • Content
  • Urban health
  • Health systemsnot simply health programs
  • Methods
  • Formative research
  • Small-scale research to test elements of
    successful program strategies
  • Operations research neededeffective relative to
    what?
  • All
  • Honest assessment of what does and doesnt 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 projectlarge
    or smalltrack 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
    strategiesduring pilot phase and at scaleis
    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!
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