ENDLINE SURVEY FINAL REPORT

World Vision, Niger

Prepared by ICF and World Vision for WHO Rapid Access Expansion (RAcE) Program March 2017

AUTHORS: Grace Nganga, Yodit Fitigu, Kirsten Zalisk

ACKNOWLEDGEMENTS

ICF and World Vision would like to thank le Ministère de la Sante Publique and l’Institute National de la Statistique for their contributions to this work. We would also like to thank the Relais Communautaires (Niger’s Community Health Workers), who work hard to provide services to caregivers and children in communities, and the caregivers who give so much to ensure and improve the health of their children. This work was made possible by the World Health Organization through funding by the Canadian Government.

RAcE Niger Endline Survey Final Report ii TABLE OF CONTENTS ABBREVIATIONS ...... iv EXECUTIVE SUMMARY ...... v 1 BACKGROUND ...... 1 1.1 RAcE Program Goals and Objectives ...... 1 1.2 World Vision Project Background ...... 1 1.3 World Vision Endline Survey Objectives ...... 2 2 SURVEY METHODS ...... 3 2.1 Survey Implementation and Partnership ...... 3 2.2 Survey Design ...... 3 2.3 Survey Questionnaire ...... 4 2.4 Selection and Training of Survey Staff ...... 5 2.5 Data Collection ...... 5 2.6 Data Entry and Management ...... 6 2.7 Data Analysis...... 6 2.8 Survey Indicators ...... 7 2.9 Survey Limitations ...... 7 3 FINDINGS ...... 8 3.1 Characteristics of Sick Children and Caregivers ...... 8 3.2 Decision-making ...... 10 3.3 Caregiver Knowledge and Perception of iCCM RComs...... 11 3.4 Care-Seeking ...... 12 3.5 Assessment ...... 13 3.6 Treatment Coverage ...... 15 3.7 First Dose of Treatment and Counseling from RCom ...... 16 3.8 Referral Adherence ...... 18 3.9 Sick Child Follow-Up ...... 18 3.10 Illness Management and Diagnostics by Sex ...... 19 4 DISCUSSION ...... 21 Annex A. List of Persons Involved in the Survey ...... 23 Annex B. Endline Sample ...... 24 Annex C. Detailed Sampling Design ...... 25 Annex D. Survey Questionnaire ...... 26 Annex E. Survey Training Schedule ...... 27 Annex F. Fieldwork Schedule ...... 30 Annex G. Details of Data Cleaning and Analysis ...... 32 Annex H. Indicator Definitions ...... 35

RAcE Niger Endline Survey Final Report iii ABBREVIATIONS

ACT artemisinin-based combination therapy CCM community case management CSI Case de Santé Intégré (Health Hut) iCCM integrated community case management INS Institute National de la Statistique (National Institute of Statistics) MSP Ministère de la Santé Publique (Ministry of Health) ODK Open Data Kit ORS oral rehydration solution PPS probability proportional to size RAcE Rapid Access Expansion RCom Relais Communautaire (community health worker) WHO World Health Organization

RAcE Niger Endline Survey Final Report iv EXECUTIVE SUMMARY

World Vision implemented the Rapid Access Expansion (RAcE) program in four health districts in Niger—Boboye, Dogondoutchi, Dosso, and Keita—since July 2013. In October 2016, World Vision conducted the RAcE endline survey, with technical assistance from ICF, and in collaboration with the Division de la Statistique (Division of Statistics) of the Ministère de la Santé Public (Ministry of Health) and the Institute National de la Statistique (National Institute of Statistics). This report presents endline data and compares baseline and endline data to assess changes in care-seeking, assessment, and treatment of sick children. Baseline and endline data are also used to assess caregivers’ knowledge of childhood illnesses and their perceptions of services provided by Relais Communautaire (RComs, or community health workers). This information is used to present project accomplishments. Results for key indicators are presented in Table 1. Caregivers’ knowledge and perceptions of RCom increased significantly over the course of the project, as expected, given that RCom were trained and deployed to provide iCCM services after the baseline survey was implemented. The percentage of caregivers who know the RCom who works in their community significantly increased, from 1 percent at baseline to 99.8 percent at endline (p<0.001). At endline, caregiver’s trust in RCom was nearly universal: 99 percent of caregivers viewed RCom as trusted health providers, and 98 percent believe RCom provide quality services. There was no significant change observed in caregiver knowledge of childhood illnesses over the course of the project. Care-seeking from an appropriate provider was high at baseline (68 percent) and remained high at endline (85 percent). As expected following the extension of health services to the communities via RCom, care-seeking from RComs was high at endline; of cases of illness among children 2-59 months who sought care from an appropriate provider, 88 percent of those sought care from an RCom The percentage of cases of illness among children aged 2-59 months taken to an RCom as the first source of care increased significantly (p<0.001), from 0.1 percent at baseline to 75 percent at endline. At baseline iCCM services had not yet been rolled out to communities and no RCom administered RDTs to assess cases of fever. At endline, 75 percent of the cases of fever among children 2-59 months that were assessed by an RCom in the two weeks prior the survey were administered an RDT. The overall percentage of illnesses receiving appropriate treatment increased significantly over the course of the project, from 37 percent at baseline to 59 percent at endline (p<0.001). The largest increase observed was for the appropriate treatment for diarrhea, which increased from 23 percent at baseline to 64 percent at endline (p<0.001). Among those who sought care from an RCom, 58 percent received appropriate treatment. Despite the overall increase in appropriate treatment from any provider, the percentage of cases receiving appropriate treatment is low (overall, and from RCom). Little more than half of the cases treated by the RCom received the first dose of the treatment in the presence of the RCom and that 98 percent of caregivers were counseled by the RCom on treatment administration. At endline, 32 percent of cases managed by an RCom were referred. Overall, reported adherence to referrals made by RCom was high at 91 percent at endline. Overall, more than 68 percent of cases were followed up by an RCom, 93 percent of which were followed-up by the RCom within three days. The findings from the endline survey suggest the value of iCCM in hard to reach communities in Niger, but greater improvements in access to quality care are needed. There is need to further investigate

RAcE Niger Endline Survey Final Report v reasons why appropriate treatment for iCCM illnesses remains low despite high care-seeking from and assessment by RCom, and to put solutions in place to address this challenge.

Table 1. Key indicator summary table Baseline Endline % Point Indicator p-value % (CI %) % (CI %) change Caregiver knowledge Percentage of caregivers of children age 2-59 months who have been sick in the two 1.0 99.8 1 weeks preceding the survey who are aware 98.8 0.0000 (0.3 - 3.2) (98.3 - 100.0) of the presence of the CCM-trained RCom in their community Percentage of caregivers of children age 2-59 months who have been sick in the two 40.0 ** 77.4 2 weeks preceding the survey who know the 37.4 0.0425 (10.2 - 79.6) (70.6 - 83.4) role of the CCM-trained RCom in their community Percentage of caregivers of children age 2-59 months who have been sick in the two weeks preceding the survey who know two 75.8 81.1 3 5.3 0.1412 or more signs of childhood illness that (70.3 - 80.5) (76.0 - 85.3) require immediate assessment by an appropriately trained provider Caregiver perceptions of iCCM services Percentage of caregivers of children age 2-59 months who have been sick in the two 20.0 ** 98.5 4 weeks preceding the survey who view CCM- 78.5 0.0000 (1.9 - 76.2) (95.6 - 99.5) trained RComs as trusted health care providers Percentage of caregivers of children age 2-59 months who have been sick in the two 20.0 ** 97.6 5 77.6 0.0000 weeks preceding the survey who believe (1.9 - 76.2) (95.1 - 98.8) CCM-trained RComs provide quality services Percentage of caregivers of children age 2-59 months who have been sick in the two 73.8 6 0* 73.8 N/A weeks preceding the survey who found the (67.4 - 79.4) CCM-trained RCom at first visit Percentage of caregivers of children age 2-59 months who have been sick in the two 60.0 ** 87.9 7 weeks preceding the survey who cite the 27.9 0.0596 (20.4 - 89.8) (80.8 - 92.7) CCM-trained RCom as a convenient source of treatment Sick child care-seeking Percentage of children age 2-59 months who have been sick in the two weeks preceding

the survey for whom advice or treatment was sought from an appropriate provider 68.8 84.7 Overall 15.9 0.0002 (62.0 - 75.0) (79.2 - 89.0) 8 72.4 88.9 Fever 16.5 0.0001 (65.7 - 78.2) (82.0 - 93.3) 65.8 84.9 Diarrhea 19.1 0.0005 (57.2 - 73.5) (78.7 - 89.6) 68.3 80.1 Fast breathing 11.8 0.0151 (59.7 - 75.8) (73.1 - 85.7) Percentage of children age 2-59 months who were sick in two weeks preceding the survey 9 taken to a CCM-trained RCom as first source of care

RAcE Niger Endline Survey Final Report vi Baseline Endline % Point Indicator p-value % (CI %) % (CI %) change 0.1 75.5 Overall 75.4 0.0000 (0.0 - 0.8) (68.3 - 81.5) 0.3 77.1 Fever 76.8 0.0000 (0.0 - 2.2) (67.8 - 84.3) 75.7 Diarrhea 0.0 75.7 0.0000 (67.8 - 82.1) 73.6 Fast breathing 0.0 73.6 0.0000 (65.9 - 80.1) Sick child assessment Percentage of children age 2-59 months with 20.6 68.2 10 fever in the two weeks preceding the survey 47.6 0.0000 (14.4 - 28.7) (57.9 - 77.0) who had finger or heel stick Percentage of children age 2-59 months for whom their caregiver received the results of 78.9 84.6 11 the malaria diagnostic test of the children 5.7 0.2498 (67.3 - 87.1) (76.2 - 90.4) who had had finger or heel stick in the two weeks preceding the survey Percentage of children age 2-59 months with cough with difficult or fast breathing (suspected pneumonia) in the two weeks 53.5 52.4 12 -1.1 0.8541 preceding the survey who had their (45.5 - 61.4) (43.0 - 61.6) respiratory rate counted to assess fast breathing Sick child assessment by RCom Percentage of children age 2-59 months with fever in the two weeks preceding the survey 75.4 13 who had a finger or heel stick by an RCom 0** 75.4 0.0912 (64.3 - 83.9) among those who sought care from an RCom Percentage of children age 2-59 months for whom their caregiver received the results of the malaria diagnostic test of the children 87.7 14 0* 87.7 n/a who had a finger or heel stick by an RCom in (79.6 - 92.9) the two weeks preceding the survey among those who sought care from an RCom Percentage of children age 2-59 months with cough with difficult or fast breathing in the two weeks preceding the survey who had 63.8 15 0* 63.8 n/a their respiratory rate counted to assess fast (50.9 - 74.9) breathing by an RCom among those who sought care from an RCom Sick child treatment Percentage of children age 2-59 months who have been sick in two weeks preceding the survey who received appropriate treatment 37.0 59.4 Overall 22.4 0.0000 (32.1 - 42.2) (51.1 - 67.1) 16 79.6 73.4 Confirmed Malaria€ (ACT within 24 hours) -6.2 0.4135 (64.4 - 89.4) (61.2 - 82.8) 23.3 64.4 Diarrhea (ORS and zinc) 41.1 0.0000 (18.8 - 28.6) (55.5 - 72.4) Cough with difficult or fast breathing 44.6 46.2 1.6 0.7651 (amoxicillin) (36.5 - 52.9) (36.3 - 56.5) Percentage of children age 2-59 months who have been sick in the two weeks preceding 17 the survey who received appropriate treatment from a CCM-trained RCom

RAcE Niger Endline Survey Final Report vii Baseline Endline % Point Indicator p-value % (CI %) % (CI %) change 48.3 Overall 0 48.3 0.0000 (40.6 - 56.2) 71.0 Confirmed Malaria€ (ACT within 24 hours ) 0 71.0 0.0000 (58.5 - 81.0) 58.2 Diarrhea (ORS and zinc) 0 58.2 0.0000 (48.3 - 67.5) Cough with difficult or fast breathing 25.3 0 25.3 0.0000 (amoxicillin) (18.6 - 33.6) Percentage of children age 2-59 months who have been sick in the two weeks preceding the survey who received the first dose of treatment in the presence of an RCom among those who received prescription medicines for a CCM condition in the two weeks preceding the survey 55.0 18 Overall 0* 55.0 n/a (42.0 - 67.4) 57.3 Fever (ACT) 0* 57.3 n/a (40.6 - 72.5) 50.3 Diarrhea (ORS and zinc) 0* 50.3 n/a (37.9 - 62.7) Cough with difficult or fast breathing 60.3 0* 60.3 n/a (amoxicillin) (40.2 - 77.4) Percentage of sick children age 2-59 months for whom their caregivers received counseling on how to provide the

treatment(s) among those who received prescription medicines for a CCM condition in the two weeks preceding the survey 98.1 Overall 0* 98.1 n/a 19 (96.3 - 99.1) 98.9 Fever (ACT) 0* 98.9 n/a (92.0 - 99.9) 96.5 Diarrhea (ORS and zinc) 0* 96.5 n/a (92.9 - 98.3) Cough with difficult or fast breathing 0* 100 100.0 n/a (amoxicillin) Sick child referral and follow-up Percentage of sick children age 2-59 who were referred in the two weeks preceding the 91.4 20 0* 91.4 n/a survey whose caregiver adhered to referral (79.9 - 96.6) advice Percentage of sick children age 2-59 months receiving treatment from an RCom in the two 68.5 21 weeks preceding the survey who received a 0* 68.5 n/a (57.8 - 77.6) follow-up visit from an RCom according to country protocol *No cases **Fewer than 10 cases. € Fever with positive blood test

RAcE Niger Endline Survey Final Report viii 1 BACKGROUND

1.1 RAcE Program Goals and Objectives In 2013, the World Health Organization (WHO) launched the Rapid Access Expansion (RAcE) program in five sub-Saharan African countries—Democratic Republic of Congo, Malawi, Mozambique, Niger, and Nigeria. The goal of the program was to increase coverage of diagnostic, treatment, and referral services for malaria, pneumonia, and diarrhea to decrease overall mortality and the number of severe cases among children aged 2–59 months. The program would accomplish this goal through the following objectives:  Catalyze the scale-up of integrated community case management (iCCM) as an integral part of government-provided health services in sub-Saharan Africa.  Stimulate policy review and regulatory update in each country on disease case management.  Accelerate adaptation of supply management and surveillance systems to include services at the community level. This effort came at a time when there was great momentum for iCCM at the country level and a high degree of interest among the global health community to understand how to best measure success and how to build country ownership and capacity to sustain iCCM interventions.

1.2 World Vision Project Background World Vision, in collaboration with the Ministère de la Santé Publique (MSP, or Ministry of Health), implemented the RAcE project in four health districts in Niger— Boboye, Dogondoutchi, Dosso, and Keita—from July 2013 to September 2017, with a target population of children aged 2-59 months. The objective of the project is to use the iCCM approach by extending health care and treatment to households from health facilities to Case de Santé Intégré (CSI, or Health Hut) through trained community health volunteers, referred to as Relais Communautaire (RCom), based within the project area. The project will also strengthen the health system, supply chain management, and health information management. This project was implemented in accordance with the National iCCM Strategy developed in 2012, part of the larger National Child Survival Strategy that focuses on harmonizing interventions that promote healthy family practices in health, nutrition, hygiene, and sanitation at the community level. One of the objectives of the MSP and RAcE strategy is to ensure that the implementation of primary health care involves community participation as a means of empowering communities in support of their health problems. The areas of the four districts in which RAcE was implemented have a total population of 1,872,929, including an estimated 414,079 children aged 2-59 months. MSP, together with WHO and World Vision, selected Boboye, Dogondoutchi, Dosso, and Keita as RAcE project areas due to high incidence rates of malaria, diarrhea, and pneumonia. Targeted areas are those that are iCCM eligible, meaning that they are villages located at least five km from a health facility, have limited number of staff at the health facilities, have insufficient access and treatment options due to lack of trained health workers, and have limited

RAcE Niger Endline Survey Final Report 1 equipment to provide adequate care. A total of 1,227 RComs were actively providing iCCM services in all four health districts at the time of the endline survey. A baseline survey was conducted from August 26 to September 18, 2013 by World Vision and ADESEN-NAFA, a local nongovernmental organization, and with technical support from ICF. The baseline survey was administered in three steps, including two preparatory phases: training of the coordinating team took place from August 26 to 29, followed by training of the supervisors and enumerators from September 1 to 6. The field data collection was conducted over a 10-day period from September 9 to September 18 in sampled households in the project area.

1.3 World Vision Endline Survey Objectives The objective of the RAcE endline household survey was to assess care-seeking behavior for sick children, iCCM coverage, and caregiver knowledge, attitudes, and practices related to pneumonia, diarrhea, and malaria in the RAcE Niger intervention areas. We compared baseline and endline data to assess changes in sick child care-seeking, assessment, and treatment coverage as well as caregivers’ knowledge of childhood illnesses and perceptions of RCom services, and used the information to make inferences about project accomplishments.

RAcE Niger Endline Survey Final Report 2 2 SURVEY METHODS

2.1 Survey Implementation and Partnership World Vision, in collaboration with the MSP Division de la Statistique (Statistical Division), conducted the RAcE endline survey, with technical assistance from ICF, and l’Institute National de la Statistique (INS, or National Institute of Statistics). World Vision and Division de la Statistique worked with ICF to finalize the questionnaire, led the training of enumerators and supervisors, and provided oversight of the survey implementation. INS, together with World Vision, conducted the training on mobile data collection and prepared data for analysis by ICF. The survey protocol received ethical approval from ICF’s Institutional Review Board and administrative approval from MSP. Annex A contains a complete list of the people involved in the survey and their roles.

2.2 Survey Design This was a cross-sectional cluster-based household survey, targeting primary caregivers of children aged 2-59 months who had recently been sick with diarrhea, fever, or cough with fast breathing. All primary caregivers of children aged 2-59 months reported to have experienced diarrhea, fever, or cough with fast breathing in the two weeks prior to the interview were considered eligible for inclusion in the survey. ICF developed standardized sampling guidance for all RAcE projects, which was adapted for World Vision Niger. To be able to detect a 20 percent difference at 90 percent power with a two-tailed test and 95 percent confidence using cluster sampling, 263 cases were needed for each disease. ICF rounded up to 300 cases to ensure a consistent number of interviews per cluster and a slight increase in the precision of the coverage estimates. The Niger household survey used a 30x30 multi-stage cluster sampling methodology. At baseline, the RAcE project area, iCCM-eligible areas—more than five km from a health facility—comprised the target population in Boboye, Dogondoutchi, Dosso, and Keita. At baseline, 30 clusters were selected using probability proportional to size (PPS). The baseline survey was conducted prior to training and equipping RCom to provide iCCM services. The same clusters sampled at baseline were planned to be sampled at endline. However, nearly the full baseline sample had to be re-selected because they were not active RAcE project areas. RComs had been recruited to provide services in all of the baseline clusters, but in 21 of the baseline clusters RAcE interventions were never implemented1. The sampling frame was updated accordingly and 21 replacement clusters were selected using PPS. Annex B contains the endline sample with the complete list of clusters and communities.

1 World Vision reported that RCom recruited in these areas either did not show up for training or did not pass the test qualifying them to provide iCCM services.

RAcE Niger Endline Survey Final Report 3 Within each cluster, 10 interviews were conducted for each of the three illness modules—diarrhea, fever, and fast breathing—for a total of 30 interviews per cluster, or 300 interviews per each illness across the project area. Within each cluster, the survey team randomly selected the first household for interview and proceeded to the household with its front door nearest to the front door of the current household until the team conducted 10 interviews for each illness. Because two communities visited did not have 10 cases of each illness, interviewers went to the nearest community of the nearest cluster to complete the questionnaires of 10 cases per illness. See Annex C for the detailed sampling design. At each household, the interviewer first determined if an eligible child lived there. An eligible child was aged 2-59 months and had been sick with diarrhea, fever, cough with rapid breathing, or any combination of the three illnesses in the two weeks preceding the survey. If there was an eligible child in the household, the interviewer administered the questionnaire, including all applicable illness modules, to the caregiver of the eligible child. If more than one child was eligible, and they were sick with different illnesses, their caregiver was asked about each instance of illness. If there was more than one eligible child in the household for an illness, the interviewer randomly selected one of the eligible children and interviewed his or her caregiver.

2.3 Survey Questionnaire ICF developed a standard questionnaire for all RAcE grantees to use for their surveys. World Vision worked with ICF to adapt the questionnaire to fit the Niger iCCM program and country context. This included including appropriate terminology for community health workers in Niger, care-seeking locations, and treatment options. The survey questionnaire contains seven modules: caregiver and household background information; caregivers’ knowledge of iCCM activities in their community; caregivers’ knowledge of childhood illness danger signs; household decision-making; and a module for each major childhood illness: fever, diarrhea, and fast breathing. In addition to collecting information about caregiver knowledge, care-seeking, and treatment coverage, the questionnaire collects standard Demographic and Health Survey data on household ownership of selected assets, materials used for housing construction, and types of water access and sanitation facilities, which ICF will analyze and use for the final evaluation. The endline survey questionnaire is approximately 30 pages in length. ICF had the questionnaire professionally translated into French, after which it was reviewed by WHO Niger and World Vision Niger prior to being fielded. However, prior to data collection, World Vision decided to use a mobile data collection program (Open Data Kit [ODK]) instead of the paper questionnaire because mobile data collection was used at baseline. With the help of Division de la Statistique, a programmer from INS programmed the mobile devices. This late decision left a short timeframe for developing the mobile program and did not provide time for ICF to review the program prior to fielding. Pretesting of the mobile questionnaire took place in Dosso in RAcE villages that were not part of the survey sample. The pretest was conducted on October 22, directly following the enumerator and supervisor training. The questionnaire was fielded in the local languages, using verbal translation by enumerators. A debriefing session was held with all coordinators, supervisors, and interviewers to discuss their pretesting experiences and identify and address problems with preparedness, field procedures, and instruments. Adjustments to the mobile questionnaire to resolve some of the missing

RAcE Niger Endline Survey Final Report 4 items in a handful of the devices were made by the INS programmer immediately after pretesting, which took a considerable amount of time. Thus, the start of data collection was postponed for a few days to update the program. Questions and the structure of the questionnaire were not changed from the paper version. The survey questionnaire is provided in Annex D.

2.4 Selection and Training of Survey Staff Selection and recruitment of enumerators and supervisors was done by the MSP Division de la Statistique; participants with the strongest technical and leadership skills were selected to be supervisors. The enumerators were selected by their skill set and their previous experience in data collection. Many of the enumerators and supervisors who were recruited for the endline survey had also taken part in the baseline survey. World Vision, together with ICF, the MSP Division de la Statistique, and INS facilitated the training of enumerators and supervisors that took place in Niamey from October 17 to 21. The five-day training covered the following:  Overview of the RAcE project goals and objectives  Objectives of the endline survey  Review of methodology, sampling, and respondent selection  Roles and responsibilities of interviewers, supervisors, and all others in the study; rules; behaviors and ethics  Detailed review of the use of mobile data collection tablets  Question by question review of the household questionnaire  Group practices, mock interviews, and role playing The survey training schedule is provided in Annex E.

2.5 Data Collection Endline survey data collection took place from October 27 to November 6 in Boboye, Dosso, and Keita, lasting approximately 10 days. The data collection team members included four coordinators and eight teams consisting of one supervisor and three enumerators. Data collection was done using the mobile program on tablets. The fieldwork schedule is provided in Annex F. Verbal informed consent was obtained from each caregiver prior to the start of the interview. Respondents were not compensated for their time away from income-earning activities or daily duties for participating in the data collection. The average length of the interview was approximately one hour per respondent. Quality control procedures during fieldwork included quality control checks by supervisors throughout the data collection process. This was done by observing interviews and going back to the households to re-interview at least 10 of the interviews to ensure quality and validity. The supervisor also oversaw correction of all errors that were detected while in the field and discussed the issues with the

RAcE Niger Endline Survey Final Report 5 enumerators before the team left the community. The supervisor edited any errors in the questionnaire to the best of his or her knowledge. Administering the questionnaire using tablets removed the data entry step, which greatly helped in ensuring the availability of data in real time.

2.6 Data Entry and Management The endline data were collected using tablets with the ODK mobile program and downloaded to a cloud data storage at INS. INS was responsible for housing the data, and together with the MSP Division de la Statistique, was responsible for cleaning and preparing the data for ICF to conduct analysis. During the baseline survey, the data were stored in World Vision Canada’s data cloud and were cleaned in Niger for analysis. Names of participants were collected only for purposes of listing and were not used during any stage of data analysis. Data entered cannot be traced back to the individuals. Access to data was restricted to authorized personnel only. After data for all clusters were validated, INS stripped the final dataset of any identifying information and shared it with ICF for analysis. However, ICF did not receive a clean dataset. After repeated requests for cleaned data from INS, ICF continued to find inconsistencies and inaccuracies with the final survey dataset sent by INS.

2.7 Data Analysis After a lengthy process of trying to obtain a clean dataset from INS, ICF did intensive data cleaning. ICF analyzed the survey data using Stata v14 and Microsoft Excel. The ICF analyst imported the Excel and Stata files sent by INS into a single, merged Stata file. The ICF analyst checked the endline data file for missing values. A list of missing data was sent to INS for corrected files, including the child roster file and missing location information in the caregiver file. There were also duplicate entries in the fever, diarrhea, and caregiver modules. A detailed explanation of the data cleaning and analysis process, including how missing values were handled, is provided in Annex G. Before analyzing the endline data, the ICF analyst had to redo the analysis of the baseline data; the baseline analysis that World Vision conducted did not account for cluster effects and did not include confidence intervals around the point estimates. Redoing the baseline analysis also allowed ICF to append the baseline and endline data files and calculate changes between the baseline and endline surveys. However, the results generated in World Vision’s initial analysis are different from those that ICF generated. World Vision was unable to share a file that detailed the data cleaning that took place. Thus, ICF excluded records that did not include cluster information and records that contained fewer than 6 of 10 completed modules. The baseline data files required a substantial amount of cleaning before they could be merged and appended to the endline dataset. Household number fields in the various modules had to be cleaned, dropping duplicates (for example, in several cases, the household number was missing or differed for the same parent record). There was no cluster variable in any of the data files. Therefore, the ICF analyst performed the following steps:

RAcE Niger Endline Survey Final Report 6  Used text fields (community and other_placename) that interviewers manually filled to generate a cluster variable; ensured that each community name was spelled the same way in all records.  Inferred six missing community names from dates, times, interviewer name, and information in other entries.  Dropped 17 records; 3 records had community names that could not be matched to any of the clusters, and 14 records were missing community information.  Encoded community names to produce a cluster number for each of the 30 communities.  Added the cluster variable to all records as the modules were merged into one baseline data file.  Dropped 13 records from the dataset that did not include at least one completed sick child module.  Dropped 144 records that had fewer than 6 completed modules out of 10. The ICF analyst did not verify or clean the child roster file; however, the analyst was able to pull age, sex, and two-week illness history for most of the sick child records. Roster information was missing for between 45 and 60 children, depending on the indicator. All variables were then recoded so that their names and values aligned with the names and values of the variables in the endline dataset. The cleaned baseline dataset was then appended to the cleaned endline dataset for analysis. The ICF analyst calculated survey indicator point estimates and 95 percent confidence intervals accounting for cluster effects, and used Pearson’s chi-squared test to determine statistical significance for binary and categorical variables and regression for continuous variables. We considered indicators with p-values less than 0.05 to show a statistically significant change between baseline and endline. Endline data are displayed disaggregated by child’s sex and illness. For the comparison of indicators between baseline and endline, we only disaggregated data by sex if we found the differences between males and females to be statistically significant.

2.8 Survey Indicators The survey collected data on 18 key indicators related to caregiver knowledge of RComs and child illnesses; caregiver perceptions of RComs; and sick child care-seeking, assessment, treatment, referral adherence, and follow-up. The survey also collected information on household and caregiver characteristics and household decision-making. Annex H contains a complete list of indicators and their definitions.

2.9 Survey Limitations The data collection team reported limitations in the ODK application. Since the mobile phones were verified twice before going to the field, it is feared that, once in the field, some data collectors may have deleted modules by mistake. These modules were, however, re-uploaded in the field. The other major issue was that the modules were not systematically linked, making it easy to skip an entire module without realizing it if a data collector was not paying adequate attention. This may explain some of the missing data, an issue identified during data analysis. The survey provides estimates for the RAcE project area as a whole. The survey was not powered to provide district-level estimates. Additionally, there are known potential biases and limitations with the

RAcE Niger Endline Survey Final Report 7 indicators that assess caregiver recall of malaria diagnostic testing and coverage of appropriate treatment for children with fever and cough with difficult or fast breathing. The potential biases and limitations of these indicators are further detailed in the findings section.

3 FINDINGS

3.1 Characteristics of Sick Children and Caregivers The endline survey collected data on a total of 889 cases of illness among children aged 2-59 months. Table 2 illustrates characteristics of the children experiencing cases of illness in the two weeks prior to the survey. Of the cases of illness, 54.7 percent were among male children, and 45 percent were among female children. The largest age group represented in the survey were children aged 12-23 months (24 percent), followed by children aged 2-11 months and aged 48-59 months (both at about 21 percent). In the baseline survey, 52 percent of sick child cases were among males, and 48 percent were among females. The largest age group during baseline was children aged 12-23 months (23 percent), followed by children aged 24-35 months (21 percent). Of the cases of illness among children aged 2-59 months who were sick in the two weeks preceding the endline survey, 82 percent had fever, 78 percent had diarrhea, and 44.5 percent had cough with difficult or fast breathing. The characteristics of caregivers are shown in Table 3. A total of 489 caregivers were surveyed at endline.

Table 2. Characteristics of sick children included in survey Baseline Endline Characteristic* % (CI %) % (CI %) Sex of sick children included in survey 51.6 54.7 Male, % (47.2 -56.0) (47.2 - 62.0) 48.4 45.3 Female, % (44.0 - 52.9) (38.0 - 52.8) Age (months) of sick children included in survey 19.2 20.7 2-11, % (15.5 - 23.6) (17.0 - 25.0) 23.1 23.8 12-23, % (19.1 - 27.8) (18.9 - 29.5) 20.5 17.2 24-35, % (16.4 - 25.2) (14.2 - 20.8) 19.2 17.8 36-47, % (16.2 - 22.7) (14.1 - 22.3) 18.0 20.5 48-59, % (15.3 - 21.0) (16.4 - 25.3) Two week history of illness of children included in survey 75.5 82.4 Had fever, % (70.2 - 80.1) (79.0 - 85.3) 61.0 78.3 Had diarrhea, % (56.4 - 65.4) (74.5 - 81.6) Had cough with difficult or 56.3 44.5 fast breathing, % (51.1 - 61.3) (37.7 - 51.4)

RAcE Niger Endline Survey Final Report 8 Average number of 1.9 2.1 illnesses, N Total number of sick children 605 489 included in survey Cases of illness included in survey Fever, N 344 305 Diarrhea, N 339 292 Cough with difficult or fast 312 292 breathing, N Total number of sick child cases 995 889 included in survey * Missing sex for 45 children at baseline and 1 child at endline; missing age for 43 children at baseline and 1 child at endline; missing fever 2-week history for 46 children at baseline and 1 child at endline; missing diarrhea 2-week history for 54 children at baseline and 1 child at endline; missing cough with difficult or fast breathing 2-week history for 56 children at baseline and 1 child at endline. Table 3. Caregiver characteristics Baseline Endline Characteristic % (CI %) % (CI %) Age (years)* 31.6 31.4 15-24 (26.5 - 37.3) (27.6 - 35.5) 43.8 42.8 25-34 (38.2 - 49.6) (38.3 - 47.4) 18.1 19.1 35-44 (14.4 - 22.5) (15.2 - 23.8) 6.5 6.7 45-60 (4.5 - 9.2) (4.6 - 9.6) Mean age (years) 29.0 28.8 Education* 86.8 85.7 None (82.4 - 90.3) (77.2 - 91.3) 9.0 10.0 Primary, ≤ year 4 (6.0 - 13.3) (5.9 - 16.3) 2.4 4.4 Primary, ≥ year 5 (1.1 - 5.0) (2.3 - 8.1) 1.8 0.0 Secondary or higher (0.8 - 4.0) (0.0 - 0.0) Marital status* Currently married or living 93.4 97.6 with partner (89.2 - 96.0) (95.3 - 98.8) Not married but living with a 1.6 0.2 partner (0.5 - 5.3) (0.0 - 1.7) 5.1 2.2 Not in union (3.3 - 7.9) (1.0 - 4.5) Partner living with caregiver (among those in union)** 79.8 92.2 Yes (73.9 - 84.7) (87.5 - 95.2) Total number of caregivers 512 489 *Missing age and education for 3 caregivers at baseline and 7 caregivers at endline; missing marital status for 2 caregivers at baseline and 28 caregivers at endline **486 caregivers in a union at baseline, and 450 caregivers in a union at endline

Table 4 shows the results for reported distance and mode of transportation to the nearest health facility. It is important to note that even though baseline data were collected for these indicators, there were a number of missing data. Similarly, there were a lot of missing responses at endline. Therefore,

RAcE Niger Endline Survey Final Report 9 these data should be interpreted with caution. Please see below the table for notes on specific missing information.

Table 4. Reported distance and mode of transport to nearest health facility

Baseline Endline % (CI%) % (CI%) Distance to nearest facility 24.2 < 5 km N/A (14.2 - 38.3) 49.8 5 - 9 km N/A (37.0 - 62.7) 20.3 N/A 10 - 19 km (12.4 - 31.4) 5.7 ≥ 20 km N/A (2.5 - 12.6) Mean distance to nearest facility N/A 7.8 km Number of caregivers N/A 458 Mode of transport 86.1 68.3 Walk (79.2 - 91.0) (60.5 - 75.2) 11.0 29.1 Motorbike/taxi/bus (7.1 - 16.6) (22.0 - 37.4) 2.9 2.6 Other (1.1 - 7.8) (0.5 - 13.3) Number of caregivers 510 457 Time to nearest facility (among those who go to the facility) 46.2 32.8 < 30 minutes (34.7 - 58.1) (24.6 - 42.3) 23.0 22.0 30 – 59 minutes (16.7 - 30.8) (16.2 - 29.2) 23.2 33.3 1 – < 2 hours (16.1 - 32.2) (23.9 - 44.1) 5.5 4.6 2 – < 3 hours (2.4 - 12.2) (2.6 - 8.1) 2.2 7.3 3 hours or more (0.9 - 5.4) (3.9 - 13.1) Mean time to nearest facility 40 minutes 55 minutes Total number of caregivers 509 454 *Missing distance to nearest facility for 31 caregivers at endline; the baseline data did not make sense so this indicator was not calculated. Missing mode of transport for 1 caregiver at baseline and 31 caregivers at endline; additionally, 1 caregiver in each survey stated that he or she does not go to the health facility. Missing time to nearest facility for 1 caregiver at baseline and 2 caregivers at endline. **The indicator for baseline was not calculated because the data do not make sense.

3.2 Decision-making As shown in Table 5, at endline, among caregivers who sought care for their child aged 2-59 months who had been sick in the two weeks before the survey, 62 percent made the decision to seek care jointly with their spouse or partner. This joint careseeking increased significantly from baseline (p<0.05).

Table 5. Joint decision-making to seek care for sick child by illness Decided to seek care jointly with partner Baseline Endline Illness p-value Baseline Endline N N % (CI %) % (CI %) 49.8 62.0 Overall 0.0161 813 753 (42.8 - 56.8) (54.0 - 69.4)

RAcE Niger Endline Survey Final Report 10 51.5 62.8 Fever 0.0305 274 250 (44.0 - 58.8) (53.5 - 71.2) 47.7 63.4 Diarrhea 0.0055 283 251 (39.6 - 55.9) (54.4 - 71.5) Cough with difficult or fast 50.4 59.9 0.1330 256 252 breathing (41.8 - 59.0) (51.3 - 68.0) * Missing information for caregivers of children with diarrhea with for 6 caregivers at baseline and 7 caregivers at endline; missing information for caregivers of children with fever with for 2 caregivers at baseline.

3.3 Caregiver Knowledge and Perception of iCCM RComs There was no significant change observed in caregiver knowledge of childhood illnesses over the course of the project. Caregivers’ knowledge and perceptions of RCom increased significantly over the course of the project, as expected, given that RCom were trained and deployed to provide iCCM services after the baseline survey was implemented. The percentage of caregivers who know the RCom who works in their community significantly increased, from 1 percent at baseline to 99.8 percent at endline (p<0.001). Of caregivers who reported knowing of an RCom in their community, the percentage who knew at least two curative services provided by an RCom was 77 percent at endline. Of the activities that RComs perform in their communities, caregivers most noted that RCom provide treatment for malaria (73 percent), malaria testing (64 percent), and oral rehydration solution (ORS) treatment for diarrhea (60 percent). At endline, caregiver’s trust in RCom was nearly universal. At endline 99 percent of caregivers viewed RCom as trusted health providers, and 98 percent believe RCom provide quality services.

Table 6. Caregiver knowledge of childhood illnesses

Baseline Endline Caregiver knowledge p-value % (CI %) % (CI %) 75.8 81.1 Knows 2+ child illness signs 0.1412 (70.3 - 80.5) (75.9 - 85.3) 89.9 84.8 Knows cause of malaria 0.1417 (85.5 - 93.0) (78.0 - 89.8) 85.7 79.4 Knows fever is a sign of malaria 0.1454 (80.6 - 89.6) (72.9 - 84.7) 60.8 58.6 Knows malaria treatment 0.7446 (52.8 - 68.3) (47.1 - 69.3) Total number of caregivers 503 481

Table 7. Caregiver knowledge of RCom Baseline Endline Caregiver knowledge p-value % (CI %) % (CI %) Knows CCM-trained RCom works in 1.0 99.8 0.0000 community (0.3 - 3.2) (98.3 - 100.0) Total number of caregivers 511 457 40.0 77.4 Knows 2+ RCom curative services* 0.0425 (10.2 - 79.6) (70.0 - 83.4) Total number of caregivers 5 456 *Only asked of caregivers who stated that there was a CCM-trained RCom in their community

RAcE Niger Endline Survey Final Report 11

Table 8. Caregiver perceptions of iCCM RComs Baseline Endline Caregiver perceptions p-value % (CI %) % (CI %) 20.0 98.5 View CCM-trained RComs as trusted health care providers 0.0000 (1.9 - 76.2) (95.6 - 99.5) 20.0 97.6 Believe CCM-trained RComs provide quality services 0.0000 (1.9 - 76.2) (95.1 - 98.8) Found the CCM-trained RCom at first visit (for all instances of 73.9 N/A N/A care-seeking included in survey)* (67.4 - 79.5) 60.0 87.9 Cite the CCM-trained RCom as a convenient source of treatment 0.0594 (20.4 - 89.8) (80.8 - 92.7) Total number of caregivers 5 456 N/A=not available * Denominator is 406 caregivers at endline—only those who sought care from an RCom for at least one sick child are included. Response missing for one caregiver who reportedly sought care from an RCom at baseline.

3.4 Care-Seeking Careseeking from an appropriate provider was high at baseline (68 percent) and remained high at endline (85 percent). As expected following the extension of health services to the communities via RCom, care-seeking from RComs was high at endline; of cases of illness among children 2-59 months who sought care from an appropriate provider, 88 percent of those sought care from an RCom The percentage of cases of illness among children aged 2-59 months taken to an RCom as the first source of care increased significantly (p<0.001), from 0.1 percent at baseline to 75 percent at endline. Looking at the sources of care sought, findings show a significant shift from public facility to RComs over the course of the project. Caregivers sought care at public facilities more at baseline (93 percent) than at endline (15 percent). However, caregivers have shifted to RComs as the source where most sought care, from 0.1 percent at baseline to 91 percent at endline. At endline, of cases of illness among children 2-59 months who sought care from an appropriate provider in the two weeks prior the survey, only 9 percent sought care from a source other than the RCom. Tables 9-12 illustrate the results of care-seeking behavior throughout the project timeframe.

Table 9. Source of care by illness Sought care from RCom was first source of appropriate provider* care Baseline Endline Illness p-value p-value Baseline Endline Baseline Endline N N % (CI %) % (CI %) % (CI %) % (CI %) 68.8 84.7 0.1 75.5 Overall 0.0002 0.0000 995 889 (62.0 - 75.0) (79.2 - 89.0) (0.0 - 0.8) (68.3 - 81.5) 72.4 88.9 0.3 77.1 Fever 0.0001 0.0000 344 305 (65.7 - 78.2) (82.0 - 93.3) (0.0 - 2.2) (67.8 - 84.3) 65.8 84.9 75.7 Diarrhea 0.0005 0.0 0.0000 339 292 (57.2 - 73.5) (78.7 - 89.6) (67.8 - 82.1) Cough with difficult or 68.3 80.1 73.6 0.0151 0.0 0.0000 312 292 fast (59.7 - 75.8) (73.1 - 85.7) (65.9 - 80.1) breathing * Appropriate providers include national, regional, or district hospitals; integrated health center; RCom; health hut and mobile or private clinics.

RAcE Niger Endline Survey Final Report 12 Table 10. Care-seeking from RCom RCom was first source of care among those who sought any care Illness p-value Baseline N Endline N Baseline Endline % (CI %) % (CI %) 0.1 87.7 Overall 0.0000 736 762 (0.0 - 1.0) (81.2 - 92.1) 0.4 85.6 Fever 0.0000 264 270 (0.1 - 2.8) (77.7 - 91.0) 86.7 Diarrhea 0.0 0.0000 240 256 (79.5 - 91.7) Cough with difficult or 91.1 0.0 0.0000 232 236 fast breathing (84.7 - 95.0)

Table 11. Cases of illness for which no care was sought Sought care but not Did not seek care p-value from RCom p-value Illness Baseline Endline Baseline Endline % (CI %) % (CI %) % (CI %) % (CI %) 26.0 14.0 99.9 9.0 Overall 0.0021 0.0000 (20.1 - 33.0) (10.2 - 18.9) (99.0 - 100.0) (5.2 - 15.2) 23.3 10.2 99.6 9.5 Fever 0.0011 0.0000 (17.7 - 29.9) (6.2 - 16.3) (97.2 - 100.0) (5.2 - 16.6) 29.2 12.7 9.8 Diarrhea 0.0006 100 0.0000 (22.1 - 37.5) (9.0 - 17.5) (5.7 - 16.3) Cough with difficult or 25.6 19.2 7.6 0.1896 100 0.0000 fast breathing (18.4 - 34.6) (13.8 - 26.1) (4.0 - 13.9) Total number of sick 995 889 736 765 child cases

Table 12. Sources of care and first source of care Source of Care First Source Location Baseline Endline Baseline Endline % (CI %) % (CI %) % (CI %) % (CI %) 92.9 15.0 85.2 8.0 Public facility (89.7 - 95.2) (9.0 - 24.1) (80.6 - 88.9) (4.4 - 14.2) 0.3 0.3 Private clinic 0.0 0.0 (0.1 - 1.1) (0.1 - 1.1) 0.1 91.0 0.1 87.7 RCom (0.0 - 1.0) (84.8 - 94.8) (0.0 - 1.0) (81.2 - 92.1) 2.6 0.7 2.2 0.5 Store, pharmacy, or market (1.2 - 5.4) (0.2 - 1.9) (0.9 - 5.2) (0.2 - 1.8) 1.2 0.4 1.2 0.1 Traditional practitioner (0.5 - 2.7) (0.1 - 1.3) (0.5 - 2.7) (0.0 - 1.0) 9.2 0.9 5.3 1.2 Other (5.9 - 14.2) (0.4 - 2.1) (3.4 - 8.2) (0.6 - 2.3) Total number of sick child cases 736 765 736 765

3.5 Assessment Caregiver recall of malaria diagnostic testing is poor, which could affect the malaria diagnosis and appropriate treatment indicators calculated. According to the Indicator Guide: Monitoring and Evaluating Integrated Community Case Management, “Studies have found poor sensitivity and specificity of maternal recall for malaria diagnostic tests (finger/heel stick). Consequently, the current

RAcE Niger Endline Survey Final Report 13 recommendation is that household surveys track treatment coverage of fever and, where possible, supplement with data from service delivery assessment to better understand the proportion of suspected malaria cases that receive appropriate diagnosis and treatment.”2 Results show a significant increase in the assessment of cases of fever among children aged 2-59 months by any provider from 21 percent at baseline to 68 percent at endline (p<0.001). At baseline iCCM services had not yet been rolled out to communities and no RCom administered RDTs to assess cases of fever. At endline, 75 percent of the cases of fever among children 2-59 months that were assessed by an RCom in the two weeks prior the survey were administered an RDT. The shift in care-seeking is similarly reflected in shifts in provider assessments. At endline, 90 percent of the cases of fever among children 2-59 months that were assessed by any provider were assessed by a RCom; 9 percent by nurses; and 0 percent by doctors or medical assistants. These results are likely due to the accessibility and presence of the RComs in the villages.

Table 13. Malaria assessment among children with fever Cases managed by RCom All cases Fever assessment Baseline Endline p-value Baseline Endline p-value % (CI %) % (CI %) % (CI %) % (CI %) 75.4 20.6 68.2 Child had blood drawn 0.0 0.0912 0.0000 (64.3 - 83.9) (14.4 - 28.7) (57.9 - 77.0) Caregiver received result 87.7 78.9 84.6 N/A 0.2498 of blood test (79.6 - 92.9) (67.3 - 87.1) (76.2 - 90.4) Blood test positive for 95.7 96.4 96.0 N/A 0.8997 malaria (90.4 - 98.2) (85.1 - 99.2) (91.1 - 98.3) Received ACT* after positive blood test, among 25.3 94.4 85.8 N/A 0.0535 those who had a positive (18.6 - 33.6) (85.0 - 98.1) (77.6 - 91.3) blood test Total number of fever 1 248 344 305 cases ACT=artemisinin-based combination therapy N/A=not available * Malaria treatment (ACT Coartem and Artesun Amodiaquine)

Table 14. Fast breathing assessment Cases managed by RCom All cases Respiratory rate Baseline Endline Baseline Endline p-value assessment %(CI %) %(CI %) %(CI %) %(CI %) 63.8 53.5 52.4 Respiratory rate assessed N/A 0.8541 (50.9 - 74.9) (45.5 - 61.4) (43.0 - 61.6) Total number of cough with difficult or fast breathing 0 218 312 292 cases N/A=not available

2 The Maternal and Child Health Integrated Program (MCHIP). Indicator Guide: Monitoring and Evaluating Integrated Community Case Management, July 2013.

RAcE Niger Endline Survey Final Report 14 3.6 Treatment Coverage The overall percentage of illnesses receiving appropriate treatment increased significantly over the course of the project, from 37 percent at baseline to 59 percent at endline (p<0.001). The largest increase observed was for the appropriate treatment for diarrhea, which increased from 23 percent at baseline to 64 percent at endline (p<0.001). At endline, the percentage of cases of illness among children aged 2-59 months who received appropriate treatment from an RCom was 48 percent. Among those who sought care from an RCom, 58 percent received appropriate treatment. Despite the overall increase in appropriate treatment from any provider, the percentage of cases receiving appropriate treatment is low (overall, and from RCom). Appropriate treatment provided by RCom, among cases who sought care from RCom, varied by illness. At endline, 73 percent of confirmed malaria cases were provided with artemisinin-based combination therapy (ACT) within the same or next day, 71 percent of cases with diarrhea received appropriate treatment of ORS and zinc, and 34 percent of cases of cough with difficult or fast breathing received treatment with amoxicillin. Treatment of cough with difficult or fast breathing must be interpreted carefully. Pneumonia treatment, for which this indicator is a proxy, is globally recognized to have validity issues3 because diagnosis of presumptive pneumonia is often inaccurate in comparison with clinical diagnosis of pneumonia at health facilities. Therefore, the number of cases of cough with difficult or fast breathing is likely an overestimate of actual clinical pneumonia cases, and the percentage of these treated with amoxicillin can, and should, reasonably not be 100 percent. It is important to note that at baseline zero illness cases received treatment from an RCom; this is expected because iCCM had not yet been rolled out to communities. For one fever case at baseline, a caregiver sought care from an RCom but received treatment from a CSI.

Table 15. Treatment coverage Received appropriate Received appropriate Condition treatment from RCom treatment Baseline Endline p-value p-value (treatment) Baseline Endline Baseline Endline N N % (CI %) % (CI %) % (CI %) % (CI %) 48.3 37.0 59.4 Overall* 0 0.0000 0.0000 705 753 (40.6 - 56.2) (32.1 - 42.2) (51.1 - 67.1) Confirmed 78.7 94.4 85.8 0 0.0000 0.0535 54 169 malaria (ACT)** (68.6 - 86.2) (85.0 - 98.1) (77.6 - 91.3) Confirmed malaria (ACT 71.0 79.6 73.4 0 0.0000 0.4135 54 169 within same or (58.5 - 81.0) (64.4 - 89.4) (61.2 - 82.8) next day)** Diarrhea (ORS 58.2 23.3 64.4 0 0.0000 0.0000 339 292 and zinc) (48.3 - 67.5) (18.8 - 28.6) (55.5 - 72.4) Cough with difficult or fast 25.3 44.6 46.2 0 0.0000 0.7651 312 292 breathing (18.6 - 33.6) (36.5 - 52.9) (36.3 - 56.5) (amoxicillin) *Calculated for confirmed malaria (ACT within 24 hours), diarrhea (ORS and zinc), and cough with fast breathing (amoxicillin) **Calculated among fever cases with a positive blood test result; malaria treatment (ACT Coartem and Asucam)

3 Campbell H, el Arifeen S, Hazir T, O'Kelly J, Bryce J, Rudan I, et al. (2013) Measuring Coverage in MNCH: Challenges in Monitoring the Proportion of Young Children with Pneumonia Who Receive Antibiotic Treatment. PLoS Med 10(5): e1001421. doi:10.1371/journal.pmed.1001421

RAcE Niger Endline Survey Final Report 15 Table 16. Treatment coverage among those who sought care from RCom Received appropriate treatment from RCom among those who sought care from Condition (treatment) RCom p-value Baseline N Endline N Baseline Endline % (CI %) % (CI %) 58.3 Overall* N/A N/A N/A 611 (50.8 - 65.4) Confirmed malaria (ACT within 73.0 N/A N/A N/A 163 same or next day)** (60.3 - 82.8) 70.9 Diarrhea (ORS and zinc) N/A N/A N/A 230 (61.0 - 79.1) Cough with difficult or fast 33.9 N/A N/A N/A 218 breathing (amoxicillin) (25.7 - 43.3) N/A=not available * Calculated for confirmed malaria (ACT within 24 hours), diarrhea (ORS and zinc), and cough with difficult or fast breathing (amoxicillin) ** Calculated among fever cases with a positive blood test result *** Malaria treatment (ACT Coartem and Asucam) The results for continued fluids and feeding during illness in Table 17 show that overall, provision of continued fluids during an episode of illness did not change over the project timeframe, although continued feeding during an episode of illness increased significantly (p<0.05), from 11 percent at baseline to 20 percent at endline. There were significant increases in continued feeding for cases of fever and cases of cough with difficult or fast breathing among children aged 2-59 months. Continued feeding for cases of fever increased significantly, from 7 percent at baseline to 17 percent at endline, and continued feeding for cough with difficult or fast breathing increased from 11 percent at baseline to 22 percent at endline. Notably, there was no significant change in continued feeding for cases of diarrhea among children 2-59 months; the proportion of these cases that had continued feeding remained low over the course of the project.

Table 17. Continued fluids and feeding during illness Continued fluids Continued feeding Baseline Endline Illness Baseline Endline p-value Baseline Endline p-value N N % (CI %) % (CI %) % (CI %) % (CI %) 36.1 41.6 11.4 20.4 Overall 0.2709 0.0079 995 889 (31.4 - 41.1) (34.3 - 49.3) (8.8 - 14.5) (15.0 - 27.0) 33.7 40.7 7.0 17.4 Fever 0.2472 0.0082 344 305 (27.1 - 41.1) (32.8 - 49.1) (4.4 - 10.8) (11.8 - 24.9) 16.5 44.7 50.7 22.3 Diarrhea 0.2679 (12.6 - 0.1501 339 292 (38.8 - 50.7) (42.2 - 59.1) (16.2 - 29.8) 21.3) Cough with 29.5 33.6 10.6 21.6 difficult or fast 0.4498 0.0139 312 292 (24.0 - 35.7) (25.8 - 42.3) (7.1 - 15.6) (15.1 - 29.9) breathing * Missing one response for continued fluids during an episode of diarrhea

3.7 First Dose of Treatment and Counseling from RCom According iCCM treatment protocols, RComs must provide the first dose of treatment and counsel caregivers on how to administer treatment to their sick child. Findings from the endline survey show that a little more than half of the cases treated by the RCom received the first dose of the treatment in

RAcE Niger Endline Survey Final Report 16 the presence of the RCom and that 98 percent of caregivers were counseled by the RCom on treatment administration.

Table 18. First dose of treatment from RCom

First Dose Received in Presence of RCom Baseline Endline Condition (Treatment) p-value N N Baseline Endline % (CI %) % (CI %) 55.0 Overall 0* 0 427 (42.0 - 67.4) 57.3 Confirmed malaria (ACT) 0* 0 185 (40.6 - 72.5) 56.2 Diarrhea (ORS) 0* 0 194 (46.3 - 65.6) 63.1 Diarrhea (zinc) 0* 0 187 (51.3 - 73.5) 50.3 Diarrhea (ORS and zinc) 0* 0 169 (37.9 - 62.7) Cough with fast breathing 60.3 0* 0 73 (Amoxicillin) (40.2 - 77.4) *No cases at baseline Missing response for 1 child who received firstline antibiotics for cough with difficult or fast breathing from a RCom, missing responses for 3 children who received ORS from a RCom, missing responses for 2 children who received zinc from a RCom, missing response for 1 child who received both ORS and zinc from a RCom

Table 19. Counseled treatment administration

Counseled on Treatment Administration Condition (Treatment) p-value Baseline N Endline N Baseline Endline % (CI %) % (CI %) 98.1 Overall 0* 0 428 (96.3 - 99.1) Confirmed malaria 98.9 0* 0 185 (ACT) (92.2 - 99.9) 99.0 Diarrhea (ORS) 0* 0 194 (95.9 - 99.8) 97.9 Diarrhea (zinc) 0* 0 187 (94.6 - 99.2) Diarrhea (ORS and 96.5 0* 0 170 zinc) (92.8 - 98.3) Cough with fast 0* 100 0 73 breathing (Amoxicillin) *No cases at baseline Missing response for 1 child who received firstline antibiotics for cough with difficult or fast breathing from a RCom at endline, missing responses for 3 children who received ORS from a RCom at endline, missing responses for 2 children who received zinc from a RCom at endline

RAcE Niger Endline Survey Final Report 17 3.8 Referral Adherence At endline, 32 percent of cases managed by an RCom were referred. Overall, reported adherence to referrals made by RCom was high at 91 percent at endline. Diarrhea cases had the highest level of referral adherence (95 percent). Looking at the reason for not complying with the referral, the majority of caregivers (41 percent) stated that they saw improvement in their sick child. Results indicate that the lack of time or transport, as well as not having the husband’s or partner’s permission, were not factors reported to have determined a caregiver’s decision to not comply with the RCom’s referral.

Table 20. Adherence to RCom referral

Baseline Endline Baseline Endline Condition p-value % (CI %) % (CI %) N N 91.4 Overall 0* 0 256 (79.9 - 96.6) 90.9 Fever 0* 0 99 (77.9 - 96.6) 94.6 Diarrhea 0* 0 93 (85.5 - 98.1) Cough with difficult or fast 87.5 0* 0 64 breathing (68.7 - 95.7) *No cases at baseline Missing responses for whether a child was referred by a RCom for 15 diarrhea cases, 8 fever cases, and 63 Cough with difficult or fast breathing cases at endline and 1 fever case at baseline. Also missing information on whether the caregiver of 1 child with cough and fast or difficult breathing adhered to the referral advice received.

3.9 Sick Child Follow-Up Overall, the results for the sick child follow-up indicator show that more than 68 percent of cases were followed up by an RCom. Cases of cough with fast breathing had the highest percentage of follow-up (73 percent). Of the 406 cases of illness followed up by an RCom, 93 percent were followed-up by the RCom within three days: a little more than half (52 percent) were followed up within one day, 31 percent within two days, and 10 percent within three days.

RAcE Niger Endline Survey Final Report 18 Table 21. RCom follow-up with sick child

Baseline Endline Condition p-value Baseline N Endline N % (CI %) % (CI %) 68.5 Overall 0* 0 604 (57.8 - 77.6) 67.8 Fever 0* 0 236 (56.5 - 77.3) 66.5 Diarrhea 0* 0 215 (54.7 - 76.6) Cough with difficult or fast 72.6 0* 0 153 breathing (60.9 - 81.8) *No cases at baseline *Missing responses for 1 caregiver at baseline and 12 caregivers at endline who sought care from a RCom for fever, 15 caregivers at endline who sought care from a RCom for diarrhea, and 65 caregivers at endline who sought care from a RCom for cough with fast or difficult breathing

3.10 Illness Management and Diagnostics by Sex Diagnosis and treatment of cases of illness among children aged 2-59 months did not vary significantly for male and female children. Tables 2–5 provide sex-disaggregated findings for diagnosis and treatment of iCCM illnesses at endline.

Table 22. Confirmed malaria management Confirmed malaria treatment* Number of children with Sex Any anti- ACT within ACT positive blood malarial 24 hours test 91.1 85.8 73.4 Overall 169 (85.4 - 94.7) (77.6 - 91.3) (61.2 - 82.8) 92.3 85.7 78.0 Male 91 (83.9 - 96.5) (74.1 - 92.6) (64.4 - 87.4) 89.7 85.9 68.0 Female 78 (80.0 - 95.0) (71.6 - 93.6) (48.6 - 82.6) ACT=artemisinin-based combination therapy * Malaria treatment (ACT Coartem and Asucam)

Table 23. Fever diagnostics Among those who had blood Number Had blood taken of Sex taken from Were given Test result children finger or heel results positive with fever 68.2 84.6 96.0 Overall 305 (57.9 - 77.0) (76.2 - 90.4) (91.1 - 98.3) 69.4 85.3 97.9 Male 157 (56.9 - 79.6) (75.5 - 91.7) (90.8 - 99.5) 66.9 83.8 94.0 Female 148 (53.2 - 78.2) (73.3 - 90.7) (84.0 - 97.9) The results for the indicators on diarrhea management provided in Table 24 show that there are no significant differences between male and female children.

RAcE Niger Endline Survey Final Report 19 Table 24. Diarrhea management Sought Sought Treatment Number Sought Given same Given same Sought any treatment treatment Treated of treatment or more or more Sex advice or from an from an Homemade with ORS children from an than usual than usual ORS Zinc treatment appropriate RCom as fluid AND Zinc with RCom to drink to eat** provider* first choice diarrhea 87.3 84.9 78.8 75.7 50.7 22.3 78.4 48.0 72.6 64.4 Overall 292 (82.5 - 91.0) (78.7 - 89.6) (71.1 - 84.9) (67.8 - 82.1) (42.2 - 59.1) (16.2 - 29.8) (69.3 - 85.4) (38.1 - 58.0) (65.7 - 78.5) (55.5 - 72.4) 86.8 85.5 80.7 79.5 49.4 17.5 78.9 48.8 74.7 68.1 Male 166 (78.2 - 92.3) (76.8 - 91.4) (72.3 - 87.1) (70.7 - 86.2) (39.8 - 59.0) (12.2 - 24.4) (69.2 - 86.2) (37.1 - 60.6) (65.7 - 82.0) (58.3 - 76.5) 88.0 84.0 76.0 70.4 52.8 28.8 77.6 47.2 69.6 59.2 Female 125 (79.9 - 93.1) (75.0 - 90.2) (65.5 - 84.1) (59.9 - 79.1) (41.0 - 64.3) (18.2 - 42.4) (65.7 - 86.3) (35.0 - 59.7) (59.4 - 78.2) (46.6 - 70.7) ORS=oral rehydration solution * Refers to those who sought care from a hospital, private clinic, other health center, or RCom ** Missing sex of one child with diarrhea

Table 25. Cough with difficult or fast breathing management Number of Sought Sought Treatment children Sought any Sought treatment from treatment from Assessed for with cough Sex advice or treatment from an appropriate an RCom as rapid breathing and fast or treatment an RCom provider* first choice Any antibiotic Amoxicillin difficult breathing 80.8 80.1 74.7 73.6 52.4 48.0 46.2 Overall 292 (73.9 - 86.2) (73.1 - 85.7) (66.9 - 81.1) (65.9 - 80.1) (43.0 - 61.6) (38.3 - 57.7) (36.3 - 56.5) 78.4 77.8 73.1 72.5 50.3 47.9 47.3 Male 167 (69.3 - 85.4) (68.6 - 85.0) (63.9 - 80.6) (63.5 - 79.9) (39.5 - 61.1) (35.2 - 60.9) (34.7 - 60.3) 84.0 83.2 76.8 75.2 55.2 48.0 44.8 Female 125 (77.0 - 89.2) (75.8 - 88.7) (67.8 - 83.9) (66.2 - 82.4) (43.6 - 66.3) (38.5 - 57.7) (34.3 - 55.8) * Refers to those who sought care from a hospital, private clinic, other health center, or RCom

RAcE Niger Endline Survey Final Report 20

4 DISCUSSION

The presence of iCCM RComs in communities within the RAcE project area has extended health care and treatment to households. Caregivers’ knowledge and perceptions of RCom has increased over the course of the project, as has care seeking from and appropriate treatment by RCom. The baseline survey was conducted during project start-up before RCom were trained and equipped to provide iCCM services in the project area. As such, baseline results for indicators relating to caregiver knowledge of RCom and any case management provided by RCom are essentially zero. Caregivers’ knowledge and perceptions of RCom increased significantly over the course of the project, as expected, given that RCom were trained and deployed to provide iCCM services after the baseline survey was implemented. Nearly all caregivers (99.8 percent) surveyed at endline know the RCom who works in their community, and most noted that RCom provide iCCM services such as malaria treatment (73 percent of caregivers) and ORS for diarrhea (60 percent of caregivers). Further, caregivers have high trust in the RCom—99 percent viewed RCom as trusted health providers, and 98 percent believe RCom provide quality services—which may be one reason that care-seeking from RCom is so high. As expected, when health services are extended to communities and households via RCom, careseeking increased. Of cases of illness among children 2-59 months who sought care from an appropriate provider, 88 percent of those sought care from an RCom and 75 percent were taken to an RCom as the first source of care. The overall percentage of illnesses receiving appropriate treatment from any provider increased significantly over the course of the project, from 37 percent at baseline to 59 percent at endline (p<0.001). At endline, among those who sought care from an RCom, 58 percent received appropriate treatment. Despite the overall increase in appropriate treatment from any provider, the percentage of cases receiving appropriate treatment is low (overall, and from RCom). Appropriate treatment provided by RCom, among cases who sought care from RCom, varied by illness: 73 percent of confirmed malaria cases were provided with artemisinin-based combination therapy (ACT) within the same or next day, 71 percent of cases with diarrhea received appropriate treatment of ORS and zinc, and 34 percent of cases of cough with difficult or fast breathing received treatment with amoxicillin. These results should be interpreted with care. Recall bias (caregiver recall of malaria diagnostic testing is poor) may influence the reported coverage of malaria treatment. Given validity issues with the pneumonia indicator4, the percentage of these treated with amoxicillin can, and should, reasonably not be 100 percent, but 34 percent seems unreasonably low. Further, little more than half of the cases treated by the RCom received the first dose of the treatment in the presence of the RCom. The findings from the endline survey suggest the value of iCCM in hard to reach communities in Niger – well-trained and supported RCom are respected sources of care and their care is sought for a high proportion of cases of illness among young children; utilization of RCom is high. These results show a

4 Campbell H, el Arifeen S, Hazir T, O'Kelly J, Bryce J, Rudan I, et al. (2013) Measuring Coverage in MNCH: Challenges in Monitoring the Proportion of Young Children with Pneumonia Who Receive Antibiotic Treatment. PLoS Med 10(5): e1001421. doi:10.1371/journal.pmed.1001421

RAcE Niger Endline Survey Final Report 21 greater need for improvements in access to quality case management of childhood illnesses in Niger at both facility and community levels.

RAcE Niger Endline Survey Final Report 22 ANNEX A. LIST OF PERSONS INVOLVED IN THE SURVEY

Name Organization Role

1. Grace Nganga World Vision RAcE Project Manager

2. Abdou Dade World Vision M&E Coordinator

3. Abdoul Wahab Alassane World Vision RAcE Project Coordinator

4. Ezekiel Mahamane World Vision Mobile Health Research Coordinator

5. Dr. Moise Moussa Division de la Interim Director of the Division of Gabriel Statistique/Ministère de la Santé Statistics Publique

6. Mme. Salamatou Institute National de la IT and Statistics Specialist Statistique

7. Yodit Fitigu ICF Niger Country Technical Support

RAcE Niger Endline Survey Final Report 23 ANNEX B. ENDLINE SAMPLE

District Name Section / CSI Name Community/Village/Localite

BOBOYE Fabiji Gardi Peulh DOUMEGA Angoual Magagi GUECHEME Sabarou

DOGONDOUTCHI KIECHE Takaré MAIKALGO Guinge MAKORWA toullou peulh RIGIA SAMNA Batamberi 2 GOROUBANKASSAM Dandiborakoira SABOUDAY Gongomoussa DOSSO Sodjadey DOGONDOUTCHI KAUTADEY DOGONDOUTCHI KOURFAYAWA DOSSO Zamadey DOSSO Bodosantche DOGONDOUTCHI TOUNGA CHAYOU BOBOYE ALKAWAL PEULH

DOSSO DOGONDOUTCHI ROUDA ADOUA DOGONDOUTCHI MAI DAKE DOGONDOUTCHI ROUNTOU MAOUDE DOGONDOUTCHI BARAYA SAIDOU BOBOYE TOUDOU DJERMA DOGONDOUTCHI SAKOIRA DOGONDOUTCHI TARAMNA DOSSO Maigari dey DOGONDOUTCHI GYAREPCHI PEULH (H) DOSSO Fondoberi DOSSO Gode Koira IBOHAMAN Keda KEITA INSAFARI Attawari TAHOUA KEITA TARAMNA

RAcE Niger Endline Survey Final Report 24 ANNEX C. DETAILED SAMPLING DESIGN

Within each cluster, the survey team selected the first household for interview using the selection by subdivision approach.5 The survey team proceeded from one household to the next by visiting the household with its front door nearest to the front door of the current household until the team conducted 10 interviews for each illness. At each household, the interviewer first determined if an eligible child lived there. An eligible child was aged 2-59 months and had been sick with diarrhea, fever, cough with difficult or rapid breathing, or any combination of the three illnesses in the two weeks preceding the survey. The interviewer administered the questionnaire, including all applicable illness modules, to the caregiver of the eligible child. If more than one child was eligible, and they were sick with different illnesses, their caregiver was asked about each instance of illness. If the children had different caregivers, each caregiver was administered a separate questionnaire and answered questions about only his or her eligible child or children. If there was more than one eligible child in the household for an illness, the interviewer randomly selected one of the eligible children and interviewed his or her caregiver.

5 Selection by subdivision instructions: Go to the population center of the sample area and identify four quadrants. Assign each quadrant a number. Write the numbers on separate slips of paper and put them in a container. Randomly select one of the slips of paper. Go to the place that equally divides the selected quadrant’s population in half. Randomly select which of the two ways to proceed, and repeat this step until you have a manageable set of households (for example, 30). Count the households in the area. Use a random number table to select the first household for interview.

RAcE Niger Endline Survey Final Report 25 ANNEX D. SURVEY QUESTIONNAIRE

Attached in a separate document.

RAcE Niger Endline Survey Final Report 26 ANNEX E. SURVEY TRAINING SCHEDULE

Horaires Thèmes Responsables 1ère journée 17/10/2016 1. Ouverture de la formation et mots de bienvenue ; 08h30 - 2. Présentation des participants; Dr Moise Moussa 09h00 3. Formalités administratives Gabriel 4. Introduction 9h00 - Yodit Fitigu  Objectifs de la formation 09h15 (ICF) 9h15 -  Présentation du projet RAcE 2015 Abdou Dade 09h40 9h40 - Dr Moise Moussa  Méthodologie 10h00 Gabriel 10h00 - PAUSE CAFE 10h30 Revue du questionnaire : 1. Fiche superviseur ; 10h30- 2. Page de garde ; Mme Ibrahim 13h00 3. Consentement ; Salamatou 4. Module 1 : Identifiant de l’enfant ; 5. Module 2 : Information sur la gardienne d’enfant. 13h00- PAUSE DEJEUNER / PAUSE PRIERE 14h00 14h00- Revue du questionnaire : Dade Abdou 16h00 1. Module3 : Contexte du paludisme ; 2. Module 4 : Prise de décision ; 16h00- PAUSE CAFE / PAUSE PREIERE 16h20 16H20- Revue du questionnaire : AbdoulWahab 17H30 1. Module 5 : ASC ou Rcom Alassane 2. Module 6 : Connaissance gardienne d’enfant 17h30- Dr Moise Moussa Rencontre des formateurs 18h00 Gabriel 2ème journée 18/10/2016 08h00- Présentation et amendement du rapport de la première journée Rapporteurs 08h20 8h20- Revue du questionnaire : Dr Moise Moussa 10h00 1. Module 7 : Diarrhée ; Gabriel 2. Module 8 : Fièvre. 10h00- PAUSE CAFE 10h30 10h30- Revue du questionnaire : Mahamane 13h00 1. Module 8 : Respiration rapide ; Ezechiel 2. Observation de l’enquêteur 13h00- PAUSE DEJEUNER / PAUSE PRIERE 14h00 14h00- 1. Introduction sur l’utilisation du smart phone ; Mme Ibrahim 2. Apprentissage sur l’Application de la collecte de données ; 16h00 Salamatou 3. Pratique sur l’utilisation de l’Application de la collecte. 16h00- PAUSE CAFE / PAUSE PRIERE 16h20

RAcE Niger Endline Survey Final Report 27 Horaires Thèmes Responsables 16h20- Mahamane 4. Pratique sur l’utilisation de l’Application de la collecte (suite) 17h00 Ezechiel 17h00- Dr Moise Moussa Rencontre des formateurs 17h30 Gabriel 3ème journée 19/10/2016 08h00- Présentation et amendement du rapport de la deuxième journée Rapporteurs 08h20 08h20- Travaux de groupe, cas pratique : Simulation & restitution Mme Ibrahim 10h00 1. Module 1 : Identifiant de l’enfant ; Salamatou 2. Module 2 : Information sur la gardienne d’enfant. 10h00- PAUSE CAFE 10h30 10h30- Travaux de groupe, cas pratique : simulation & restitution Abdou Dade 12h00 1. Module3 : Contexte du paludisme ; 2. Module 4 : Prise de décision ; 12h00- Travaux de groupe, cas pratique : Simulation & restitution AbdoulWahab 13h00 1. Module 5 : ASC ou Rcom ; Alassane 2. Module 6 : Connaissance gardienne d’enfant 13h00 - PAUSE DEJEUNER / PAUSE PRIERE 14h00 14h00 - Travaux de groupe, cas pratique : Simulation & restitution Dr Moise Moussa 16h00 1. Module 7 : Diarrhée ; Gabriel 2. Module 8 : Fièvre ; 16h00- PAUSE CAFE / PAUSE PRIERE 16h20 16h20- Travaux de groupe, cas pratique : Simulation & restitution Mahamane 17h00 1. Module 8 : Respiration rapide. Ezechiel 17h00- AbdoulWahab Informations et directives de la journée pré-test (visite terrain) 17h20 Alassane 17h20- Dr Moise Moussa Rencontre des formateurs 17h45 Gabriel 4ème journée 20/10/2016 07H45- Rassemblement Equipe pour test terrain : Bureau National de World Vision : AbdoulWahab 08h00 08h00 - Départ de l’équipe sur le terrain 08h10 AbdoulWahab 14h00- Alassane Retour de l’équipe du terrain 14h15 14h15- PAUSE DEJEUNER / PAUSE PRIERE 15h00 15h00- Présentation et amendement du rapport de la troisième journée Rapporteurs 15h20 15h20- Restitution de l’étape pré-test (visite terrain) Abdou Dade 16h00 16h00- PAUSE CAFE / PAUSE PRIERE 16h20 16h20- Mme Ibrahim Restitution de l’étape pré-test (visite terrain), smart phone 17h00 Salamatou 17h00- Dr Moise Moussa Rencontre des formateurs 17h30 Gabriel 5ème journée 21/10/2016

RAcE Niger Endline Survey Final Report 28 Horaires Thèmes Responsables 8h 30 - Présentation et amendement du rapport de la quatrième journée Rapporteurs 09h00 09h00- Observations et Corrections de l’Application de la collecte Abdou Dade 10h00 10h00- PAUSE CAFE 10h30 10h30- Mme Ibrahim Observations et Corrections de l’Application de la collecte (suite et fin) 12h30 Salamatou 12h30- PAUSE DEJEUNER / PAUSE PRIERE 14h15 14h15- AbdoulWahab Répartition des équipes de la collecte de données 14h30 Alassane 14h30- Dr Moise Moussa Plan de travail de la semaine du 24 Octobre au 02 Novembre 2016 15h00 Gabriel 14h30- Dr Moise Moussa Clôture 15h00 Gabriel 15h00- Dr Moise Moussa Rencontre des formateurs 16h00 Gabriel 16h30 Fin

RAcE Niger Endline Survey Final Report 29 ANNEX F. FIELDWORK SCHEDULE

Plan De Supervision Pour L’évaluation Finale Du Projet RAcE NICE

Districts CSI De Nom Du Coordonnateurs Superviseurs Equipes Nbre De Rattachement Village Terrain De Proximite Enqueteurs Repondants Attendu Goroubankassam Dandiborakoira - Ehennou K. DHR = 40 Joelle FIEVRE = 40 Sabouday Gongomoussa Oumoulkairou - Kimba TOUX = 40 Sabouday Sodjadey Assane Sido Kautadey Aka Harouna Mangue Koira Kofadey - Amadou Ide Mangue Koira Zamadey Elhadji Ibrahima -Souleymane DHR = 40 Dosso Tondigam Bodosantche Adamou Hassane FIEVRE = 40 - Idrissa TOUX = 40 Tombo Koirey Maigari Dey Salamatou H.Youssouf Ibrahim - Ibrahim Wangal Kaina Fondoberi Bizo Hassane Farrey Gode Koira - Ibrahim DHR = 40 Fabiji Sirakatou Kimba FIEVRE = 40 Hassane TOUX = 40 Kouringuel Alkawal Peulh Mme Ibrahim Rachidatou - Aboubacar Boboye Salamatou Sidibé Toudou Mahamane Kofo Djerma - Balkissa Illiassou Lido Angoual Kade - Issoufou DHR = 40 Bohari FIEVRE = 40 Makorwa Sakoira Moustapha TOUX = 40 Guecheme Kourfayawa -Mahamadou Salissou Sani Mahaman Abdoulaziz Makorwa Toullou - Moussa Mahaman Salissou Guecheme Mai Dake - Hassane DHR = 30 Guecheme Sabarou Abdou Abdel FIEVRE = 30 Nasser TOUX = 30 Abdou Dadé Saratou - Rakiatou Tounga Abdoulaye Doumega Ousmane Chayou - Fatouma Ousmane Dogondoutchi Kieche Rouda Adoua - Abdoulaye DHR = 40 Tibiri Gyarepchi Bako FIEVRE = Maikalgo Guinge Mahamane 40 Zakari Lawaly TOUX = 40 Amadou - Hanifa Idi Kieche Takare Tondi - Michel Gabriel Rigia Samna Batama Beri 2 - Mamane DHR = 40 Rountou Moussa FIEVRE = Doutchi Sud Maoude - Maman 40 Anass Maman Lawan TOUX = 40 Abdoulwahab Wagé - Zaourou Soucoucoutan Baraya Saidou Alassane Djmarou Nafissa

Makourdi Taramna 1 Keita Ibohaman Keda DHR = 30

RAcE Niger Endline Survey Final Report 30 Districts CSI De Nom Du Coordonnateurs Superviseurs Equipes Nbre De Rattachement Village Terrain De Proximite Enqueteurs Repondants Attendu Insafari Attawari - Harouna FIEVRE = Djataou M. 30 Siradji TOUX = 30 Aboubacar - Magagi Ali Keita Taramna 2 Manirou - Hassane Moussa M.Saguirou

RAcE Niger Endline Survey Final Report 31 ANNEX G. DETAILS OF DATA CLEANING AND ANALYSIS

RAcE Niger Endline Survey Data Cleaning Log:

Issue Identified by ICF Response from INS

1 It looks like there are only 29 in the dataset, Regarding the clusters, there are actually 30. The two data but I was expecting 30. collection teams—one at Douctchi and the other at Tahoua—gave the same name to two different villages. I separated them by adding 1 to one and 2 to the other.

2 There are considerably fewer observations [ICF: received updated data file but no information about in the data file “module2bg_information de what was done or how it was done.] This was corrected by baseq201” than in the other caregiver data merging module 'information de base' with module 'gardien' files. (Only 302 vs. around 500 in the through identifiers created by ODK. others.) I would like to know the reason for this. I was expecting one entry per caregiver interviewed.

3 Within the same data file, there are [ICF: received updated data file but no information about 11 entries that are missing information in the what was done or how it was done.] This was corrected location fields (village code, name of using identifiers that were generated by ODK. household head, department, house number), and 17 entries that do not include the caregiver number. How can we identify what these fields should be?

4 In both the fever and diarrhea modules, The fever module has no double information. The key for there are duplicate entries for the same identifying duplicates is the village code, the household household in the same cluster. According to number, and the child number. The fever base has no the sampling protocol, this should not have duplicate information so it has not been changed. happened, and I think these duplicates may have resulted because of entry errors on the The diarrhea module has only one double observation and tablets. Is this something that you can it is a false duplicate. So, at the level of village No. 12, correct? Household No. 11, there are two children each bearing the No. 1 so the 2nd must take the No. 1.

4 In the corrected diarrhea module from INS, [ICF: received updated data file but no information about a they corrected the child line number in the what was done to correct the data. For instance, was the one instance they mentioned in the email— household number wrong and corrected? Was the record but they seem to be saying that the an exact duplicate? If the record was a duplicate but observations for households in which different, how did you decide which to keep?] multiple children with the same illness were

included in the survey are valid, which was not how the sampling protocol was written. This was a numbering error which was corrected. There was supposed to be only one child included in the survey with each illness in a household. If more than one child had the same illness, one was supposed to be randomly selected. I’ve included a list of the villages and households that have two or three children included in the diarrhea module. If all these records are valid, we have to decide how to handle them during

RAcE Niger Endline Survey Final Report 32

Issue Identified by ICF Response from INS the analysis. One option is to randomly select one of the children for each household. The same would be true for the fever module.

5 There are different numbers of observations The interviewers did not follow the sequential numbering of in the caregiver modules (2–6), but there households in the village, and the agent code entered is not should have been one entry in each of these in the mask. I also found that in some households modules for each caregiver interviewed. interviewers forgot to administer certain modules. This is Were modules sometimes skipped by the reason why the size of the individuals surveyed interviewers? sometimes differs from one file to another. However, the difference is not great.

6 Module 3 (contexte du paludisme)—there This was completed only one time; however, with ODK are several (63) households with more than when there is a page 2 (which in this case is INS) 1 entry. In one case, there are 6 records for automatically a new page is formed in Excel. the same household. The module was only supposed to be completed one time per household, so I’m wondering if INS can clarify what happened here. (There is a separate file that contains the household’s bednet roster, which could have multiple records per household.)

6 There are now no duplicates, but it looks It is indeed the raw database. The malaria context had 476 a like there are about 20 fewer records for records, after clearing (removing duplicates), there are this module than any of the other modules, exactly 463 records. so just want to confirm that this is expected.

ICF: Can INS confirm that Module 3 was not completed for the households that are missing records?

Yes this is so, these were missing information.

7 Module 5 (asc)—there are 3 households that [ICF: received updated data file but no information about have duplicate entries for the same what was done or how it was done.] caregiver. There are no households with

multiple entries in any of the other caregiver modules (2, 4, or 6), so should one record in There was an error in household number which was each of these duplicates be removed? corrected by household identifiers created by ODK.

8 The information in Module 1 The data collectors gave code 0 or 99 which means n/a or (identifiantenfantq109) contains a lot of not concerned instead of leaving this void. I merged q101 errors. and q109 to arrive to the present update.

RAcE Niger Endline Survey Final Report 33

Issue Identified by ICF Response from INS

In the child roster file [ICF: received updated data file but no information about (identifiantenfantq101), no household is what was done or how it was done.] listed as having more than 3 children, so in

Module 1, p109_1, p110_1, p111_1 (child line number) should never have a value > 3, This was a numbering error which was corrected by but there are numerous instances in which classifying households by order of child identifiers. this is not true. These need to be corrected, and any noted as missing filled in using data in the sick child modules and in the child roster.

Also, p109_3, p110_3, p111_3 (caregiver [ICF: received updated data file but no information about number) should never have a value > 3. what was done or how it was done.] Furthermore, there is never an entry for a

second caregiver in any of the caregiver modules (2, 4, 5, or 6), so really the This is confirmed to be so that only one caregiver was caregiver number should ALWAYS be 1. interviewed per household per instructions given during the Does this sound correct—that there was training. only ever one caregiver interviewed in all households? If this can be confirmed to be correct, I can correct this easily on my end as I prepare the data for analysis.

9 In the Niger endline dataset, 244 of 512 [ICF: Can INS confirm that this makes sense? Did this just caregivers indicated that they were not the happen by chance, or was it how the interviewers were only caregiver of children 2-59 months in instructed to conduct their interviews? Or is there another their household, but only one caregiver was explanation?] interviewed in each household.

This is how the interviewers were instructed to conduct the interviews.

1 In the Niger endline dataset, none of the [ICF: Can INS confirm that this makes sense? Did this just 0 households had more than two children happen by chance, or was it how the interviewers were under 5 listed in their child rosters. instructed to conduct their interviews? Or is there another explanation? During the ICF/WV/INS phone call on Feb 7, 2017, INS indicated this was because interviewers only recorded children who were eligible for the survey (2-59 months and sick in the past two weeks). Can INS please confirm in writing that this was the protocol?]

Yes this is the conclusion drawn that interviewers limited themselves to the eligible children only, however this is not by protocol.

RAcE Niger Endline Survey Final Report 34 ANNEX H. INDICATOR DEFINITIONS

CHILD CHARACTERISTICS

1. Sex of sick children included in Number of children age 2‐59 months who have been survey: Proportion of sick children age 2- sick in the two weeks preceding the survey who were 59 months included in the survey who male/female were male/female Number of children age 2‐59 months included in the survey

2. Age of sick children included in Number of children age 2‐59 months who have been survey: Proportion of sick children age 2- sick in the two weeks preceding the survey who were 59 months included in the survey who 2‐11 months/12‐23 months/24‐35 months/36‐47 were 2-11 months/12-23 months/24-35 months/48‐59 months months/36-47 months/ 48-59 months Number of children age 2‐59 months included in the survey

3. Two-week history of illness of Number of sick children age 2-59 months included in children included in survey: Proportion the survey who had fever/diarrhea/cough with difficult of sick children age 2-59 months included or fast breathing in the two weeks preceding the in the survey who had fever/diarrhea/cough survey with difficult or fast breathing in the two weeks preceding the survey Number of children age 2-59 months included in the survey

CAREGIVER CHARACTERISTICS

1. Age of caregivers included in survey: Number of caregivers of sick children age 2‐59 Proportion of caregivers of sick children age months included in the survey who were 15‐24 2-59 months included in the survey who years/25‐34 years/35‐44 years/45+ years were 15-24 years/25-34 years/35-44 Number of caregivers included in the survey years/45+ years *Categories may vary by survey analysis; adjust as needed

2. Highest education of caregivers Number of caregivers of sick children age 2‐59 included in survey: Proportion of months included in the survey whose highest level caregivers of sick children age 2-59 months of education was none/primary school, up to level included in the survey whose highest level of 4/primary school, greater than level 4/secondary or education was none/primary school, up to higher level 4/primary school, greater than level Number of caregivers included in the survey 4/secondary or higher *Categories may vary by survey analysis; adjust as needed

RAcE Niger Endline Survey Final Report 35 3. Marital status of caregivers included in Number of caregivers of sick children age 2-59 survey: Proportion of caregivers of sick months included in the survey who were married/ children age 2-59 months included in the living with a partner as if married/not in a union at survey who were married/ living with a the time of the survey partner as if married/not in a union at the time of the survey Number of caregivers included in the survey

4. Partner living with caregiver: Proportion Number of caregivers of sick children age 2-59 of caregivers of sick children age 2-59 months months included in the survey who were living with included in the survey who were living with their partner, among those who were in a union at their partner, among those who were in a the time of the survey union at the time of the survey Number of caregivers included in the survey who were in a union at the time of the survey

NEAREST FACILITY

1. Distance to nearest health facility: Number of caregivers of sick children age 2‐59 Proportion of caregivers of sick children age months included in the survey who live <5 km/5‐9 2-59 months included in the survey who live km/10‐19 km/≥20 km from the nearest health <5 km/5-9 km/10-19 km/≥20 km from the facility nearest health facility Number of caregivers included in the survey *Categories may vary by survey analysis; adjust as needed

2. Mode of transport to nearest health Number of caregivers of sick children age 2‐59 facility: Proportion of caregivers of sick months included in the survey whose mode of children age 2-59 months included in the transport to the nearest health facility is survey whose mode of transport to the walking/motorbike, bus, or taxi/other nearest health facility is walking/motorbike, Number of caregivers included in the survey who bus, or taxi/other, among those who report report that they go to their nearest health facility that they go to the nearest health facility

3. Time to nearest health facility: Number of caregivers of sick children age 2-59 Proportion of caregivers of sick children age months included in the survey who report it takes 2-59 months included in the survey who <30 min/30-59 min/1 - <2 hours/2 - <3 hours/≥ 3 report it takes <30 min/30-59 min/1 - <2 hours to get to the nearest health facility hours/2 - <3 hours/≥ 3 hours to get to the nearest health facility, among those who Number of caregivers included in the survey who report that they go to the nearest health report that they go to their nearest health facility facility

RAcE Niger Endline Survey Final Report 36 HOUSEHOLD DECISION‐MAKING

1. Major household purchases joint Number of caregivers of children age 2‐59 months decision-making: Proportion of caregivers who have been sick in the two weeks preceding the of children age 2-59 months who have been survey who report that they usually make decisions about making major household purchases jointly sick in the two weeks preceding the survey with their partner who report that they usually make decisions about making major household purchases Number of caregivers of sick children age 2-59 jointly with their partner. months in the survey who were married or living together with a man as if married at the time of the survey

Number of caregivers of children age 2-59 months 2. Major household purchases decision- who have been sick in the two weeks preceding the making: Proportion of caregivers of children survey who report that the decision about making age 2-59 months who have been sick in the major household purchases is usually made by two weeks preceding the survey who report themselves/their partner/jointly with their that the decision about making major partner/someone else household purchases is usually made by themselves/their partner/jointly with their Number of caregivers of sick children age 2-59 partner/someone else months in the survey who were married or living together with a man as if married at the time of the survey

3. Joint care-seeking decision-making for Number of caregivers of children age 2-59 months caregiver: Proportion of caregivers of who have been sick in the two weeks preceding the children age 2-59 months who have been sick survey who report that they usually make decisions about healthcare for themselves jointly with their in the two weeks preceding the survey who partner report that they usually make decisions about healthcare for themselves jointly with their Number of caregivers of sick children age 2-59 partner months in the survey who were married or living together with a man as if married at the time of the survey

RAcE Niger Endline Survey Final Report 37 Number of caregivers of children age 2-59 months 4. Care-seeking decision-making for who have been sick in the two weeks preceding the caregiver: Proportion of caregivers of survey who report that the decision to seek children age 2-59 months who have been sick healthcare for themselves is usually made by in the two weeks preceding the survey who themselves/their partner/jointly with their report that the decision to seek healthcare partner/someone else for themselves is usually made by themselves/their partner/jointly with their Number of caregivers of sick children age 2-59 partner/someone else. months in the survey who were married or living together with a man as if married at the time of the survey

CAREGIVER KNOWLEDGE

1. Caregiver knowledge of CCM-trained Number of caregivers of children age 2-59 months RCOM presence: Proportion of caregivers who have been sick in the two weeks preceding the of children age 2-59 months who have been survey who are aware of the presence of the CCM- sick in the two weeks preceding the survey who trained RCom in their community are aware of the presence of the CCM- trained RCOM in their community Number of caregivers of sick children age 2-59 months in the survey

2. Caregiver knowledge of location where Number of caregivers of children age 2-59 months CCM-trained RCom offers services: who have been sick in the two weeks preceding the Proportion of caregivers of children age 2-59 survey who know the location where the CCM- months who have been sick in the two weeks trained RCom provide treatment for sick children preceding the survey who know the location where the CCM-trained RCom provides Number of caregivers of children age 2-59 months treatment for sick children, among those who who have been sick in the two weeks preceding the are aware of the presence of the CCM- survey who are aware of the presence of the CCM- trained RCom in their community trained RCom in their community

RAcE Niger Endline Survey Final Report 38 3. Caregiver knowledge of CCM-trained Number of caregivers of children age 2-59 months RCom role: Proportion of caregivers of who have been sick in the two weeks preceding the children age 2-59 months who have been sick survey who know the role of the CCM-trained in the two weeks preceding the survey who RCom* in their community know the role of the CCM-trained RCOM in their community Number of caregivers of children age 2-59 months who have been sick in the two weeks preceding the survey who are aware of the presence of the CCM- trained RCom in their community *Caregiver is able to identify at least 2 curative services provided by the CCM-trained RCom in the community

4. Caregiver knowledge of signs of child Number of caregivers of children age 2-59 months illness (2+): Proportion of caregivers of who have been sick in the two weeks preceding the children age 2-59 months who have been sick survey who know two or more signs of childhood in the two weeks preceding the survey who illness that require immediate assessment by an know two or more signs of childhood illness appropriately trained provider that require immediate assessment by an appropriately trained provider Number of caregivers of sick children age 2-59 months in the survey

5. Caregiver knowledge of signs of child Number of caregivers of children age 2-59 months illness (3+): Proportion of caregivers of who have been sick in the two weeks preceding the children age 2-59 months who have been sick survey who know three or more signs of childhood in the two weeks preceding the survey who know three or more signs of childhood illness illness that require immediate assessment by an that require immediate assessment by an appropriately trained provider appropriately trained provider Number of caregivers of sick children age 2-59 months in the survey

6. Caregiver knowledge of malaria cause: Number of caregivers of children age 2-59 months Proportion of caregivers of children age 2-59 who have been sick in the two weeks preceding the months who have been sick in the two weeks survey who know the preceding the survey who know the cause of cause of malaria malaria Number of caregivers of sick children age 2-59 months in the survey

7. Caregiver knowledge of fever as a Number of caregivers of children age 2-59 months symptom of malaria: Proportion of who have been sick in the two weeks preceding the caregivers of children age 2-59 months who survey who know that fever is a symptom of malaria have been sick in the two weeks preceding the survey who know that fever is a symptom Number of caregivers of sick children age 2-59 of malaria months in the survey

RAcE Niger Endline Survey Final Report 39 8. Caregiver knowledge of correct malaria Number of caregivers of children age 2-59 months treatment: Proportion of caregivers of who have been sick in the two weeks preceding the children age 2-59 months who have been sick survey who know the correct treatment for malaria in the two weeks preceding the survey who (ACT) know the correct treatment for malaria Number of caregivers of sick children age 2-59 months in the survey

9. Caregiver knowledge of CCM-trained Number of caregivers of children age 2-59 months RCom activities: Proportion of caregivers who have been sick in the two weeks preceding the of children age 2-59 months who have been survey who know that the CCM-trained RCom sick in the two weeks preceding the survey who know that the CCM-trained RCom performs “X” activity performs each of the activities listed in the Number of caregivers of children age 2-59 months survey questionnaire, among who are aware of the presence of the CCM-trained CH RCom who have been sick in the two weeks preceding the W in their community survey who are aware of the presence of the CCM- trained RCom in their community

10. Caregiver knowledge of signs of child Number of caregivers of children age 2-59 months illness: Proportion of caregivers of children who have been sick in the two weeks preceding the age 2-59 months who have been sick in the survey who know that each of the signs of illness two weeks preceding the survey who know that each of the signs of illness listed in the listed in the survey questionnaire that indicate their survey questionnaire that indicate their child child needs treatment needs treatment Number of caregivers of sick children age 2-59 months in the survey

CAREGIVER PRECEPTIONS OF RCom QUALITY

1. CCM-trained RCOM quality (Trusted Number of caregivers of children age 2-59 months providers): Proportion of caregivers of who have been sick in the two weeks preceding the children age 2-59 months who have been sick survey who view CCM-trained RComs as trusted in the two weeks preceding the survey who health care providers view CCM-trained RCom as trusted health Number of caregivers of children age 2-59 months care providers who have been sick in the two weeks preceding the survey who are aware of the presence of the CCM- trained RCom in their community *Caregivers included in the numerator agree with the two statements: (1) People go to the CCM-trained RCom first for treatment of sick children, (2) People trust in the CCM-trained RCom’s ability to cure sick children.

RAcE Niger Endline Survey Final Report 40 2. CCM-trained RCOM quality (Quality Number of caregivers of children age 2-59 months services): Proportion of caregivers of who have been sick in the two weeks preceding the children age 2-59 months who have been sick survey who believe CCM-trained RCOMs provide in the two weeks preceding the survey who quality services believe CCM-trained RComs provide quality Number of caregivers of children age 2-59 months services who have been sick in the two weeks preceding the survey who are aware of the presence of the CCM- trained RCom in their community *Caregivers included in the numerator agree with at least 3 of the 4 statements: (1) Medicines are always available with the CCM-trained RCOM. (2) The CCM-trained RCom gives medicines that are good quality. (3) The CCM-trained RCom shows respect for patients. (4) The CCM-trained RCom conducts home visits and follow-ups.

3. CCM-trained RCOM quality Number of caregivers of children age 2-59 months (Available): Proportion of caregivers of who have been sick in the two weeks preceding the children age 2-59 months who have been sick survey who found the CCM-trained RCom at first in the two weeks preceding the survey who visit found the CCM-trained RComs at first visit Number of caregivers of children age 2-59 months who have been sick in the two weeks preceding the survey who sought care from a CCM-trained *Caregivers included in the numerator had to find the RCom at first visit for each instance of illness included in the survey if the caregiver responded to multiple illness modules

4. CCM-trained RCOM quality Number of caregivers of children age 2-59 months (Convenient): Proportion of caregivers of who have been sick in the two weeks preceding the children age 2-59 months who have been sick survey who cite the CCM-trained RCOM as a in the two weeks preceding the survey who convenient source of treatment cite the CCM-trained RComs as a convenient Number of caregivers of children age 2-59 months source of treatment who have been sick in the two weeks preceding the survey who are aware of the presence of the CCM- trained in their community *Caregivers included in the numerator agree with the two statements: (1) The CCM-trained RCOM is nearby. (2) It is easy to find the CCM-trained RCOM when RCom he or she is needed.

RAcE Niger Endline Survey Final Report 41 DECIDED TO SEEK CARE JOINTLY WITH PARTNER

1. Decided to seek care jointly with Number of children age 2-59 months who had fever in partner (Fever): Proportion of children age the two weeks preceding the survey for whom the 2-59 months who had fever in the two weeks decision to seek advice or treatment was made preceding the survey for whom the decision jointly by their caregiver and their caregiver’s to seek advice or treatment was made jointly partner, among caregivers in a union by their caregiver and their caregiver’s Number of children age 2-59 months who had fever in partner, among caregivers in a union the survey whose caregiver was in a union

2. Decided to seek care jointly with Number of children age 2-59 months who had partner (Diarrhea): Proportion of children diarrhea in the two weeks preceding the survey for age 2-59 months who had diarrhea in the two whom the decision to seek advice or treatment weeks preceding the survey for whom the was made jointly by their caregiver and their decision to seek advice or treatment was caregiver’s partner, among caregivers in a union made jointly by their caregiver and their Number of children age 2-59 months who had caregiver’s partner, among caregivers in a diarrhea in the survey whose caregiver was in a union union

3. Decided to seek care jointly with Number of children age 2-59 months who had cough partner (Cough with difficult or fast with difficult or fast breathing in the two weeks breathing): Proportion of children age 2-59 preceding the survey for whom the decision to seek months who had cough with difficult or fast advice or treatment was made jointly by their breathing in the two weeks preceding the caregiver and their caregiver’s partner, among survey for whom the decision to seek advice caregivers in a union or treatment was made jointly by their Number of children age 2-59 months who had cough caregiver and their caregiver’s partner, with difficult or fast breathing in the survey whose among caregivers in a union caregiver was in a union

4. Decided to seek care jointly with Number of cases of illness among children age 2-59 partner (Sick child): Proportion of months who have been sick in the two weeks children age 2-59 months who have been sick preceding the for which the decision to seek advice in the two weeks preceding the survey for or treatment was made jointly by their caregiver whom the decision to seek advice or and their caregiver’s partner treatment was made jointly by their caregiver and their caregiver’s partner, among Number of cases of illness among sick children age 2- caregivers in a union 59 months in the survey whose caregiver was in a union

RAcE Niger Endline Survey Final Report 42 SICK CHILD CARE

1. Appropriate sick child care (Continued Number of cases of illness among children age 2-59 fluids): Proportion of children age 2-59 months who were sick in the two weeks preceding months who have been sick in the two weeks the survey that were offered same or more than usual preceding the survey who were offered same to drink or more than usual to drink Number of cases of illness among sick children age 2- *In all surveys except Niger and Nigeria (Abia 59 months in the survey State), this indicator includes only cases of diarrhea. In Niger and Nigeria (Abia State) it includes fever, diarrhea, and cough with difficult or fast breathing. Adapt indicator as applicable.

2. Appropriate sick child care (Continued Number of cases of illness among children age 2-59 feeding): Proportion of children age 2-59 months who were sick in the two weeks preceding months who have been sick in the two weeks the survey that were offered same or more than usual preceding the survey who were offered same to eat or more than usual to eat Number of cases of illness among sick children age 2- *In all surveys except Niger and Nigeria (Abia 59 months in the survey State), this indicator includes only cases of diarrhea. In Niger and Nigeria (Abia State) it includes fever, diarrhea, and cough with difficult or fast breathing. Adapt indicator as applicable.

CARE SEEKING FROM AN APPROPRIATE PROVIDER

1. Care-seeking from appropriate Number of children age 2-59 months who had fever in provider (Fever): Proportion of children the two weeks preceding the survey for whom advice age 2-59 months who had fever in the two or treatment was sought from an appropriate provider weeks preceding the survey for whom advice Number of children age 2-59 months who had fever in or treatment was sought from an appropriate the survey provider

2. Care-seeking from appropriate Number of children age 2-59 months who had provider (Diarrhea): Proportion of diarrhea in the two weeks preceding the survey for children age 2-59 months who had diarrhea whom advice or treatment was sought from an in the two weeks preceding the survey for appropriate provider whom advice or treatment was sought from Number of children age 2-59 months who had an appropriate provider diarrhea in the survey

RAcE Niger Endline Survey Final Report 43 3. Care-seeking from appropriate Number of children age 2-59 months who had cough provider (Cough with difficult or fast with difficult or fast breathing in the two weeks breathing): Proportion of children age 2-59 preceding the survey for whom advice or treatment months who had cough with difficult or fast was sought from an appropriate provider breathing in the two weeks preceding the Number of children age 2-59 months who had cough survey for whom advice or treatment was with difficult or fast breathing sought from an appropriate provider

4. Care-seeking from appropriate Number of cases of illness among children age 2-59 provider (Sick child): Proportion of months who have been sick in the two weeks children age 2-59 months who have been sick preceding the survey for which advice or treatment in the two weeks preceding the survey for was sought from an appropriate provider whom advice or treatment was sought from an appropriate provider Number of cases of illness among sick children age 2- 59 months in the survey

RCOM AS FIRST SOURCE OF CARE

5. RCOM as first source of care (Fever): Number of children age 2-59 months who had fever in Proportion of children age 2-59 months who two weeks preceding the survey taken to a CCM- had fever in two weeks preceding the survey trained RCOM as first source of care taken to a CCM-trained RCOM as first Number of children age 2-59 months who had fever in source of care the survey

6. RCOM as first source of care Number of children age 2-59 months who had (Diarrhea): Proportion of children age 2-59 diarrhea in two weeks preceding the survey taken to a months who had diarrhea in two weeks CCM-trained RCOM as first source of care preceding the survey taken to a CCM-trained Number of children age 2-59 months who had RCOM as first source of care diarrhea in the survey

7. RCOM as first source of care (Cough Number of children age 2-59 months who had cough with difficult or fast breathing): with difficult or fast breathing in two weeks preceding Proportion of children age 2-59 months who the survey taken to a CCM-trained RCOM as first had cough with difficult or fast breathing in source of care two weeks preceding the survey taken to a Number of children age 2-59 months who had cough CCM-trained RCOM as first source of care with difficult or fast breathing in the survey

8. RCOM as first source of care (Sick Number of cases of illness among children age 2-59 child): Proportion of children age 2-59 months who have been sick in two weeks preceding months who were sick in two weeks the survey taken to a CCM-trained RCOM as first preceding the survey taken to a CCM-trained source of care RCOM as first source of care Number of cases of illness among sick children age 2- 59 months in the survey

RAcE Niger Endline Survey Final Report 44 RCOM AS FIRST SOURCE OF CARE, ANY CARE

9. RCOM as first source of care, any care Number of children age 2-59 months who had (Fever): Proportion of children age 2-59 fever in two weeks preceding the survey taken to a months who had fever in two weeks CCM-trained RCOM as first source of care preceding the survey taken to a CCM-trained RCOM as first source of care, among those Number of children age 2-59 months who had for whom any care was sought fever in the survey for whom any care was sought

10. RCOM as first source of care, any care Number of children age 2-59 months who had (Diarrhea): Proportion of children age 2-59 diarrhea in two weeks preceding the survey taken months who had diarrhea in two weeks to a CCM-trained RCOM as first source of care preceding the survey taken to a CCM-trained RCOM as first source of care, among those Number of children age 2-59 months who had for whom any care was sought diarrhea in the survey for whom any care was sought

11. RCOM as first source of care, any care Number of children age 2-59 months who had (Cough with difficult or fast breathing): cough with difficult or fast breathing in two weeks Proportion of children age 2-59 months who preceding the survey taken to a CCM-trained had cough with difficult or fast breathing in RCOM as first source of care two weeks preceding the survey taken to a CCM-trained RCOM as first source of care, Number of children age 2-59 months who had among those for whom any care was sought cough with difficult or fast breathing in the survey for whom any care was sought

12. RCOM as first source of care, any care Number of cases of illness among children age 2-59 (Sick child): Proportion of children age 2-59 months who have been sick in two weeks months who were sick in two weeks preceding the survey taken to a CCM-trained preceding the survey taken to a CCM-trained RCOM as first source of care, among those RCOM as first source of care for whom any care was sought Number of cases of illness among sick children age 2-59 months in the survey for which any care was sought

RAcE Niger Endline Survey Final Report 45 SOURCES OF CARE

1. Sources of care (Sick child): Proportion Number of cases of illness among children age 2-59 of children age 2-59 months who were sick in months who were sick in two weeks preceding the two weeks preceding the survey taken to a survey taken to a public facility/private public facility/private facility/RCOM/Store, facility/RCOM/Store, pharmacy, or pharmacy, or market/traditional practitioner/other for advice or treatment, market/traditional practitioner/other for advice or among those for whom any care was sought treatment Number of cases of illness among sick children age 2-59 months in the survey for which any care was sought

2. First source of care (Sick child): Number of cases of illness among children age 2-59 Proportion of children age 2-59 months who months who were sick in two weeks preceding the were sick in two weeks preceding the survey survey taken to a public facility/private taken to a public facility/private facility/RCOM/Store, pharmacy, or facility/RCOM/Store, pharmacy, or market/traditional practitioner/other first for market/traditional practitioner/other first for advice advice or treatment, among those for whom or treatment any care was sought Number of cases of illness among sick children age 2-59 months in the survey for which any care was sought

SICK CHILD ASSESSMENT

1. Malaria diagnostic testing (Blood drawn): Number of children age 2-59 months who had fever in Proportion of children age 2-59 months who the two weeks preceding the survey who had finger or had fever in the two weeks preceding the heel stick survey who had finger or heel stick Number of children age 2-59 months who had fever in the survey

2. Malaria diagnostic testing result shared: Number of children age 2-59 months whose caregiver Proportion of children age 2-59 months received the results of the malaria diagnostic test whose caregiver received the result of the malaria diagnostic test, among those who had Number of children age 2-59 months who had fever in had a finger or heel stick in the two weeks the survey who had had finger or heel stick preceding the survey

3. Malaria diagnostic testing result: Number of children age 2-59 months who had a Proportion of children age 2-59 months who positive malaria diagnostic test result had a positive malaria diagnostic test result, among those whose caregiver received the Number of children age 2-59 months whose caregiver result of the malaria diagnostic test received the malaria diagnostic test result

RAcE Niger Endline Survey Final Report 46 4. Confirmed malaria treatment: Number of children age 2-59 months who received Proportion of children age 2-59 months who ACT received ACT, among those who received a positive malaria diagnostic test result Number of children age 2-59 months who received a positive malaria diagnostic test result

5. Suspected pneumonia assessment: Number of children age 2-59 months who had cough Proportion of children age 2-59 months who with difficult or fast breathing in the two weeks had cough with difficult or fast breathing in preceding the survey who had their respiratory rate the two weeks preceding the survey who had counted to assess fast breathing their respiratory rate counted to assess fast breathing Number of children age 2-59 months who had cough with difficult or fast breathing in the survey

SICK CHILD ASSESSMENT BY RCOM

6. RCOM malaria diagnostic testing (Blood Number of children age 2-59 months who had fever in drawn): Proportion of children age 2-59 the two weeks preceding the survey who had finger or months who had fever in the two weeks heel stick by a CCM-trained RCOM preceding the survey who had finger or heel stick by a CCM-trained RCOM Number of children age 2-59 months who had fever in the survey whose caregiver sought care from a RCOM

7. RCOM malaria diagnostic testing result Number of children age 2-59 months whose caregiver shared: Proportion of children age 2-59 received the result of the malaria diagnostic test months whose caregiver received the result of the malaria diagnostic test, among those Number of children age 2-59 months who had fever in who had had a finger or heel stick by a CCM- the survey who had had finger or heel stick by a trained RCOM in the two weeks preceding CCM-trained RCOM the survey

8. RCOM malaria diagnostic testing Number of children age 2-59 months who had a result: Proportion of children age 2-59 positive malaria diagnostic test result months for whom the result of the malaria diagnostic test was positive, among those Number of children age 2-59 months for whose whose caregiver received the result of the caregiver received the result of the malaria diagnostic malaria diagnostic test performed by a CCM- test performed by a CCM-trained RCOM trained RCOM

9. RCOM confirmed malaria treatment: Number of children age 2-59 months who received Proportion of children age 2-59 months who ACT from a RCOM received ACT from a RCOM, among those who received a positive malaria diagnostic Number of children age 2-59 months who received test result from a RCOM a positive result from a malaria diagnostic test performed by a RCOM

RAcE Niger Endline Survey Final Report 47 10. RCOM suspected pneumonia Number of children age 2-59 months who had cough assessment: Proportion of children age 2-59 with difficult or fast breathing in the two weeks months who had cough with difficult or fast preceding the survey who had their respiratory rate breathing in the two weeks preceding the counted by a CCM-trained RCOM to assess fast survey who had their respiratory rate breathing counted by a CCM-trained RCOM to assess fast breathing Number of children age 2-59 months who had cough with difficult or fast breathing in the survey whose caregiver sought care from a RCOM

APPROPRIATE TREATMENT COVERAGE

1. Treatment coverage (Fever: Number of children age 2-59 months who received Appropriate ACT treatment with positive appropriate ACT treatment, according to national diagnostic test): Proportion of children age policy 2-59 months who received appropriate ACT treatment, according to national policy, Number of children age 2-59 months who had among those with fever who had a positive fever in the survey who had a positive malaria malaria diagnostic test result in the two weeks diagnostic test result preceding the survey

2. Treatment coverage (Fever: Number of children age 2-59 months who received Appropriate & prompt ACT treatment appropriate ACT treatment the same day or the day with positive diagnostic test): Proportion of after the fever started, according to national policy children age 2-59 months who received timely and appropriate ACT treatment, Number of children age 2-59 months who had fever according to national policy, among those in the survey who had a positive malaria diagnostic with fever who had a positive malaria test result diagnostic test result in the two weeks preceding the survey

3. Treatment coverage (Diarrhea: ORS & Number of children age 2-59 months who had zinc): Proportion of children age 2-59 diarrhea in the two weeks preceding the survey who months who had diarrhea in the two weeks received ORS and zinc according to national policy preceding the survey who received ORS and zinc, according to national policy Number of children age 2-59 months who had diarrhea in the survey

4. Treatment coverage (Cough with Number of children age 2-59 months who had cough difficult or fast breathing: First-line with difficult or fast breathing in the two weeks antibiotics): Proportion of children age 2-59 preceding the survey who received first-line antibiotic months who had cough with difficult or fast treatment according to national policy breathing in the two weeks preceding the survey who received first-line antibiotic Number of children age 2-59 months who had cough treatment, according to national policy with difficult or fast breathing in the survey

RAcE Niger Endline Survey Final Report 48 5. Overall treatment coverage (Sick Number of cases of illness among children age 2-59 child): Proportion of children age 2-59 months who have been sick in two weeks preceding months who have been sick in the two weeks the survey that received appropriate treatment preceding the survey who received appropriate treatment, according to national Number of cases of illness among sick children age 2- policy 59 months in the survey* *This indicator includes indicators 2, 3, and 4 in *Fever cases only include those with a positive malaria this section. Indicator 1 is not included. diagnostic test result

APPROPRIATE TREATMENT COVERAGE BY RCOMS *This set of indicators uses the same denominator as the Appropriate Treatment Coverage indicators above; thus the percentages will always be equal to or less than the percentages for indicators 1-5 in this section.

6. RCOM treatment coverage (Fever: Number of children age 2-59 months who received Appropriate ACT treatment with positive appropriate ACT treatment from a CCM-trained diagnostic test): Proportion of children age RCOM, according to national policy 2-59 months who received appropriate ACT treatment from a CCM-trained RCOM, Number of children age 2-59 months who had according to national policy, among those fever in the survey who had a positive malaria with fever who had a positive malaria diagnostic test result diagnostic test result in the two weeks preceding the survey

7. RCOM treatment coverage (Fever: Number of children age 2-59 months who received Appropriate & prompt ACT treatment appropriate ACT treatment from a CCM-trained with positive diagnostic test): Proportion of RCOM the same day or the day after the fever children age 2-59 months who received started, according to national policy timely and appropriate ACT treatment from a CCM-trained RCOM, according to national Number of children age 2-59 months who had fever policy, among those with fever who had a in the survey who had a positive malaria diagnostic positive malaria diagnostic test result in the test result two weeks preceding the survey

8. RCOM treatment coverage (Diarrhea: Number of children age 2-59 months who had ORS & zinc): Proportion of children age 2-59 diarrhea in the two weeks preceding the survey who months who had diarrhea in the two weeks received ORS and zinc from a CCM-trained RCOM, preceding the survey who received ORS and according to national policy zinc from a CCM-trained RCOM, according to national policy Number of children age 2-59 months who had diarrhea in the survey

9. RCOM treatment coverage (Cough Number of children age 2-59 months who had cough with difficult or fast breathing: First-line with difficult or fast breathing in the two weeks antibiotics): Proportion of children age 2-59 preceding the survey who received antibiotic months who had cough with difficult or fast treatment from a CCM-trained RCOM, according to breathing in the two weeks preceding the national policy survey who received antibiotic treatment according to national policy Number of children age 2-59 months who had cough with difficult or fast breathing in the survey

RAcE Niger Endline Survey Final Report 49 10. RCOM treatment coverage (Sick child): Number of cases of illness among children age 2-59 Proportion of children age 2-59 months who months who have been sick in two weeks preceding have been sick in the two weeks preceding the survey that received appropriate treatment from a the survey who received appropriate CCM-trained RCOM, according to national policy treatment from a CCM-trained RCOM Number of cases of illness among sick children age 2- *This indicator includes indicators 7, 8, and 9 in 59 months in the survey* this section. Indicator 6 is not included. *Fever cases only include those with a positive malaria diagnostic test result

APPROPRIATE TREATMENT COVERAGE BY RCOMS, AMONG THOSE WHO SOUGHT CARE FROM RCOM

11. RCOM treatment coverage (Fever: Number of children age 2-59 months who received Appropriate & prompt ACT treatment appropriate ACT treatment from a CCM-trained with positive diagnostic test): Proportion of RCOM the same day or the day after the fever children age 2-59 months who received started, according to national policy timely and appropriate ACT treatment from a CCM-trained RCOM, according to national Number of children age 2-59 months who had fever policy, among those with fever who had a in the survey who had a positive malaria diagnostic positive malaria diagnostic test result in the test result whose caregiver sought care from a two weeks preceding the survey RCOM

12. RCOM treatment coverage (Diarrhea: Number of children age 2-59 months who had ORS & zinc): Proportion of children age 2-59 diarrhea in the two weeks preceding the survey who months who had diarrhea in the two weeks received ORS and zinc from a CCM-trained RCOM, preceding the survey who received ORS and according to national policy zinc from a CCM-trained RCOM, according to national policy, among those who sought Number of children age 2-59 months who had care from a RCOM diarrhea in the survey whose caregiver sought care from a RCOM

13. RCOM treatment coverage (Cough Number of children age 2-59 months who had cough with difficult or fast breathing: First-line with difficult or fast breathing in the two weeks antibiotics): Proportion of children age 2-59 preceding the survey who received antibiotic months who had cough with difficult or fast treatment from a CCM-trained RCOM, according to breathing in the two weeks preceding the national policy survey who received antibiotic treatment according to national policy, among those Number of children age 2-59 months who had cough who sought care from a RCOM with difficult or fast breathing in the survey whose caregiver sought care from a RCOM

14. RCOM treatment coverage (Sick child): Number of cases of illness among children age 2-59 Proportion of children age 2-59 months who months who have been sick in two weeks preceding have been sick in the two weeks preceding the survey that received appropriate treatment from a the survey who received appropriate CCM-trained RCOM, according to national policy treatment from a CCM-trained RCOM, among those who sought care from a RCOM Number of cases of illness among sick children age 2- 59 months in the survey whose caregiver sought *This indicator includes indicators 11, 12, and 13 care from a RCOM* in this section. *Fever cases only include those with a positive malaria diagnostic test result

RAcE Niger Endline Survey Final Report 50 TREATMENTS TAKEN

15. Diarrhea treatment taken: Proportion of Number of children age 2-59 months who had children age 2-59 months who had diarrhea diarrhea in the two weeks preceding the survey in the two weeks preceding the survey who who took ORS/zinc/government-approved took ORS/zinc/government-approved homemade fluid homemade fluid Number of children age 2-59 months who had diarrhea in the survey

16. Other diarrhea treatment taken: Number of children age 2-59 months who had Proportion of children age 2-59 months who diarrhea in the two weeks preceding the survey had diarrhea in the two weeks preceding the who took “X” medicine survey who took any of the medicines listed in the survey questionnaire, among children Number of children age 2-59 months who had with diarrhea who took any other medicines diarrhea in the survey who took any other medicine (beside ORS, zinc or government-approved homemade fluid)

17. Fever treatment taken: Proportion of Number of children age 2-59 months who had fever children age 2-59 months who had fever in in the two weeks preceding the survey who took the two weeks preceding the survey who “X” medicine took any of the medicines listed in the survey questionnaire, among children with fever who Number of children age 2-59 months who had fever in took any medicines the survey who took any medicine

18. Cough with difficult or fast breathing Number of children age 2-59 months who had treatment taken: Proportion of children cough with difficult or fast breathing in the two age 2-59 months who had cough with difficult weeks preceding the survey who took “X” or fast breathing in the two weeks preceding the survey who took any of the medicines medicine listed in the survey questionnaire, among Number of children age 2-59 months who had cough children with cough with difficult or fast breathing who took any medicines with difficult or fast breathing in the survey who took any medicine

SOURCE OF TREATMENT

1. Source of treatment (Malaria: ACT): Number of children age 2-59 months who had Proportion of children age 2-59 months who fever in the two weeks preceding the survey who had fever in the two weeks preceding the received ACT for malaria from a public survey who received ACT from a public facility/private facility/RCOM/Store, pharmacy, or facility/private facility/RCOM/Store, pharmacy, or market/traditional market/traditional practitioner/other practitioner/other, among those who Number of children age 2-59 months in the survey received ACT for malaria who received ACT for malaria

RAcE Niger Endline Survey Final Report 51 2. Source of treatment (Diarrhea: ORS): Number of children age 2-59 months who had Proportion of children age 2-59 months who diarrhea in the two weeks preceding the survey had diarrhea in the two weeks preceding the who received ORS from a public facility/private survey who received ORS from a public facility/RCOM/Store, pharmacy, or facility/private facility/RCOM/Store, pharmacy, or market/traditional market/traditional practitioner/other practitioner/other, among those who Number of children age 2-59 months in the survey received ORS for diarrhea who received ORS for diarrhea

3. Source of treatment (Diarrhea: zinc): Number of children age 2-59 months who had Proportion of children age 2-59 months who diarrhea in the two weeks preceding the survey had diarrhea in the two weeks preceding the who received zinc from a public facility/private survey who received zinc from a public facility/RCOM/Store, pharmacy, or facility/private facility/RCOM/Store, pharmacy, or market/traditional market/traditional practitioner/other practitioner/other, among those who Number of children age 2-59 months in the survey received zinc for diarrhea who received zinc for diarrhea

4. Source of treatment (Cough with Number of children age 2-59 months who had difficult or fast breathing): Proportion of cough with difficult or fast breathing in the two children age 2-59 months who had cough weeks preceding the survey who received first-line with difficult or fast breathing in the two antibiotics from a public facility/private weeks preceding the survey who received first-line antibiotics from a public facility/RCOM/Store, pharmacy, or facility/private facility/RCOM/Store, market/traditional practitioner/other pharmacy, or market/traditional Number of children age 2-59 months in the survey practitioner/other, among those who received first-line antibiotics for cough with who received first-line antibiotics for cough with difficult or fast breathing difficult or fast breathing

FIRST DOSE OF TREATMENT IN FRONT OF RCOM

1. First dose of treatment (Malaria): Number of children age 2-59 months who had fever in Proportion of children age 2-59 months who the two weeks preceding the survey who received the had fever in the two weeks preceding the first dose of ACT in the presence of a RCOM survey who received the first dose of ACT in the presence of a RCOM, among those who Number of children age 2-59 months who had fever in received ACT from a RCOM the survey who received ACT from a RCOM

2. First dose of treatment (Diarrhea: Number of children age 2-59 months who had ORS): Proportion of children age 2-59 diarrhea in the two weeks preceding the survey who months who had diarrhea in the two weeks received the first dose of ORS in the presence of a preceding the survey who received the first RCOM dose of ORS in the presence of a RCOM, among those who received ORS from a Number of children age 2-59 months who had RCOM diarrhea in the survey who received ORS from a RCOM

RAcE Niger Endline Survey Final Report 52 3. First dose of treatment (Diarrhea: Number of children age 2-59 months who had zinc): Proportion of children age 2-59 diarrhea in the two weeks preceding the survey who months who had diarrhea in the two weeks received the first dose of zinc in the presence of a preceding the survey who received the first RCOM dose of zinc in the presence of a RCOM, among those who received zinc from a Number of children age 2-59 months who had RCOM diarrhea in the survey who received zinc from a RCOM

4. First dose of treatment (Diarrhea: ORS Number of children age 2-59 months who had and zinc): Proportion of children age 2-59 diarrhea in the two weeks preceding the survey who months who had diarrhea in the two weeks received the first dose of both ORS and zinc in the preceding the survey who received the first presence of a RCOM dose of both zinc and ORS in the presence of a RCOM, among those who received both Number of children age 2-59 months who had ORS and zinc from a RCOM diarrhea in the survey who received both ORS and zinc from a RCOM

5. First dose of treatment (Cough with Number of children age 2-59 months who had cough difficult or fast breathing): Proportion of with difficult or fast breathing in the two weeks children age 2-59 months who have had cough preceding the survey who received the first dose of with difficult or fast breathing in the two weeks first-line antibiotics in the presence of a RCOM preceding the survey who received the first dose of first-line antibiotics in the presence of Number of children age 2-59 months who had cough a RCOM, among those who received first- with difficult or fast breathing in the survey who line antibiotics from a RCOM received first-line antibiotics from a RCOM

6. First dose of treatment (Sick child): Number cases of illness among of children age 2-59 Proportion of children age 2-59 months who months who have been sick in the two weeks have been sick in the two weeks preceding the preceding the survey that received the first dose of survey who received the first dose of treatment in the presence of a RCOM treatment in the presence of a RCOM Number of cases of illness among sick children age 2- *This indicator includes indicators 1, 4, and 5 in 59 months in the survey that received treatment from this section. Indicators 2 and 3 are not included. a RCOM

TREATMENT ADMINISTRATION COUNSELING BY RCOM

1. Counseling quality (Malaria): Proportion Number of children age 2-59 months who had fever in of children age 2-59 months who had fever in the two weeks preceding the survey whose caregiver the two weeks preceding the survey whose received counseling on how to administer ACT to caregiver received counseling on how to their child administer ACT, among those who received ACT from a RCOM for malaria Number of children age 2-59 months with fever in the survey who received ACT from a RCOM

RAcE Niger Endline Survey Final Report 53 2. Counseling quality (Diarrhea: ORS): Number children age 2-59 months who had diarrhea Proportion of children age 2-59 months who in the two weeks preceding the survey whose had diarrhea in the two weeks preceding the caregiver received counseling on how to administer survey whose caregiver received counseling ORS to their child on how to administer ORS, among those who received ORS from a RCOM for Number of children age 2-59 months with diarrhea in diarrhea the survey who received ORS from a RCOM

3. Counseling quality (Diarrhea: zinc): Number children age 2-59 months who had diarrhea Proportion of children age 2-59 months who in the two weeks preceding the survey whose had diarrhea in the two weeks preceding the caregiver received counseling on how to administer survey whose caregiver received counseling zinc to their child on how to administer zinc, among those who received zinc from a RCOM for diarrhea Number of children age 2-59 months who had diarrhea in the survey who zinc for diarrhea from a RCOM

4. Counseling quality (Diarrhea: ORS and Number children age 2-59 months who had diarrhea zinc): Proportion of children age 2-59 in the two weeks preceding the survey for whose months who had diarrhea in the two weeks caregiver received counseling on how to administer preceding the survey whose caregiver both ORS and zinc to their child received counseling on how to administer both ORS and zinc, among those who Number of children age 2-59 months in the survey received both ORS and zinc from a RCOM who received both ORS and zinc for diarrhea from a for diarrhea RCOM

5. Counseling quality (Cough with difficult Number children age 2-59 months who had cough or fast breathing: first-line antibiotic): with difficult or fast breathing in the two weeks Proportion of children age 2-59 months who preceding the survey whose caregiver received had cough with difficult or fast breathing in counseling on how to administer first-line antibiotics the two weeks preceding the survey whose to their child caregiver received counseling on how to administer first-line antibiotics, among those Number of children age 2-59 months in the survey who received first-line antibiotics from a who received first-line antibiotics for cough with RCOM for cough with difficult or fast difficult or fast breathing from a RCOM breathing

6. Counseling quality (Sick child): Number of cases of illness among sick children age 2- Proportion of sick children age 2-59 months 59 months for which caregivers received counseling whose caregiver received counseling on how on how to provide the treatment(s) received to provide the treatment(s) received among those who received treatment(s) for a CCM Number of cases of illness among sick children age 2- illness in the two weeks preceding the survey 59 months in the survey that received treatment(s) for a CCM illness *This indicator includes indicators 1, 4, and 5 in this section. Indicators 2 and 3 are not included.

RAcE Niger Endline Survey Final Report 54 RCOM REFERRAL ADHERENCE

1. RCOM referral adherence (Fever): Number of children age 2-59 month who had fever in Proportion of children age 2-59 months who the two weeks preceding the survey whose caregiver had fever in the two weeks preceding the adhered to the RCOM’s referral advice survey whose caregiver adhered to the RCOM’s referral advice, among those who Number of children age 2-59 months who had fever in were referred to a health facility by a CCM- the survey who were referred to a health facility by trained RCOM a CCM-trained RCOM

2. RCOM referral adherence (Diarrhea): Number of children age 2-59 month who had diarrhea Proportion of sick children age 2-59 months in the two weeks preceding the survey whose the who had diarrhea in the two weeks preceding caregiver adhered to the RCOM’s referral advice the survey whose caregiver adhered to the RCOM’s referral advice, among those who Number of children age 2-59 months who had were referred to a health facility by a CCM- diarrhea in the survey who were referred to a health trained RCOM facility by a CCM-trained RCOM

3. RCOM referral adherence (Cough with Number of children age 2-59 month who had cough difficult or fast breathing): Proportion of with difficult or fast breathing in the two weeks sick children age 2-59 months who had cough preceding the survey whose the caregiver adhered to with difficult or fast breathing in the two weeks the RCOM’s referral advice preceding the survey whose caregiver adhered to the RCOM’s referral advice, among those Number of children age 2-59 months who had cough who were referred to a health facility by a with difficult or fast breathing in the survey who were CCM-trained RCOM referred to a health facility by a CCM-trained RCOM

4. RCOM referral adherence (Sick child): Number of cases of illness among sick children age 2- Proportion of children age 2-59 months who 59 months for which the caregiver adhered to the were sick in the two weeks preceding the RCOM’s referral advice survey whose caregiver adhered to the RCOM’s referral advice, among those who Number of cases of illness among sick children age 2- were referred to a health facility by a CCM- 59 months that were referred to a health facility by trained RCOM a CCM-trained RCOM in the two weeks preceding the survey

5. Reasons caregiver did not adhere to Number of sick children age 2-59 months included RCOM referral (Sick child): Proportion of in the survey whose caregiver reported not children age 2-59 months who were sick in adhering to the RCOM’s referral advice because of the two weeks preceding the survey whose caregiver did not adhere to the RCOM’s reason “X” referral advice because of the reasons listed Number of children age 2-59 months whose in the survey questionnaire, among those who did not adhere to the referral advice caregiver did not adhere to the RCOM’s referral advice

RAcE Niger Endline Survey Final Report 55 RCOM SICK CHILD FOLLOW-UP VISIT

1. RCOM sick child follow-up visit (Fever): Number of children age 2-59 months who had fever in Proportion of children age 2-59 months who the two weeks preceding the survey who received a had fever in the two weeks preceding the follow-up visit from a CCM-trained RCOM survey who received a follow-up visit from a RCOM, among those who sought care from a Number of children age 2-59 months who had fever in CCM-trained RCOM the survey whose caregiver sought care from a CCM- trained RCOM

2. RCOM sick child follow-up visit Number of children age 2-59 months who had (Diarrhea): Proportion of children age 2-59 diarrhea in the two weeks preceding the survey who months who had diarrhea in the two weeks received a follow-up visit from a CCM-trained RCOM preceding the survey who received a follow- up visit from a RCOM, among those who Number of children age 2-59 months who had sought care from a CCM-trained RCOM diarrhea in the survey whose caregiver sought care from a CCM-trained RCOM

3. RCOM sick child follow-up visit (Cough Number of children age 2-59 months who had cough with difficult or fast breathing): with difficult or fast breathing in the two weeks Proportion of children age 2-59 months who preceding the survey who received a follow-up visit had cough with difficult or fast breathing in the from a CCM-trained RCOM two weeks preceding the survey who received a follow-up visit from a RCOM, Number of children age 2-59 months who had cough among those who sought care from a CCM- with difficult or fast breathing in the survey whose trained RCOM caregiver sought care from a CCM-trained RCOM

4. RCOM sick child follow-up visit (Sick Number of cases of illness among sick children age 2- child): Proportion of children age 2-59 59 months in the two weeks preceding the survey that months who were sick in the two weeks received a follow-up visit from a CCM-trained RCOM preceding the survey who received a follow- up visit from a RCOM, among those who Number of cases of illness among sick children age 2- sought care from a CCM-trained RCOM 59 months in the survey whose caregiver sought care from a CCM-trained RCOM

5. When the sick child follow-visit Number of cases of illness among children age 2-59 occurred (Sick child): Proportion of months who were sick in the two weeks preceding children age 2-59 months who were sick in the survey that received a follow-up visit from a the two weeks preceding the survey who received a follow-up visit from a RCOM RCOM one/two/three/four/ five/more than five one/two/three/four/ five/more than five days days after the initial RCOM visit after the initial RCOM visit, among those who received a follow-up visit from a RCOM Number of cases of illness among children age 2-59 months included in the survey that received a follow-up visit from a RCOM

RAcE Niger Endline Survey Final Report 56 DID NOT SEEK CARE

1. Did not seek care (Fever): Proportion of Number of children age 2-59 months who had fever in children age 2-59 months who had fever in the two weeks preceding the survey for whom advice the two weeks preceding the survey for or treatment was not sought whom advice or treatment was not sought Number of children age 2-59 months who had fever in the survey

2. Did not seek care (Diarrhea): Proportion Number of children age 2-59 months who had of children age 2-59 months who had diarrhea in the two weeks preceding the survey for diarrhea in the two weeks preceding the whom advice or treatment was not sought survey for whom advice or treatment was Number of children age 2-59 months who had not sought diarrhea in the survey

3. Did not seek care (Cough with difficult Number of children age 2-59 months who had cough or fast breathing): Proportion of children with difficult or fast breathing in the two weeks age 2-59 months who had cough with difficult preceding the survey for whom advice or treatment or fast breathing in the two weeks preceding was not sought the survey for whom advice or treatment Number of children age 2-59 months who had cough was not sought with difficult or fast breathing

4. Did not seek care (Sick child): Number of cases of illness among children age 2-59 Proportion of children age 2-59 months who months who have been sick in the two weeks have been sick in the two weeks preceding the preceding the survey for which advice or treatment survey for whom advice or treatment was was not sought not sought Number of cases of illness among sick children age 2- 59 months in the survey

5. Reasons did not seek care (Sick child): Number of sick children age 2-59 months included Proportion of children age 2-59 months who in the survey whose caregiver reported not seeking were sick in the two weeks preceding the care because of reason “X” survey whose caregiver did not seek care because of the reasons listed in the survey Number of cases of illness among sick children age 2- questionnaire, among those who did not seek 59 months in the survey for which care was not care sought

SOUGHT CARE BUT NOT FROM RCOM

6. Sought care but not from RCOM Number of children age 2-59 months who had fever in (Fever): Proportion of children age 2-59 the two weeks preceding the survey for whom advice months who had fever in the two weeks or treatment was not sought from a CCM-trained preceding the survey for whom advice or RCOM treatment was not sought from a CCM- Number of children age 2-59 months who had fever in trained RCOM, among those who sought any the survey whose caregiver sought any care care

RAcE Niger Endline Survey Final Report 57 7. Sought care but not from RCOM Number of children age 2-59 months who had (Diarrhea): Proportion of children age 2-59 diarrhea in the two weeks preceding the survey for months who had diarrhea in the two weeks whom advice or treatment was not sought from a preceding the survey for whom advice or CCM-trained RCOM treatment was not sought from a CCM- Number of children age 2-59 months who had trained RCOM, among those who sought any diarrhea in the survey whose caregiver sought any care care

8. Sought care but not from RCOM Number of children age 2-59 months who had cough (Cough with difficult or fast breathing): with difficult or fast breathing in the two weeks Proportion of children age 2-59 months who preceding the survey for whom advice or treatment had cough with difficult or fast breathing in was not sought from a CCM-trained RCOM the two weeks preceding the survey for Number of children age 2-59 months who had cough whom advice or treatment was not sought with difficult or fast breathing whose caregiver sought from a CCM-trained RCOM, among those any care who sought any care

9. Sought care but not from RCOM (Sick Number of cases of illness among children age 2-59 child): Proportion of children age 2-59 months who have been sick in the two weeks months who have been sick in the two weeks preceding the survey for which advice or treatment preceding the survey for whom advice or was not sought from a CCM-trained RCOM treatment was not sought from a CCM- trained RCOM, among those who sought any Number of cases of illness among sick children age 2- care 59 months in the survey whose caregiver sought any care

10. Reasons did not seek care from RCOM Number of sick children age 2-59 months included (Sick child): Proportion of children age 2-59 in the survey whose caregiver reported not seeking months who were sick in the two weeks care from a RCOM because of reason “X” preceding the survey whose caregiver did not seek care because of the reasons listed in the Number of cases of illness among sick children age survey questionnaire, among those who 2-59 months in the survey for which care was sought care but did not from a CCM-trained RCOM sought but not from a CCM-trained RCOM

ADDITIONAL SEX-DISAGGREGATED TREATMENT COVERAGE INDICATORS

1. Sought any advice or treatment (Sick Number of children age 2-59 months who had child): Proportion of children age 2-59 fever/diarrhea/cough with difficult or fast breathing months who had fever/diarrhea/cough with for whom advice or treatment was sought from any difficult or fast breathing for whom advice or source treatment was sought from any source Number of children age 2-59 who had fever/diarrhea/cough with difficult or fast breathing included in the survey

RAcE Niger Endline Survey Final Report 58 2. Sought treatment from a RCOM (Sick Number of children age 2-59 months who had child): Proportion of children age 2-59 fever/diarrhea/cough with difficult or fast breathing months who had fever/diarrhea/cough with for whom advice or treatment was sought from a difficult or fast breathing for whom advice or CCM-trained RCOM treatment was sought from a CCM-trained RCOM Number of children age 2-59 who had fever/diarrhea/cough with difficult or fast breathing included in the survey

3. Malaria treatment (Any antimalarial): Number of children age 2-59 months who had fever in Proportion of children age 2-59 months who the two weeks preceding the survey who received any had fever in the two weeks preceding the antimalarial survey who received any antimalarial Number of children age 2-59 months who had fever in the survey

4. Confirmed malaria treatment (Any Number of children age 2-59 months who had fever antimalarial – positive diagnostic test): in the two weeks preceding the survey who had a Proportion of children age 2-59 months with positive malaria diagnostic test result and received fever in the two weeks preceding the survey any antimalarial who received any antimalarial, among those with a positive malaria diagnostic test result Number of children age 2-59 months with fever included in the survey who had a positive malaria diagnostic test result

5. Malaria treatment (ACT): Proportion of Number of children age 2-59 months who had fever in children age 2-59 months who had fever in the two weeks preceding the survey who received the two weeks preceding the survey who ACT received ACT Number of children age 2-59 months who had fever in the survey

6. Confirmed malaria treatment (ACT – Number of children age 2-59 months who had fever positive diagnostic test): Proportion of in the two weeks preceding the survey who had a children age 2-59 months with fever in the positive malaria diagnostic test result and received two weeks preceding the survey who ACT received ACT, among those with a positive malaria diagnostic test result Number of children age 2-59 months with fever included in the survey who had a positive malaria diagnostic test result

7. Malaria treatment (ACT within 24 Number of children age 2-59 months who had fever in hours): Proportion of children age 2-59 the two weeks preceding the survey who received months with fever in the two weeks ACT the same day or the day after the fever started preceding the survey who received ACT the Number of children age 2-59 months who had fever in same day or the day after the fever started the survey

RAcE Niger Endline Survey Final Report 59 8. Confirmed malaria treatment (ACT Number of children age 2-59 months (disaggregated within 24 hours – positive diagnostic by sex) who had fever in the two weeks preceding the test): Proportion of children age 2-59 survey who received ACT the same day or the day months (disaggregated by sex) with fever in after the fever started the two weeks preceding the survey who Number of children age 2-59 months with fever received ACT the same day or the day after the fever started, among those with a positive included in the survey who had a positive malaria diagnostic test results diagnostic test result

9. Suspected pneumonia treatment (Any Number of children age 2-59 months who had antibiotic): Proportion of children age 2-59 cough with difficult or fast breathing in the two months who had cough with difficult or fast weeks preceding the survey who received any breathing in the two weeks preceding the antibiotic survey who received any antibiotic Number of children age 2-59 months who had cough with difficult or fast breathing in the survey

10. Diarrhea treatment (ORS): Proportion of Number of children age 2-59 months who had children age 2-59 months who had diarrhea diarrhea in the two weeks preceding the survey who in the two weeks preceding the survey who received ORS received ORS Number of children age 2-59 months who had diarrhea in the survey

11. Diarrhea treatment (zinc): Proportion of Number of children age 2-59 months who had children age 2-59 months who had diarrhea diarrhea in the two weeks preceding the survey who in the two weeks preceding the survey who received zinc received zinc Number of children age 2-59 months who had diarrhea in the survey

12. Diarrhea treatment (government- Number of children age 2-59 months who had approved homemade fluid): Proportion diarrhea in the two weeks preceding the survey who of children age 2-59 months who had received a government-approved homemade fluid diarrhea in the two weeks preceding the Number of children age 2-59 months who had survey who received a government-approved homemade fluid diarrhea in the survey

RAcE Niger Endline Survey Final Report 60