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ANNEX X. FINAL KPC REPORT

FINAL SURVEY REPORT: KNOWLEDGE PRACTICE AND COVERAGEHealthy Start Child Survival Project Konni Department, Relief International NigerMahaman Hallarou, MD Child Survival Project Manager/Head of Country Office and Survey Team Leader 12/30/2011 This Final KPC Survey Report has been made possible through support provided by the United States Agency for International Development, under the terms of the USAID Cooperative Agreement# GHS-A-00-07-00028 between USAID and Relief International, for Healthy Start Child Survival Project in the Republic of Niger.

ACKNOWLEDGEMENTSThe author of this report, Dr. Mahaman Hallarou of Relief International (RI), would like to thank various contributors who participated in this Knowledge, Practice and Coverage final survey. In particular, thanks are due to the people who supported this survey either through their involvement in its planning and implementation. These include the staff of the Konni District Ministry of Health (MOH), especially Medical District Coordinator Dr. Alio Tayabou; MOH Supervisor Abuzeidi Chahabou; District Administrator Suleymane Issaka; Health Supervisor Abuzeidi Chahabou; Konni Statistics Department Supervisor Alio Nahantchi, Mouviento Por La Paz Medical Officer Dr. Soumana Oumarou; and Initiative for Secure Households Supervisor Sangar; survey personnel listed in Appendix 1; Meredith Chang of the USAID-Child Survival and Health Grants Program (CSHGP); and Paulin Ntawangundi of RI. Thanks are also due to the USAIDCSHGP, which funded the implementation of the survey.

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TABLE OF CONTENTSACKNOWLEDGEMENTS.........................................................................................................1 EXECUTIVE SUMMARY.........................................................................................................5 1. BACKGROUND.....................................................................................................................6 1.1. Project location.................................................................................................................6 1.2. Characteristics of the target beneficiary population.........................................................6 1.3 Health, social and economic conditions in the project area...............................................7 1.4. National standards and policies regarding maternal and child health..............................8 1.5. Overview of the Healthy Start Child Survival Project.....................................................8 2. PROCESS AND PARTNERSHIP BUILDING....................................................................10 2.1. Steering Committee collaboration..................................................................................10 3. METHODS............................................................................................................................10 3.1. Questionnaire..................................................................................................................10 3.2. KPC indicators................................................................................................................11 3.3. Sampling design..............................................................................................................12 3.4. Training...........................................................................................................................13 3.5. Data collection................................................................................................................14 3.6. Data analysis...................................................................................................................14 3.7. Challenges faced during survey implementation............................................................14 4. RESULTS..............................................................................................................................15 4.1. Final KPC Rapid CATCH indicators.............................................................................15 4.2. Demographic characteristics...........................................................................................16 4.3. Maternal and newborn care............................................................................................17 4.4. Breastfeeding..................................................................................................................19 4.5. Complementary feeding..................................................................................................20 4.6. Vitamin A supplementation............................................................................................20 4.7. Child immunization........................................................................................................20 4.8. Malaria............................................................................................................................22 4.9. Nutritional Status............................................................................................................22 5. DISCUSSION........................................................................................................................23 RELIEF INTERNATIONAL Final KPC Survey Report 3

5.1. Key findings and programmatic implications.................................................................23 6. CONCLUSION......................................................................................................................27 7. BIBLIOGRAPHY..................................................................................................................28 Appendix 1. Survey personnel...................................................................................................29 Appendix 2. Maps of Niger and Konni District........................................................................31 Appendix 3. Survey Steering Committee invitation letter.........................................................32 Appendix 4. Questionnaire (English)........................................................................................33 Appendix 5. Questionnaire (French).........................................................................................51 Appendix 6. English-French-Haussa translations of key survey words....................................68 Appendix 7. Population list of communities.............................................................................69 Appendix 8. Budget...................................................................................................................71 Appendix 9. Training of Trainers agenda (English and French)...............................................72 Appendix 10. Enumerator training agenda (English and French).............................................73 Appendix 11. Comparison of Baseline and Final KPC indicators..............................................0 Appendix 11. Comparison of Baseline and Final KPC indicators Table 1. Summary Table of Beneficiary Population........................................6 Table 2. Summary of Final KPC Rapid CATCH Indicators.........................................................15 Table 3. Age of children under 24 months..........................................................16 Table 4. Sex of children under 24 months..........................................................17 Table 5. Clean delivery kit use...................................................................................18 Table 6. Post-natal check for mother within first week.............................18 Table 7. Post-natal check within three days for newborn........................19 Table 8. Time of breastfeeding after birth.........................................................19 Table 9. Exclusive breastfeeding vs. breastmilk and water....................19 Table 10. Complementary feeding...........................................................................20 Table 11. Possession of vaccination card......................................................................20 Table 12. Children who received Penta 1 or Penta 3...................................21 Table 13. Children who received Vitamin A ,as shown on vaccination card.............................................................................................................................................21 Table 14. Children receiving BCG vaccination..................................................21 Table 15. Children receiving measles vaccination.........................................21 Table 16. Children who had malaria and received appropriate treatment................................................................................................................................22

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Table 16. Children who had malaria and received appropriate treatment

ABBREVIATIONS AND ACRONYMSCSHGP Child Survival and Health Grants Program DHS Demographic and Health Survey DD/AT/DC Direction Departementale de lamnagement du Territoire/Developpement communautaire DPT Diphtheria-Pertussis-Tetanus vaccine DS Health district of Konni (French: District Sanitaire) EOP End of Project ISCV Initiative for Secure Households KPC Knowledge, Practice and Coverage MOH Ministry of Health MPDL Mouviento Por La Paz NCHS National Center for Health Statistics ONG Non-governmental organization (Organisation Non Gouvernementale) ORS Oral Rehydration Solution ORT Oral Rehydration Therapy TBA Traditional Birth Attendant TT Tetanus Toxoid UNICEF United Nations Childrens Fund USAID The U.S. Agency for International Development WHO World Health Organization

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EXECUTIVE SUMMARYThe Healthy Start Child Survival project, designed and implemented by Relief International (RI) in partnership with the Nigerien MOH is located in the Department of Konni in the Tahoua Region. The estimated direct beneficiary population of the project activities is 91,297 women of reproductive age and 83,324 children under five. The project addresses leading causes of childhood morbidity and mortality in the project areas and interventions include (a) malarial control and prevention, (b) control of diarrheal diseases, (c) maternal and child health, and (d) nutrition. Using behavior change communication (BCC) at the community level, an adaptation of the care group model, and training for health care providers at the facility level, the project has implemented activities in 60 villages to date in order to increase demand for services, promote healthy behaviors for child survival, and improve the quality of services offered at health posts and health centers.Figure 1. Relief International Care Group

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1. BACKGROUND1.1. Project location Niger is a landlocked Sub-Saharan African nation that is ranked third from the last on the 2010 Human Development Index, with 69% of its population living below the poverty line(). Like the rest of the Sahel, Niger has a long history of endemic hunger characterized by seasonal fluctuations and geographic variation. In 2005, a severe drought resulted in a famine that affected nearly three million people and exacerbated the already fragile health and nutritional status of the country, with disproportional suffering among women and children. While the current crop harvests have ameliorated some of the immediate concerns, many areas do not have transitional support to ensure sustained recovery. In 2007, in the aftermath of a nutritional crisis, Relief International (RI) launched a four-year USAID-funded Child Survival project in Konni District in Niger1. The Department of Birni nKonni occupies a 5,317 square miles area in the southwestern section of the Tahoua region, 417 kilometers east of Niamey. It is divided into six communes: Konni City, Allela, Bazaga, Malbaza, Dogueraoua, and Tsernaoua. Villages are widely disbursed. The climate is dry and hot. A map of Niger and the Department of Birni nKonni is included as Appendix 2. 1.2. Characteristics of the target beneficiary population Located in the Department of Konni, the project targets 91,297 women of reproductive age (WRA) and 83, 324 children under five():Table 1. Summary Table of Beneficiary Population ESTIMATED POPULATION2 24,200 25,944

CATEGORY Infants, 0-11 months Children, 12-23 months

1 RI implemented its first project in northern Niger in 2005 in to improve food security for pastoralists. During theHealthy Start project period of 2007-2011, RI-Niger also implemented a United States Department of Agriculturefunded Food for Education in Dosso and Tillabery regions and a professional training project for water drillers in Dosso and Tillabery regions. 2 When the project period began in 2007, the Konni Departments population was estimated at 428,623 individuals. Since 2007, the population of Konni Department grew rapidly to an estimated 478,687 individuals, including 93,057 children aged under five, and 101,960 women of reproductive age.

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Children, 24-59 months Total children 0-59 months

33,180 83,324

1.3 Health, social and economic conditions in the project area The Republic of Niger covers a land area of almost 1,270,000 km2 and is inhabited by 14 million people. Nigers national development is hampered by food and political insecurity. The largely agrarian and subsistence-based economy is frequently disrupted by extended, deadly droughts common to the Sahel region of Africa. Niger has experienced two droughts during the projects implementation period, requiring Niger to import 60% of its food in 2009 and threatening the health of more than a million people in 2010. Political instability, such as violent conflict in northern region and last years presidential coup, discourages foreign investment and complicates the implementation of public services. Poorly resourced health services are reflected in national health indicators. The 2010 maternal mortality rate per 100,000 births for Niger is 820. This is compared with 600.7 in 2008 and 890.1 in 1990. The neonatal mortality as a percentage of under 5's mortality is 22(). The under-five mortality rate (U5MR) is 131 in per 1000 live births, according to the Niger National Institute of Statistics. Despite this challenging national context, the economy and welfare of the Department of Konni benefits from its privileged location as a hub of commercial transportation in Nigers fertile south. Konni exports onions and cattle to countries throughout West Africa. Village households in Konni rely on agriculture and trade for income. The major ethnic group in the Konni department is Hausa, with a minority Tuareg and Peulh population. Hausa are traditionally sedentary agriculturalists, while the Tuareg and Peulh groups are nomadic pastoralists. Konnis population has a high illiteracy rate, which is a constraint for information dissemination for behavior change programs. The predominant religion is Islam. As common to traditional subSaharan social norms, men maintain control over resources. In some villages, women must ask male household leaders for permission to access health services outside the home. The provision of health services is divided between private and public sector providers. Private health care providers in Konni City include one private hospital in Galmi, six clinics, and two drugstores. The Ministry of Health District Health Team manages Konni Departments public health infrastructure, which is based on a two-tiered system that covers 35% of Konnis population3. There is one public hospital in Konni City. Twelve integrated health centers (Centre de Sant Intgr) and 44 health posts (Case de Sant) provide outreach services to rural areas. People seeking care must either travel long distances on bad roads to health posts or rely on

3 The Konni Department is the political territory within Tahoua Region. The Konni District is the territory of the local office of Ministry of Health responsible for the management of public health services.

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traditional birth attendants in their villages. Malaria, respiratory infections and diarrhea are leading morbidities. Malnutrition is a common aggravating co-morbidity. 1.4. National standards and policies regarding maternal and child health Nigers National Health Plan for 2011 to 2015 seeks to contribute to the reduction of maternal and child mortality by building on existing capacity to improve the efficiency and quality of the health system(). Government-mandated free health care has been in force since 2006 for children under-five, as well as for antenatal care, caesarean sections, and family planning. Since 2005, active screening, referral and case management of Severe Acute Malnutrition (SAM) have been scaled up. Nigers Expanded Programme on Immunization (EPI) provides three doses of combined diphtheria/pertussis/tetanus/Hemophilus influenza/Hepatitis B vaccine (PENTA)3DPT). Vaccination campaigns against measles are coupled with the distribution of vitamin A capsules. Public sector facilities and non-governmental organizations implement large-scale distribution of bednets. The 2008 National Child Survival Strategy includes increased access to health services through community-based disease management, reinforced human resources and supply chains and monitoring(). Niger is currently finalizing its formation Management System,Health InHuman Resources Development Plan, Nutrition Plan, and National Strategy on Community Case management(). In support of the decentralization of health service management, regional and district Ministry of Health directorates also create fiveyear plans. 1.5. Overview of the Healthy Start Child Survival Project 1.5.1. Project goal The goal of the Healthy Start Child Survival project was to reduce morbidity and mortality rates of mothers and children under five years of age through strengthening community based health care services and information; developing mechanisms to augment food security and food availability for improved maternal and child nutrition; and, create awareness of key behaviors for health at the community and household level through capacity building of local primary health care workers, committee members and local organizations. The projects levels of effort were divided between Maternal and Newborn Care (30% level of effort); Malaria (30%); Diarrheal Disease Prevention and Control (20%); and Nutrition (30%). 1.5.2. Project objectives The projects Strategic Objectives were: SO1: Increase practice of selected emphasis behaviors for Mother and Child survival SO2: Institutionalize sustainable MOH and community support for community health workers SO3: Strengthen capacity of communities, local and district health teams

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1.5.3. Intervention activities The intervention activities for achieving the Strategic Objectives were designed to: 1. Increase access to, demand for, and use of quality maternal and child health services, including emergency care; in order to improved family behaviors related to maternal and child health. 2. Improve case management of malaria at the community and health post levels; increase access to treatment for malaria; improve access and use of treated mosquito nets; and to improve use of chemoprophylaxis for malaria among pregnant women. 3. Improve prevention and treatment of diarrheal disease among rural children under five. 4. Improve nutrition of women and children, through education and household/community food security and nutrition activities. 5. Improve the capacity of the Ministry of Health and local partner agencies, to plan, implement, monitor and evaluate child survival interventions at the community and district levels, with an emphasis on capacity in maternal and child health, nutrition, and household food security. The project plan initially targeted 90 villages in a two-phased coverage approach. The project established 266 women care groups and support for 50 health posts. After the mid-term evaluation (MTE) the project plan was revived to focus on an intervention area of 61 villages. RI and partners conducted the Baseline KPC Survey, Health Facility Assessment, and Detailed Implementation Plan workshop from January to February 2008. RI brought together stakeholders from the Ministry of Health, NGOs, and rural communities to design the project. To drive consensus on a project plan, the RI project management team facilitated structured problem solving from rigorous analysis of the household and facility surveys. RI and the partners agreed to implement a Care Group model adapted to the context of Konni Department and to conduct training for health care providers at the facility level. The MTE reported in January 2010 that Phase 1 activities had increased stakeholder knowledge and practice of malaria prevention, improved nutrition, control of diarrheal disease, and increased access to essential obstetric and neonatal care. In September 2011, RI and partners conducted the Final KPC Survey as part of the Final Evaluation Process. 1.5.4. Objectives of the Final KPC Survey The general goal of the Final KPC Survey was to inform the RI project team, local partners and stakeholders on the level of achievement of the Healthy Start project. More specifically, the objectives of the study were: 1. To collect data on the Rapid CATCH indicators by: Assessing the knowledge and practice of mothers in selected technical packages RELIEF INTERNATIONAL Final KPC Survey Report 10

Measuring the nutritional status of children aged 0-23 months in the project zone; 2. To build the capacity of project local staff and partners data collection and analysis.

2. PROCESS AND PARTNERSHIP BUILDING2.1. Steering Committee collaboration In August 2011, RI contacted the following institutions to invite representatives to participate in a Steering Committee for the Final KPC Survey: USAID Mission in Niamey Tahoua Regional Ministry of Health Konni Health District Konni Department Directorate of Agriculture Konni Department Directorate of Planning Konni non-governmental organizations (NGOs) including Mouviento Por La Paz (MPDL) and the Initiative for Secure Households (ISCV) National Directorate for Health Information (DSSRE) A sample invitation letter is included as Appendix 3. The Final KPC Survey Steering Committee met on September 16-17, 2011, to advise on the preparation of the survey. The Steering Committee reviewed and provided guidance and on the terms of reference for the training of enumerators; drafts of the data collection tools; survey logistical needs (including measurement equipment such as height boards, scales, medicines, and bednets; and the identification of enumerators. Steering Committee representatives agreed to contribute staff and materials from their respective institutions. The Konni Health District provided a staff member to work as a survey supervisor, and contributed scales, bednets and samples of the medicines Paracetamol, iron folic acid, vitamin A, zinc, and sulfadoxine/pyrimethamine. The local NGO ISCV provided staff to work as supervisor and enumerators, and contributed a video projector and chairs for the enumerator training. The Konni District Directorate provided staff to work as supervisors, and contributed basic demographic data essential to survey planning. The international NGO Concern-Tahoua contributed height boards and scales.

3. METHODS3.1. Questionnaire The survey questionnaire covered the Healthy Start Projects four technical areas: 1. Maternal and Newborn Care 2. Malaria 3. Diarrheal disease prevention and control 4. Nutrition RELIEF INTERNATIONAL Final KPC Survey Report 11

The survey questionnaire was 88 questions in length, excluding anthropometrics. The anthropometrics module consisted of three measurements: height, weight, and mid-upper arm circumference when appropriate. RI translated the questionnaire into French from the final English version. The questionnaire in English is included as Appendix 4, and the French translation is included as Appendix 5. During the survey, the French questionnaire was used as a guide for the verbalization of the survey into Konnis local language of Hausa. The Hausa translations of key words are included in Appendix 6. 3.2. KPC indicators The 2006 Rapid CATCH indicators covered by the questionnaire were: Maternal and Newborn Care: Maternal TT vaccination: Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child Skilled delivery assistance: Percentage of children age 0-23 months whose births were attended by skilled personnel Post-natal visit to check on newborn within the first 3 days after birth: Percentage of children age 0-23 who received a post-natal visit from an appropriate trained health worker within three days after the birth of the youngest child Breastfeeding and Infant and Young Child Feeding (IYCF) Exclusive breastfeeding: Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours Infant and young child feeding:% of infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Vitamin A supplementation in the last 6 months: Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months (Mothers recall) Immunization Measles vaccination: Percentage of children age 12-23 months who received a measles vaccination Access to immunization services: Percentage of children age 12-23 months who received a DPT1 vaccination before they reached 12 months Health system performance regarding immunization services: Percentage of children age12-23 months who received a DPT3 vaccination before they reached 12 months Malaria Child with fever receives appropriate antimalarial treatment: Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began Child sleeps under an insecticide-treated bednet: Percentage of children age 0-23 months who slept under an insecticide-treated bed net (in malaria risk areas, where bed net use is effective) the previous night. RELIEF INTERNATIONAL Final KPC Survey Report 12

Control of Diarrhea ORT use: Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids Acute Respiratory Infections Appropriate care seeking for pneumonia: Percentage of children age 0-23 months with chest-related cough and fast and/ or difficult breathing in the last two weeks who were taken to an appropriate health provider. Water and Sanitation Point of use: Percentage of households of children age 0-23 months that treat water effectively Appropriate hand washing practices: Percentage of mothers of children 0-23 months who live in a household with soap or a locally appropriate cleanser at the place for hand washing that and who washed their hands with soap at least 2 of the appropriate times during the day or night before the interview Anthropometry Underweight: Percentage of children 0-23 months who are underweight (-2 standard deviation for the median weight for age, according to WHO/NCHS reference population) 3.3. Sampling design The Core Team designed the Final KPC Survey to survey 30 clusters of 12 households each. Only one mother of a child aged between 0-23 months was interviewed per household, for a total sample size of 360. The sampling design of the Final survey was modified from the Baseline survey. The Baseline KPC Survey sampling was conducted from a population of 453 villages throughout the whole department area. After the first phase of the project, RI followed recommendations made in the MTE to focus interventions in 61 villages. To identify a sampling design that would fairly measure the the projects impact in the revised intervention area, RI and the Core Team consulted with the Final Evaluation Consultant and the Maternal and Child Health Integrated Program team, and agreed to adjust the sampling design to choose 30 clusters from a sampling frame of 61 villages. The Core Team then agreed the details of the sampling design. The population of the villages was provided by the Niger Bureau of Statistics. A master list with cumulative population totals was constructed including all villages. The total estimated population of the project intervention zone of 61 villages is 83,286 divided by 30, giving a sampling interval of 2,776. A start number of 3,839 was randomly identified among the last four numbers of a serial number on a Niger 10,000 CFA currency note. After the selection of the first cluster, the remaining 29 clusters were identified using the sampling interval. The list of selected villages is included as Appendix 7. RELIEF INTERNATIONAL Final KPC Survey Report 13

3.4. Training 3.4.1. Core Team Training The RI project team assembled a Core Team to oversee survey trainings and data collection. The Core Team consisted of six persons: the Healthy Start Projects manager, training coordinator, and Monitoring and Evaluation Officer; the Konni District Communications Officer, and representatives of the Konni agricultural office and the local NGO Community Development Office. The Core Team prepared for the trainings and data collection by reviewing the purpose and methodology of the Final KPC Survey; reviewing and adapting the questionnaire for use in training exercises; and finalizing logistical arrangements and the activities budget. RIs project team worked with the Core Team to plan the survey training and implementation to meet budgetary and time constraints stemming from a project budget realignment process conducted in end summer 2011. The budget realignment process delayed the transfer of a project funds wire to Niger until only a few weeks before the end of the project funding period. The team worked within the revised budget by apportioning remaining funds among the Final KPC Survey, Final Evaluation and project costs. The budget for the survey and data management is included as Appendix 8. The team addressed the challenge of a compressed timeline by conducting focused trainings of two days duration for a Training of Enumerators Trainers and two days for a Training of Enumerators. To save time and to ensure the quality of the survey results, the Core Team also decided to recall survey trainers and enumerators who had participated in the Baseline KPC Survey in 2008. 3.4.2. Training of Enumerators Trainers On September 16 and 17, 2011, staff from RI and the Konni Health District and the Local Government Technical Services Chief Officer trained five supervisors as Enumerators Trainers. Three supervisors participated in the Baseline KPC Survey. All of the trainers had previous professional survey experience. The agenda included a review of the surveys sampling methodology and questionnaire, and planning for the training of enumerators. The enumerators trainers were instrumental in adapting the French questionnaire into Hausa, contributing insights into relevant local traditions and cultural issues that could impact survey results, and brainstorming solutions to overcome bias. The training agenda is included as Appendix 9. 3.4.3. Training of Enumerators RIs survey supervisors conducted a two-day training of 30 survey enumerators to prepare them for the use of the questionnaire, anthropometric measurement equipment, and presentation samples. Since half of the enumerators had participated in the 2008 Baseline KPC Survey, the supervisors asked them to help train the new enumerators. The teams of interviewers practiced completing the questionnaire in Konni town on the second training day. The supervisors RELIEF INTERNATIONAL Final KPC Survey Report 14

identified enumerators with experience in taking anthropometric measurements to establish five specialized teams for field anthropometric data collection. The supervisors met with the RI project manager and the Core Team at the end of each day for feedback and to finalize plans for the survey implementation. The training was a collaborative effort. The agenda for the training of enumerators is included as Appendix 10. 3.5. Data collection Six teams of enumerators collected data for five days. ( Sept 18-22) Each team was composed of four enumerators, one measurer and one supervisor. Each day, a team covered one cluster and filled out 12 questionnaires. At the end of the data collection, the teams had completed a total of 360 questionnaires. The supervisors were responsible for the selection of the starting household and survey direction. Information and approval from village authorities were received before data collection commenced, facilitating easy access to households. The team took daily round trips to Konni because of the clusters proximity. The team adapted a two-level quality control which included a daily check of questionnaires by the team supervisor. Questionnaires were completed and collected on a daily basis, and then reviewed again in the evening. This quality assurance process was in place to detect and address recurrent errors. Each team was supervised at least twice by a member of the Core Team. 3.6. Data analysis The survey data management team was comprised of one staff person from the MOH health information systems office, one project monitoring and evaluation officer, and the RI project manager. The team entered data into Epi Info 7 software for analysis and later transferred on SPSS for cross analysis. The RI project manager collaborated with a World Health Organization statistician to analyze the indicators. Rapid CATCH indicator confidence limits were calculated with a design effect of 2, for 95% confidence that the indicators represented true proportions of knowledge, practice and coverage in the target population. Confidence intervals and the twotailed tests for statistical significance of differences in results between the Baseline and Final indicators were calculated using STATA 10. Anthropometric data was analyzed using Emergency Nutrition Assessment (ENA) software. 3.7. Challenges faced during survey implementation The Core Team faced the challenge of having only nine days before the end of the project funding period to complete the survey and to support the End Point Evaluation Consultant Despite the commitment of the Core Team and their partners, the large amount of work in a compressed time period resulted in some biases.

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Data collection phase: Some mothers prenatal consultation cards were not filled out even though their childrens vaccinations were confirmed by the village workers registers and the mothers recall. Anthropometric weight-for-height measurements were done by a single team of six measurers, which increased the risk of measurement errors. Anthropometric weight measurements may have been biased. For children who were aged under one month, or were too small or sick to be weighed, anthropometric weight measurements were replaced by birth weight in the Child Cards or were by the weights of same-aged children who were known either by recall or in the Child Health Cards. Data analysis: During data analysis, the data management team realized that two questionnaires were missing for a remote cluster. The team did not have any practical option for returning to the missed villages to complete the missing questionnaire. Lack of time for data verification resulted in missing data in some questionnaires.

4. RESULTSThis section presents the findings of the Final knowledge, attitude and coverage survey that was conducted in the Konni District, Niger. This section also compares the results between the Final and Baseline KPC Surveys. 4.1. Final KPC Rapid CATCH indicators Table 2 summarizes the indicators measured in the Final KPC Survey. Values listed in boldfaced font are statistically significantly different from values recorded by the Baseline KPC Survey.Table 2. Summary of Final KPC Rapid CATCH Indicators NUMERAT DENOMINAT INDICATOR OR OR 1. Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child 2. Percentage of children age 0-23 months whose births were attended by skilled personnel 261 322 CONFIDEN CE LIMITS 75.187.1%

VALUE 81.1%

189

358

52.8%

45.560.1%

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INDICATOR 3. Percentage of children age 0-23 who received a post-natal visit from an appropriate trained health worker within three days after the birth of the youngest child 4. Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours 5.% of infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices 6. Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months (Mothers recall) 7. Percentage of children age 12-23 months who received a DPT1 vaccination before they reached 12 months 8. Percentage of children age12-23 months who received a DPT3 vaccination before they reached 12 months 9. Percentage of children age 12-23 months who received a measles vaccination according to the vaccination card or mothers recall by the time of the survey 10. Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective antimalarial drug within 24 hours after the fever began 11. Percentage of children age 0-23 months who slept under an insecticide-treated bed net the previous night 12. Percentage of children age 0-23 months with diarrhea in the last two

NUMERAT OR 38

DENOMINAT OR 358

VALUE 10.6%

CONFIDEN CE LIMITS 6.115.1%

70

105

66.7%

54.079.4%

147

251

58.6%

50.067.2%

184

251

73.3%

65.681%

94

120

78%

49

120

40.8%

28.453.2%

94

189

49.7%

39.659.8%

144

212

67.9%

59.076.8%

266

344

77.3%

71.083.6%

96

193

49.7%

39.7 59.7%

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INDICATOR weeks who received oral rehydration solution (ORS) and/or recommended home fluids 13. Percentage of children age 0-23 months with chest-related cough and fast and/ or difficult breathing in the last two weeks who were taken to an appropriate health provider 14. Percentage of households of children age 0-23 months that treat water effectively 15. Percentage of mothers of children 0-23 months who live in a household with soap or a locally appropriate cleanser at the place for hand washing 16. Percentage of children 0-23 months who are underweight

NUMERAT OR

DENOMINAT OR

VALUE

CONFIDEN CE LIMITS

8685

189358

44%7%2 3.

17.529.9%

270

358

75.4%

69.181.7%

85

358

23.7%

17.529.9%

145

350

41.4%

33.848.7%

4.2. Demographic characteristicsTable 3. Age of children under 24 months AGE 0 to 5 months 6 to 11 months 12 to 23 months Total FREQUENCY 107 95 156 358 PERCENT 30.0% 26.5% 43.6% 100.0%

Table 4. Sex of children under 24 months SEX FREQUENCY Female 137 Male Total 163 358

PERCENT 45.7% 54.3% 100.0%

4.3. Maternal and newborn careTable 5. Birth attendance by skilled personnel BIRTH ASSISTANT FREQUENCY PERCENT Doctor/Nurse/Midwife 161 45.0%

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Health Post worker Traditional birth attendant Other Not assisted Total

28 140 25 2 358

7.8% 39.1% 7.0% 1.0% 100.0%

Almost half of all deliveries are assisted by a qualified person. 40% of deliveries are attended by traditional birth attendants (TBAs, or matrons) even though they are not considered as skilled personnel. The project has devoted a considerable level of effort to sensitization activities to teach TBAs about their new role as companions to delivery. Some of health post workers are nurses, but may not be known as such by respondents.Table 6. Home delivery by Traditional Birth Attendant (TBA) HOME DELIVERY BY TBA FREQUENCY PERCENT Yes 67 47.2% No Total 75 142 52.8% 100.0%

More than half of deliveries assisted by TBAs (matrons) occurred in health centers (75/142). This is a well-known practice, particularly in integrated health centers and district hospitals, where matrons work night shifts under the supervision of a midwife. Officially, matrons are expected in those centers to only accompany parturient women to the maternity ward and help mothers in the post-partum wards. In reality, the matrons continue to assist deliveries when midwifes rest during night shifts.Table 7. Delivery at health center or home DELIVERY LOCATION FREQUENCY Health center 213 Home Total 144 357 PERCENT 59.7% 40.3% 100.0%

60% of deliveries take place in health centers, doubling the baseline measurement (29%). The Healthy Start Projects interventions to improve health care delivery and support community mobilization in the project area may have contributed to the change. The increase in access may also be related to a modest increase in the extension of health facility coverage in Konni District between 2007 and 2011 (52 and 60 health posts, respectively). In the surveyed villages, the number of health posts and integrated health centers has remained unchanged.

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Table 5. Clean delivery kit use CLEAN DELIVERY KIT USED FREQUENCY Yes No Did not know Total 272 84 2 358

PERCENT 76.0% 23.0% 1.0% 100.0%

Clean delivery kits were used in 76% of the deliveries performed in these facilities, a significant increase from the Baseline KPC value of 20%. The Healthy Start Project provided a single use delivery kit to each health center. The kit includes a cloth of two yards in length for wrapping newborns, a razor blade for cutting the umbilical cord, gloves, and soap. While 60% of deliveries occurred in health centers, approximately 16% of kits were used either at home or elsewhere.Table 6. Post-natal check for mother within first week TIME OF MOTHERS POST-NATAL CHECK FREQUENCY PERCENT Hour 1 159 79.1% Day 1 Week 1 Did not know Total 19 3 20 201 9.5% 1.5% 10.0% 100.0%

88.6% (178/201) of mothers who delivered in health centers received a post-natal check within the first week and 80% of them were checked the day after delivery. The total number of the respondents matches with 213 who delivered in Health Center. Only 29 mothers were able to identify the health personnel who performed the post-natal check. Half of them (51%) were done by a health post worker. Midwives performed four post-natal checks doctors performed two checks. It appears that doctors and midwives are more recognizable or may be more communicative with mothers than nurses or health post workers, since the number of deliveries assisted by midwives and doctors are the same for the post-natal checks.Table 7. Post-natal check within three days for newborn POST-NATAL CHECK FOR NEWBORN FREQUENCY PERCENT

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Yes No Total

34 29 63

54.0% 46.0% 100.0%

36% (63/216) of mothers said that their baby was ever checked by the health personnel of the facility where they delivered. Half of the newborns (38) were checked within the week after birth. Only 10.6% of children received a post-natal visit within three days after birth, less than the baseline value. 4.4. BreastfeedingTable 8. Time of breastfeeding after birth TIME OF BREASTFEEDING FREQUENCY Within 1 hour 339 After 1 hour Did not know Total 13 6 358 PERCENT 94.7% 62.0% 2.7% 100.0%

94.7% of newborns were breastfed immediately after delivery (within one hour). The same proportion was given colostrum during the first three days after birth, and 84% of the newborns were not given any other food during the first three days after birth. The increase in immediate breastfeeding behavior is significant, and the Final KPC value doubles the proportion of newborns reported in the baseline survey to be immediately breastfed (42% at baseline).Table 9. Exclusive breastfeeding vs. breastmilk and water TYPE OF FEEDING FREQUENCY PERCENT Exclusive breastfeeding 77 72 Breastmilk and water 9* 8.4%

The findings show 72% of children aged under six months were exclusively breastfed. This is a significant increase compared to baseline value of 36 percent. Exclusive breastfeeding is a cost -effective child survival intervention, especially in the developing country context of Niger. 4.5. Complementary feeding.Table 10. Complementary feeding BREASTFEEDING STATUS FREQUENCY Breastfed 138 Not breastfed Did not know 8 6 PERCENT 55% 3%

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Total

147

59

The Final KPC Survey noted that 59% of children at 6-23 months of age were fed appropriate minimum frequency of meals. Breastfed children were more likely to be fed a minimum frequency of meals than non-breastfed children (44% or 138/324 vs. 24% or 8/34). In rural areas, children who are not breastfed after six months are commonly orphans, have sick mothers, or may have been weaned early. 4.6. Vitamin A supplementationVITAMIN A RECEIVED Yes No Did not know Blank Total FRQUENCY 184 62 4 1 251 PERCENT 74% 24.7% 1.0% 0.1% 100.0%

Among children at 6-23 months of age, 74% received a dose of vitamin A in the six months before data collection, which was not a significant increase from the baseline survey (72%). 4.7. Child immunizationTable 11. Possession of vaccination card HAVING VACCINATION CARD FREQUENCY Yes, and seen by enumerator 273 Did not know Not available Never had a card Total 1 68 16 358

PERCENT 76.3% 0.3% 19.0% 4.5% 100.0%

73% of mothers possess health or vaccination cards, a significant increase from the baseline value of 61 percent. The major issue with Health/vaccination card is that they are not filled mostly by Health personnel. 72% (258/358) of mothers reported vaccinations that are not recorded on their cards.Table 12. Children who received Penta 1 or Penta 3 PENTA 1/PENTA 3 RECEIVED FREQUENCY PERCENT Penta 1 94 78.3%

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Penta 3

49

40.8%

In Niger, Penta 1 and 3, which include five antigens, now are provided in place of DPT1 and DPT3.Table 13. Children who received Vitamin A ,as shown on vaccination card VITAMIN A SHOWN ON CARD FREQUENCY PERCENT Yes 140 55.8% No 46 18.3% Did not know 65 * 25.9% Total 251 100.0%

This result is obtained from a cross tabulation of survey questions 44 (Did the child receive a single dose of Vitamin A with the last 6 months?) and 45 (Does the mother possess a vaccination card?). The 65 responses categorized as NA includes children at 8-23 months of age who had a card that was not available (n=50), had never possessed a vaccination card (n= 11), or and one mother respondent who was unsure if she possessed a card and was classified as No. If ownership of a vaccination card is not considered in the calculation, the percentage of children reported to have received Vitamin A increases to 74%.Table 14. Children receiving BCG vaccination BCG RECEIVED FREQUENCY PERCENT Yes 236 65.9% No 32 8.9% Did not know 90 * 24.1% Total 358 100.0%

Overall, 66% of children were reported to have received BCG vaccinations. BCG was provided to 70% of infants under 12 months of age (137/202) and 63% (99/156) of children at 12-23 months of age. Konni District appears to have a lower proportion of children receiving BCG than Tahoua Region (72%), according to the 2010 national Nutrition and Child Survival Survey(). Historically, Konni District has experienced low vaccination coverage and recurrent outbreaks of measles, meningitis.Table 15. Children receiving measles vaccination MEASLES VACCINE RECEIVED FREQUENCY PERCENT Yes 94 49.7% No 48 25.4% Did not know 40 * 21.2%

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Total

189

100.0%

The percentage of children at 9-23 months of age who had measles vaccination is 51 percent. The percentage is the same for among children at 12-23months of age (52%, 78/151). 4.8. MalariaTable 16. Children who had malaria and received appropriate treatment APPROPRIATE MALARIA TREATMENT RECEIVED FREQUENCY PERCENT Yes 144 67.9% No 72 34.0% Did not know Total 212 100.0%

59% (212/358) of children had fevers in the two weeks prior the survey. An appropriate antimalarial (Artemisinin-based combination therapy, Fansidar, chloroquine, or amodiaquine) was provided to 68% of children within 24 hours of the onset of the fever4. 4.9. Nutritional StatusFigure 2. Nutritional status of children

The nutritional status of children in the intervention area remains poor, as represented in Figure 2 by the red curve for weight-for-age skewed to the left of the WHO/National Center for Health Statistics reference. The survey found that 41.7% (145/350) are underweight.4 Choloroquine was an appropriate treatment in 2008 according to the Niger MOH, and was therefore included in the Baseline survey. The Final survey included chloroquine as an appropriate treatment for comparability, although national policy requires ACTs be provided as first-line therapy.

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5. DISCUSSIONFindings of the Final KPC Survey in Konni District have shown two major trends: (1) significant improvements in indicators for maternal and newborn care, the prevention and treatment of infant disease, child immunization, and water and sanitation; and, (2) a deterioration in the nutritional status of children in the project area. 5.1. Key findings and programmatic implications Indicator 1. Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child A significantly increased proportion (81% vs. 28.8% at baseline) of mothers with children at 023 of age had received at least two doses of Tetanus Toxoid (TT) vaccine before the birth of their youngest child. (A table comparing indicators from the Final and Baseline KPC surveys in included as Appendix 11.) The Final result exceeded the End of Project (EOP) target of 40%. The indicator is higher than in Tahoua Region (62.1%)(). The increase may be linked to an increased utilization of antenatal consultation and maternal health services. Despite several vaccine stock-outs during the four year project period, the Government of Nigers 2008 policy of free mother and child care and the Healthy Starts community sensitization activities may also have contributed to the increased utilization of services. The survey found that 73% of mothers possessed health/vaccination cards, and that 60% of mothers gave birth in health centers. The project area showed a higher correlation of completed ANC/TT visits and subsequent births in health facility than the 2010 National Child Survey, which who showed that despite a significant increase of Antenatal visits (55% in Tahoua Region), deliveries in health facilities were uncommon (31%). Indicator 2. Percentage of children age 0-23 months whose births were attended by skilled personnel Among the 60% of pregnant women who gave birth in health centers, 52% of the deliveries were attended by skilled personnel, a significant increase from the baseline value (26.4%). The Final result exceeded the EOP target of 40%. Although Ministry of Health policy does not consider health post workers to be skilled personnel, they account for 60% of all health workers in the 60 health posts of Konni District. Therefore, the Healthy Start Project trained health post workers in clean delivery, and included them in the tabulation of this Rapid CATCH indicator. Indicator 3. Percentage of children age 0-23 who received a post-natal visit from an appropriate trained health worker within three days after the birth of the youngest child RELIEF INTERNATIONAL Final KPC Survey Report 25

The indicator for post-partum check did not change significantly for mothers (88% vs. 92% at baseline) and children (11% vs. 13%). While these results may indicate a stagnation of the postnatal check-ups, it should be noted that the responses rate in the Final KPC is low. Even though 60% (201/358) of mothers answered positively that they were checked after delivery, only 29 mothers were able to identify who assisted her during the delivery. Indicator 4. Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours The survey has noted a significant increase (72% vs. 36%) in the proportion of children at 0-5 months of age who were exclusively breastfed during the 24 hours prior to the survey. This is more than twice the proportion of 26.9% found by the national-level Nutrition and Child Survival Survey of June 2010. The KPC Final Survey results support the observations made in the Healthy Start Project MTE Evaluation that breastfeeding behavior has increased in the project area. Indicator 5. Percent of infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices 50 % of children at 6-23 months of age who were fed according to a minimum of appropriate feeding practices (147/251). This a significant increase over the baseline estimate of 36%. Indicator 6. Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months (Mothers recall) According to mothers recall, 74% of children at 6-23 months of age received a dose of Vitamin A in the six months prior to the survey, a significant increase over the baseline (10%). When excluding responses from mothers whose cards did not show a precise date for when Vitamin A was received, the proportion drops to 8% (20/251). This indicator was expected to be higher. Two months before the survey, in June 2010, Niger distributed Vitamin A as part of its semi-annual national vaccination day. This indicator result indicates that Nigers distribution strategy is not achieving full coverage. Indicator 8. Percentage of children age12-23 months who received a DPT3 vaccination before they reached 12 months 41% of children at 12-23 months of age received a Penta 3 vaccination (which now replaces DPT3 in Niger), a significant increased over the baseline value of 28%. This indicator exceeds the EOP target of 40%, despite repeated vaccine stock-outs reported in Konni Districts annual health plan evaluations.

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Indicator 9. Percentage of children age 12-23 months who received a measles vaccination according to the vaccination card or mothers recall by the time of the survey 51% of children received measles vaccination, a significant increase over the baseline value of 38% and exceeding the EOP target of 40%. Indicator 10. Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began Indicator 11. Percentage of children age 0-23 months who slept under an insecticide-treated bed net the previous night The Survey found a significant improvement in the prevention and treatment of malaria. Use of 67.9% of children who had experienced a febrile episode two weeks before the survey had been treated with an appropriate antimalarial, a significant increase over the baseline (17.6%) and exceeding the EOP target of 40%. Furthermore, 77.3% of children had slept under a bednet, compared to 40.0% at baseline, exceeding the EOP target of 60%. Despite public sector stock outs of nets during the project period the Healthy Start Projects timing of behavior change activities around peak malaria transmission periods (rainy seasons) and an increased availability of bednets in the communities may have contributed to these positive results. Indicator 12. Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids 49.7% of children received ORS when they had diarrhea, a significant increase from the baseline value of 17.5%, but below the EOP target of 70%. ORS coverage might be improved through direct distribution at the household level through care group volunteers. Instead, access to ORS is limited to mothers who are able to access and utilize health post services. Indicator 13. Percentage of children age 0-23 months with chest-related cough and fast and/ or difficult breathing in the last two weeks who were taken to an appropriate health provider The endline survey identified a significant improvement in health seeking behavior among mothers with children aged 0-23 months, as evidenced by increased use of appropriate health provider to manage cough and fast and/or difficult breathing of children at 0-23 months of age from baseline findings (44% vs 18.2%). Even though ARI management is not among the 4 priority technical intervention of the Konni Project.

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The project supported the improvement in the case management of childhood illnesses through capacity building of health post workers in Community-based Integrated Management of Childhood Illness and care group mobilization to strengthen community-based referral systems. Indicator 14. Percentage of households of children age 0-23 months that treat water effectively 75.4% of households treat water effectively, a significant increase from 15.2%. The projects behavior change messages included locally- and culturally-appropriate methods for protecting water quality. Indicator 15. Percentage of mothers of children 0-23 months who live in a household with soap or a locally appropriate cleanser at the place for hand washing 23.7% of mothers of children at 0-23 months of age live in houses with soap or cleanser at the place for hand washing, a significant increase from the baseline value of 11.5%. The promotion of hand washing was a challenging activity for several reasons. The project adopted a gradual introduction of BCC packages, so hand washing messages were introduced in Year 2 and did not benefit from as much time for sensitization as did maternal and newborn care or breastfeeding. Second, the placement of soap at an appropriate point of use is highly culturally dependent. Soap is usually used in the bathing area and for prayer ablution. People instead wash their hands using a kettle, without soap. Soap and detergent cannot be left in the open air by latrines because birds, hens or domestic animals tend to displace or spoil them, nor kept in a container because they can easily melt or dilute in the midday heat. Not least, soap and detergent are costly, so the project launched training for women volunteers in soap production during the last quarter of implementation period (April-June 2010). Village residents expressed interest in continuing the activity. Indicator 16. Percentage of children 0-23 months who are underweight 41.7% (145/350) of children at 0-23 months of age were measured to be underweight (having a weight for age measurement that is -2 standard deviations from the median weight for age, according to WHO/NCHS reference population). This indicator is significantly higher than the baseline survey result of 30.3%. Despite increases in exclusive breastfeeding and complementary feeding practices noted in the final KPC, the nutritional status of people in Konni District may have been compromised by Nigers repeated food insecurity during the project period. In 2009 and 2010, Niger recorded food shortages with almost half of the population estimated to be food insecure. At the Konni District level in 2009, 169 villages were identified by the Local Government Food Security Watching Committee system to have a crop deficit of 50-80%.

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The 2006 Niger DHS found that 46% of children aged under five were underweight. Based on this prevalence, the projected underweight prevalence target for 2011 is 25% to meet the Millennium Development Goal for reduced infant mortality. A Situational Analysis of IYCF policies and programmatic activities in Niger conducted in 2008-2009 showed that, Mortality rates are on track to reaching the Millennium Development Goal to reduce mortality among young children by two-thirds by 2015, but there has been no change in under nutrition, and total mortality rates are still high among young children().

6. CONCLUSION

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7. BIBLIOGRAPHY

Institut National de la Statistique. (2010). Nutrition and Child Survival Survey among children aged 6 to 59 months. Niger, May - June 2010. Niamey: Institute National de la Statistique-Niger/UNICE/WFP/HKI. Ministry of Health. (2005). Konni Health District Development Plan 2005-2010. Konni City: Government of Niger. Ministry of Health. (2008). National Child Survival Strategy (Avant-projet de Stratgie National de Survie de lEnfant). Niamey: Republic of Niger-Ministry of Health. Ministry of Health. (2011). National Nutritional Plan 2011-2015 (Plan National pour la Nutrition PNN 2011-2015). Niamey: Republic of Niger- Ministry of Health. Ministry of Health. (2011). Plan de Developpement Sanitaire du Niger. Niamey: Republic of Niger-Ministry of Health. Relief International. (2008). FY1 Annnual Report. Los Angeles: Relief International. Tilford, K. (March 2010). Child Survival Mid-term Evaluation Report. Los Angeles: Relief International/USAID. UNDP. (2011). Niger Country Profile: Human Development Indicators. Retrieved September 30, 2011, from International Human Development Indicators: http://hdrstats.undp.org/en/countries/profiles/NER.html Unicef. (2010, March 2). At a glance: Niger. Retrieved December 22, 2011, from unicef: http://www.unicef.org/infobycountry/niger_statistics.html United Nations Population Fund. (2011). State of the World's Midwifery. Geneva: UNFPA. Whueler, S., & Biga, A. (2011). Situational analysis of infant and young child nutrition. Maternal and Child Nutrition 7 (Suppl. 1), 133156.

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Appendix 1. Survey personnelThe following people were instrumental in bringing the Final KPC Survey and report to a successful completion:CORE TEAM NAME Salissou Iliassou ORGANIZATION Drection DepartementaleP/Amenagem ent du Territoire/Developpement Communautaire Konni DS Konni MPDL Konni RI RI RI Consultant PHONE CONTACT 96 87 94 64

Abouzeidi Chouhabou Dr Soumana Oumarou Dr Mahaman Hallarou Moustapha Tcharimi Rakia Azouma Remi Sugurono

96 96 96 96 96 90

87 08 29 88 87 61

89 11 27 33 66 22

38 33 84 75 43 27

SURVEY SUPERVISORS NAME Abouzeidi Chouhabou Ali Hantchi Ary Issaka Ousmane Garba Nana Haouaou Kamay Goga Maman Sani Moussa Oumarou Moussa Maman Tela Moustapha Tcharimi Tchari Sangar Rachide Dr Soumana Oumarou

ORGANIZATION DS Konni DDP/AT/DC Konni Jeunesse Sport Konni ISCV Konni Alphabtisation ISCV Konni ISCV Konni PSE/RI Konni ISCV Konni MPDL Konni

PHONE CONTACT 96 87 89 38 96 59 07 60 98 09 19 04 90 79 09 60 96 88 76 92 91 79 38 57 96 87 89 38 90 46 65 51 96 99 45 52 96 08 11 33

ENUMERATORS NAME Abdou Andin Abdoul Razakou Habou Nagodi Abdoulkarim Ado Aichatou Abdou Garba Ali Abdoul Karim Alzouma Mahaman Moustapha Alzouma Mayaki Oumarou Arzika Halimatou Bga Alou Binta Ibrahim

PROFESSION Teacher Logistics assistant Marketer Teacher DDP/AT/DC Student Student Biologist Sociologist Teacher

PHONE CONTACT 91 59 95 35 96 50 40 96 96 89 75 48 96 89 89 97 96 29 03 63 96 57 44 20 96 21 88 44 94 25 45 87 96 27 78 38 96 58 72 63

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Dakaou Alio Fatimatou Issaka Bilali

Sociologist Nurse

96 46 73 34 96 26 75 84

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NAME Garba Kano Hadiza Ibrahim Hassane Almou Amadou Ibrahim Gado Ibrahim Maman Sani Ibrahim Oumarou Ibro Mahamadou Maman Fati Idi Mato Touraki Mohamed Abolbol Moussa Abdou Moussa Jean Traor Oumarou Djibo Oumarou Ibrahim Salamatou Habou Salifou Moumouni Kadidja Salissou Dan Nana Souley Hamidine

PROFESSION Retired teacher Rural development specialist Animateur Professor Professor Student Animateur Planning agent Journalist Sociologist Extension agent Sociologist Teacher Student Journalist, Radio Anfani Sociologist Sociologist/ Municipal agent Sociologist

PHONE CONTACT 96 97 29 14 97 28 74 80 90 04 12 63 98 74 37 40 96 46 66 01 96 52 95 02 96 07 69 59 98 58 42 66 96 75 89 77 96 98 08 66 90 57 95 34 91 71 50 83 96 01 43 04 96 02 76 40 96 06 42 47 96 58 04 76 91 36 34 32 96 40 20 88

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Appendix 2. Maps of Niger and Konni DistrictMap 1. Niger regions5

5 Source: Focus on Niger website, Departments Map. http://www.joelmayer.com/niger/images/departements.gif.Accessed March 20, 2008

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Map 2. Konni Department6

6 Source: Relief International and the Konni District Ministry of Health, 2007

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Appendix 3. Survey Steering Committee invitation letter

Tl. : (227) 20 35 08 79 / 21 76 74 69 Fax 20 64 00 29 BP : 12 245 NIAMEY

Reprsentation au Niger

Mr. Noble Williams USAID Program Manager USAID Office Niamey, Niger Reference: USAID CA # GHS-A-00-0-00028-00,Niger Child Survival Project

Dear Mr. Williams, Thank you for the opportunity to inform you that under the referenced project, Relief International (RI) is planning to carry out a Final Evaluation that will enable the Ministry of Health, the local community, and RI to verify achievements towards the project objectives. Planned evaluation activities are participatory and we are expected to invite donors and partner organizations including USAID to participate in the evaluation activities in Konni district. The attached documents provides information on planned field level evaluation activities in Konni District and we would appreciate it very much if you could confirm your availability to participate in this evaluation activity so that we can also take into account the Missions ideas and concerns in current and future health program development activities in the region.

Sincerely yours, Edwards Farrel RI Country Director Project Manager

Encl.

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Appendix 4. Questionnaire (English)Ask the mother if she has a child under 24 months who lives with her. If yes, proceed with interview, if no thank the mother and end the interview. Identification Cluster Number Household Number Record Number Community Name of Mother Name of Supervisor Data Entered by Date: ___/___/____ day/month/year Interview date Name of Interviewer Result Code* *Result Codes: 1. Completed 2. Respondent not at home 3. Postponed 4. Refused 5. Other______________________________________ Specify 1 ___/___/____ day/month/year 2 ___/___/____ day/month/year 3 ___/___/____ day/month/year Final Visit For Supervisor Day Month Year Result Code

ConsentINFORMED CONSENT Hello. My name is ______________________________, and I am working with Relief International and MSP. We are conducting a survey and would appreciate your participation. I would like to ask you about your health and the health of your youngest child under the age of two. This information will help Relief International and MSP to plan health services and assess whether it is meeting its goals to improve childrens health. The survey usually takes _______ minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons. Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important. Will you participate in this survey? At this time, do you want to ask me anything about the survey? Signature of interviewer: __________________________________________________ Date: ____________________ ESPONDENT AGREES TO BE INTERVIEWED__________RESPONDENT DOES NOT AGREE TO BE INTERVIEWED

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Questionnaire ALL QUESTIONS ARE TO BE ADDRESSED TO MOTHERS WITH A CHILD LESS THAN 24 MONTHS OF AGE Introduction No. 1 Questions and Filters Coding Categories Total number of children 2 What is the name, sex, date of birth of your youngest child that you gave birth to and that is still alive? Youngest Child Name _______________________________ Sex Male....1 Female.......2 Date of Birth Day Month Year Tetanus Toxoid Immunization NO. 3 4 QUESTIONS AND FILTERS During pregnancy with (NAME) did you receive an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth? While pregnant with (NAME), how many times did you receive such an injection? CODING CATEGORIES Yes.....................................................................1 No......................................................................2 Dont know.........................................................9 Times................................................................... Dont know.........................................................9 5 At any time before the pregnancy with (NAME) did you receive any tetanus injections? How many other times did you receive a tetanus injection? IF 7 OR MORE TIMES, RECORD 7 Yes.....................................................................1 No......................................................................2 Dont know.........................................................9 Times................................................................... Dont know.........................................................9 6 7 7 SKIP 4 5 5 Skip

How many children do you have?

6

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Skilled attendance and clean cord care NO. QUESTIONS AND FILTERS 7 Who assisted you with the delivery of (NAME)? Anyone else? PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED. IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.

CODING CATEGORIES HEALTH PERSONNEL DOCTOR........................................................A NURSE or MIDWIFE......................................B AUXILIARY MIDWIFE...................................C OTHER HEALTH STAFF WITH MIDWIFERY SKILLS....................................D OTHER PERSON TRADITIONAL BIRTH ATTENDANT.............E COMMUNITY HEALTH WORKER................F RELATIVE/FRIEND.......................................G OTHER___________________....................H (SPECIFY) NO ONE............................................................Y

SKIP

8 9

Was a Clean Delivery Kit used during delivery? (SHOW DELIVERY KITS LOCALLY PROMOTED) What instrument was used to cut the cord?

Yes....................................................................1 No......................................................................2 Dont know.........................................................9 New razor blade................................................1 New and boiled razor blade..............................2 Used razor blade...............................................3 Used and boiled razor blade.............................4 New scissors.....................................................5 New and boiled scissors....................................6 Used scissors....................................................7 Used and boiled scissors..................................8 Knife..................................................................9 Reed................................................................10 Other ____________________.....................96 (Specify) Dont know.......................................................97

10 9 9

Active management at delivery 10 Immediately after (NAME) was born, before the placenta was delivered, did you receive an injection to prevent you from bleeding too much? 11 Immediately after you got an injection to prevent you from bleeding, did the birth attendant hold your stomach and pulled on the cord to help the placenta come out? Immediately after the Placenta was delivered, did someone massage your uterus to make it contract strongly and to prevent you from bleeding too much?

Yes.....................................................................1 No......................................................................2 Dont know.........................................................9 Yes.....................................................................1 No......................................................................2 Dont know.........................................................9 Yes.....................................................................1 No......................................................................2 Dont know.........................................................9

11 13 13 12 13 13

12

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Drying and wrapping after birth NO. QUESTIONS AND FILTERS 13 14 Was (NAME) dried (wiped) immediately after birth before the placenta was delivered?

CODING CATEGORIES Yes....................................................................1 No......................................................................2 Dont know.........................................................9 Yes....................................................................1 No......................................................................2 Dont know.........................................................9 Yes....................................................................1 No......................................................................2 IMMEDIATE....................................................00 HOURS................................................................ DAYS................................................................... Dont remember.................................................9 YES ..................................................................1 NO ..................................................................2 DONT KNOW .................................................9 YES .................................................................1 NO ..................................................................2 DONT KNOW .................................................9 Milk of animals Powdered milk simple water sugar water Salt water sweetened Dcoctions. / infusions Fruit juice honey Other specify YES NO 1 2

SKIP

Was (NAME) wrapped in a warm cloth or blanket immediately after birth before the placenta was delivered? Breastfeeding/ Infant and Young Child Feeding 15 Did you ever breastfeed (NAME)? 16 How long after birth did you first put (NAME) to the breast? IF LESS THAN 1 HOUR, RECORD 00 HOURS, IF LESS THAN 24 HOURS RECORD THE HOURS, OTHERWISE RECORD DAYS 17 During the first three or four days after delivery, before your regular milk began flowing, did you give (NAME) the liquid (colostrum) that came from your breasts? In the first three days after delivery, was (NAME) given anything to drink other than breast milk?

16 19

18

19

Now I would like to ask you about liquids or foods (NAME) had yesterday during the day or at night. Did (NAME) drink/eat: READ THE LIST OF LIQUIDS (A THROUGH E, STARTING WITH BREAST MILK).

20 21

Currently do you breastfeed (NAME)? How long did you breastfeed? IF LESS THAN A MONTH RECORD '00 'MONTH .

MONTHS..........................

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NO. 22

QUESTIONS AND FILTERS PLEASE FILL OUT THE FOLLOWING TABLE WITH THE ANSWERS TO THE QUESTIONS BELOW: Now I would like to ask you about (other) liquids or foods that (NAME) may have had yesterday during the day or at night. I am interested in whether your child had the item even if it was combined with other foods. Did (NAME) drink/eat: CHECK THE BOX IF THE CHILD drank the liquid in question.

CODING CATEGORIES

SKIP

A............................................ B............................................ C............................................

22A 22B 22C 22D

Breast milk? Water Plate? Milk powder sold in commerce? Milk as in any other box, powder, fresh milk or animal? Fruit juice? Other liquids such as sugar water, tea, coffee, soft drinks or broth?

D............................................

22E 22F

E............................................ F............................................

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NO.

QUESTIONS AND FILTERS Now I would like to ask you about the types of aliments4 that [NAME] ate yesterday during the day or night.

CODING CATEGORIES

SKIP

Does [NAME] ate the following foods during the day or last night?

Check the box if the child to eat the food in question.

22G

Foods made of seeds [eg, millet, sorghum, maize, rice, wheat, boiled, or other local seeds]?

G............................................

22H

Pumpkin, red or yellow yams or squash, carrots or sweet potatoes red?

H............................................

22I

Any other food from roots or tubers [eg, potatoes, white yams, cassava and other roots / tubers local]? 5

I.............................................22J 22K Of green leafy vegetables?

Mango, papaya [or other local fruits rich in Vitamin A]?

J.............................................

22L

Other fruits and vegetables [eg, bananas, apples / applesauce, avocados, tomatoes]?

K............................................

22M 22N

Meat, poultry, fish, seafood or eggs?

L............................................Food prepared from vegetables [eg, lentils, beans, soybeans, pulses, peanuts or]?

22O 22P

Cheese or yogurt?

M........................................... N............................................

Food-based oil, grease or butter?

O............................................ P..

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NO. 23

QUESTIONS AND FILTERS How many times did (NAME) eat solid, semi-solid, or soft foods other than liquids yesterday during the day or at night? IF CAREGIVER ANSWERS SEVEN OR MORE TIMES, RECORD 7 WE WANT TO FIND OUT HOW MANY TIMES THE CHILD ATE ENOUGH TO BE FULL. SMALL SNACKS AND SMALL FEEDS SUCH AS ONE OR TWO BITES OF MOTHERS OR SISTERS FOOD SHOULD NOT BE COUNTED. LIQUIDS DO NOT COUNT FOR THIS QUESTION. DO NOT INCLUDE THIN SOUPS OR BROTH, WATERY GRUELS, OR ANY OTHER LIQUID. USE PROBING QUESTIONS TO HELP THE RESPONDENT REMEMBER ALL THE TIMES THE CHILD ATE YESTERDAY

CODING CATEGORIES

SKIP

Number of Times Dont Know .9

24 25

Can I see the salt used for cooking? 6 TAKE A teaspoon of SALT and test it for iodine.

IODINE PRSENT 1 IODINE NOT PRSENT...................................2 YES 1 NO 2 DONT KNOW...................................................8 HOME (own or other)........................................1 HEALTH FACILITY (public sector or private) . .2 33 27 28 30

Has (NAME) received a dose of Vitamin A like this in the past six months? 7 BULB SHOW / CAPSULE / SYRUP. Postpartum visit (for mother) 26 Where did you give birth to (NAME)?

27 28

After (NAME) was born, before you were discharged, did any health care provider check on your health? How long after delivery did the first check take place? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

Yes.....................................................................1 No......................................................................2 HOURS................................................................ DAYS................................................................... WEEKS................................................................

29

Who checked on your health at that time? PROBE FOR MOST QUALIFIED PERSON.

DON'T KNOW.................................................99 HEALTH PERSONNEL DOCTOR...........................................................A NURSE or CLINICAL OFFICER.......................B MIDWIFE..........................................................C AUXILIARY.......................................................D OTHER PERSON TRADITIONAL BIRTH ATTENDANT.....................................................E HEALTH WORKER...........................................F OTHER..............................................................Z (SPECIFY) Yes.....................................................................1 No......................................................................2

30

After you were discharged, did any health care provider or a traditional birth attendant check on your health?

31 36

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31

How long after delivery did the first check take place? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS................................................................ DAYS................................................................... WEEKS................................................................ DON'T KNOW.................................................99

NO.

QUESTIONS AND FILTERS

CODING CATEGORIES

SKIP

32

Who checked on your health at that time? PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL DOCTOR...........................................................A NURSE or CLINICAL OFFICER.......................B MIDWIFE..........................................................C AUXILIARY.......................................................D OTHER PERSON TRADITIONAL BIRTH ATTENDANT.....................................................E HEALTH WORKER...........................................F TRAINED TBA .................................................G TRAINED HW...................................................H OTHER..............................................................Z (SPECIFY)

33

After (NAME) was born, did any health care worker or a traditional birth attendant check on your health?

Yes.....................................................................1 No......................................................................2

34 42

34

How long after delivery did the first check take place? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS................................................................ DAYS................................................................... WEEKS................................................................ DON'T KNOW.................................................99

35

Who checked on your health at that time? PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL DOCTOR...........................................................A NURSE or CLINICAL OFFICER.......................B MIDWIFE..........................................................C AUXILIARY.......................................................D OTHER PERSON TRADITIONAL BIRTH ATTENDANT.....................................................E HEALTH WORKER...........................................F TRAINED TBA .................................................G TRAINED HW...................................................H OTHER..............................................................Z (SPECIFY)

42 42 42 42

42 42 42 42 42

Postnatal visit (for baby) 36 After (NAME) was born, before you were discharged from the health facility, did any health care provider check on (NAME)s health? Yes.....................................................................1 No......................................................................2 37 39

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37

How many hours, days or weeks after the birth of (NAME) did the first check of (NAME) take place?

HOURS................................................................ DAYS................................................................... WEEKS................................................................ DON'T KNOW.................................................99

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NO. 38

QUESTIONS AND FILTERS Who checked on (NAME)s health at that time? PROBE FOR MOST QUALIFIED PERSON.

CODING CATEGORIES HEALTH PERSONNEL DOCTOR...........................................................A NURSE or CLINICAL OFFICER.......................B MIDWIFE..........................................................C AUXILIARY.......................................................D OTHER PERSON TRADITIONAL BIRTH ATTENDANT.....................................................E HEALTH WORKER...........................................F OTHER..............................................................Z (SPECIFY) Yes.....................................................................1 No......................................................................2 HOURS................................................................ DAYS................................................................... WEEKS................................................................

SKIP

39 40

After you were discharged, did any health care provider or a traditional birth attendant check on (NAME)s health? How many hours, days or weeks after the birth of (NAME) did the first check of (NAME) take place? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

40 45

41

Who checked on (NAME)s health at that time? PROBE FOR MOST QUALIFIED PERSON.

DON'T KNOW.................................................99 HEALTH PERSONNEL DOCTOR...........................................................A NURSE or CLINICAL OFFICER.......................B MIDWIFE..........................................................C AUXILIARY.......................................................D OTHER PERSON TRADITIONAL BIRTH ATTENDANT.....................................................E HEALTH WORKER...........................................F TRAINED TBA .................................................G TRAINED HW...................................................H OTHER..............................................................Z (SPECIFY) Yes.....................................................................1 No......................................................................2 HOURS................................................................ DAYS................................................................... WEEKS................................................................ DON'T KNOW.................................................99

42 43

During the first days after (NAME) was born, did any health care provider or a traditional birth attendant check on (NAME)s health? How many hours, days or weeks after the birth of (NAME) did the first check of (NAME) take place? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

43 45

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44

Who checked on (NAME)s health at that time? PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL DOCTOR...........................................................A NURSE or CLINICAL OFFICER.......................B MIDWIFE..........................................................C AUXILIARY.......................................................D OTHER PERSON TRADITIONAL BIRTH ATTENDANT.....................................................E HEALTH WORKER...........................................F TRAINED TBA .................................................G TRAINED HW...................................................H OTHER..............................................................Z (SPECIFY)

Childhood Immunization NO. 45 QUESTIONS AND FILTERS Did (NAME) take a vitamin A dose like this during the last 6 months? SHOW AMPULE/CAPSULE/SYRUP. 46 Do you have a card where (NAMES) vaccinations are written down? IF YES: May I see it please? YES, SEEN BY INTERVIEWER...................1 NOT AVAILABLE/LOST/MISPLACED..........2 NEVER HAD A CARD...................................3 DONT KNO