ENDLINE SURVEY FINAL REPORT

Malaria Consortium, NIGER STATE, NIGERIA Prepared by ICF and Malaria Consortium for WHO Rapid Access Expansion (RAcE) Program May 2017

AUTHORS: Debra Prosnitz, Helen Counihan, Olusola Oresanya, Jonathan Jiya, and Olatunde Adesoro ACKNOWLEDGEMENTS

ICF and Malaria Consortium would like to thank the Niger State Ministry of Health and Mr. Olalekan Onitiju for their contributions to this work. We would also like to thank the community-oriented resource people and community health extension workers who work hard to provide services to caregivers and children in communities, and to 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 State, Nigeria Endline Survey Final Report i TABLE OF CONTENTS ABBREVIATIONS ...... iii EXECUTIVE SUMMARY ...... iv 1 BACKGROUND ...... 1 1.1 RAcE Program Goals and Objectives ...... 1 1.2 RAcE Project Background in Niger State, Nigeria ...... 1 1.3 RAcE 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 ...... 4 2.5 Data Collection ...... 5 2.6 Data Entry and Management ...... 5 2.7 Data Analysis ...... 6 2.8 Survey Indicators ...... 6 2.9 Survey Limitations ...... 6 3 FINDINGS ...... 7 3.1 Characteristics of Sick Children and Caregivers ...... 7 3.2 Decision-Making ...... 10 3.3 Caregiver Knowledge and Their Perception of CORPs ...... 10 3.4 Care-Seeking ...... 12 3.5 Assessment ...... 14 3.6 Treatment Coverage ...... 15 3.7 First Dose of Treatment and Counseling from CORP ...... 18 3.8 CORP Referrals and Referral Adherence ...... 19 3.9 CORP Follow-Up with Sick Child ...... 20 3.10 Illness Management and Diagnostics by Sex ...... 20 4 DISCUSSION ...... 23 Annex A. People Involved in the Survey ...... 25 Annex B. Endline Survey Sample ...... 27 Annex C. Endline Survey Questionnaire ...... 28 Annex D. Endline Survey Training Schedule ...... 29 Annex E. RAcE Endline Survey Process Report ...... 33 Annex F. Endline Survey Fieldwork Schedule ...... 61

RAcE Niger State, Nigeria Endline Survey Final Report ii ABBREVIATIONS

ACT artemisinin-based combination therapy CHEW community health extension worker CORP community-oriented resource person iCCM integrated community case management LGA local government area ORS oral rehydration solution PHCDA Primary Health Care Development Agency PPS probability proportional to size RAcE Rapid Access Expansion RDT rapid diagnostic test SMOH State Ministry of Health TOT training of trainers WHO World Health Organization

RAcE Niger State, Nigeria Endline Survey Final Report iii EXECUTIVE SUMMARY

Malaria Consortium, in partnership with the Niger State Ministry of Health and the Primary Health Care Development Agency, implemented the Rapid Access Expansion (RAcE) program in six local government areas in Niger State, Nigeria, starting in 2013. In January 2017, Malaria Consortium, with the State Ministry of Health, conducted the RAcE endline survey, with technical assistance from ICF. 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 services provided by community-oriented resource persons (CORPs). We used the information to make inferences about project accomplishments. Caregivers’ knowledge of signs of childhood illness increased significantly, as did knowledge of correct treatment for malaria and diarrhea. Notably, caregivers had highly positive perceptions of CORPs at endline: 94 percent of caregivers view CORPs as trusted health care providers, and 96 percent believe that CORPs provide quality services and cite CORPs as a convenient source of treatment. The increase in knowledge of caregivers on signs and correct treatment for childhood illnesses and their confidence in the ability of CORPs to treat the illnesses was likely enhanced by the demand-generation activities of the RAcE project. Overall, care-seeking from an appropriate provider increased significantly, from 75 percent at baseline to 91 percent at endline. Care-seeking practices changed substantially in terms of the provider over the life of the program, with caregivers selecting to seek care from CORPs in their communities for the majority of cases of all illnesses (84 percent) experienced by their children at endline. The percentage of cases of fever in the two weeks preceding the survey who had a blood test increased significantly over the course of the project, from 34 percent at baseline to 77 percent at endline. Results suggest that overall better assessment and management of fever cases was provided by CORPs, compared to all cases that were managed by other providers. Among cases of fever who sought care from a CORP at endline, 77 percent received a blood test from the CORP, compared to only 57 percent of those who sought care from providers other than a CORP receiving a blood test for malaria. For confirmed malaria cases, the percentage of children who received artemisinin-based combination therapy (ACT) the same or next day after onset of fever improved significantly, from 57 percent at baseline to 74 percent at endline. For cases of cough with difficult or fast breathing who sought care from a CORP, 56 percent reported having their respiratory rate counted and endline, and 61 percent were treated with amoxicillin at endline. Among those who sought care from other providers, only 41 percent report having had their respiratory rate counted at endline, and only 30 percent received amoxicillin. Among the cases of diarrhea that sought care from a CORP, 82 percent received oral rehydration solution (ORS) and zinc, compared to only 17 percent of cases of diarrhea managed by other providers. CORPs referred 39 percent of cases of illness at endline. The reasons for these referrals were not recorded. Among sick child cases that did receive a referral, nearly all (93 percent) reported adhering to the referral at endline. Overall, across all cases of illness among children aged 2–59 months, 81 percent received a follow-up visit from a CORP at endline, in line with national integrated community case management (iCCM) protocol.

RAcE Niger State, Nigeria Endline Survey Final Report iv The RAcE project in Niger State provided a series of quality assurance measures, training, and tools that likely contributed to CORPs' adherence with iCCM protocols and caregiver’s perceptions of the high quality of care measured at endline.

Table 1. Changes in key indicators 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 7.8 92.9 1 the two weeks preceding the survey who 85.1 0.0000 (5.0 - 12.0) (85.6 - 96.7) are aware of the presence of the CORP in their community Percentage of caregivers of children age 2-59 months who have been sick in 14.3 78.1 2 the two weeks preceding the survey who 63.8 0.0000 (7.4 - 25.8) (69.7 - 84.6) know the role of the CORP in their community* Percentage of caregivers of children age 2-59 months who have been sick in the two weeks preceding the survey who 55.9 68.2 3 12.3 0.0463 know two or more signs of childhood (45.9 - 65.4) (58.9 - 76.3) illness that 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 76.8 94.1 4 the two weeks preceding the survey who 17.3 0.0033 (59.6 - 88.1) (88.1 - 97.2) view CORPs as trusted health care providers* Percentage of caregivers of children age 2-59 months who have been sick in 67.9 95.6 5 27.7 0.0000 the two weeks preceding the survey who (48.7 - 82.5) (89.7 - 98.2) believe CORPs provide quality services* Percentage of caregivers of children age 2-59 months who have been sick in 85.7 96.1 6 10.4 0.0015 the two weeks preceding the survey who (75.9 - 91.9) (93.7 - 97.6) found the CORP at first visit Percentage of caregivers of children age 2-59 months who have been sick in 85.7 96.0 7 the two weeks preceding the survey who 10.3 0.0314 (68.4 - 94.3) (90.7 - 98.3) cite the CORP 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 75.5 91.4 Overall 16.0 0.0000 8 (68.3 - 81.5) (87.2 - 94.3) 78.0 94.0 Fever 16.0 0.0001 (70.6 - 83.9) (88.8 - 96.9) 71.9 91.3 Diarrhea 19.4 0.0000 (64.3 - 78.5) (86.7 - 94.4) 76.4 88.7 Cough with fast or difficult breathing 12.6 0.0110 (68.1 - 83.1) (82.3 - 93.0)

RAcE Niger State, Nigeria Endline Survey Final Report v Baseline Endline % point Indicator p-value % (CI %) % (CI %) change Percentage of children age 2-59 months who were sick in two weeks preceding the survey taken to a CORP as first source of care 1.6 76.6 Overall 75 0.0000 (0.6 - 4.0) (65.9 - 84.8) 9 1.7 78.4 Fever 76.7 0.0000 (0.6 - 4.9) (66.3 - 87.0) 0.8 75.7 Diarrhea 74.9 0.0000 (0.1 - 5.9) (64.8 - 84.0) 2.3 75.8 Cough with fast or difficult breathing 73.5 0.0000 (0.9 - 6.1) (64.4 - 84.4) Sick child assessment Percentage of children age 2-59 months 33.9 76.7 10 with fever in the two weeks preceding the 42.8 0.0000 (27.6 - 40.8) (69.3 - 82.8) survey who had finger or heel stick Percentage of children age 2-59 months for whom their caregiver received the 65.7 87.5 11 results of the malaria diagnostic test of the 21.8 0.0028 (54.7 - 75.3) (79.3 - 92.7) children who had had finger or heel stick in the two weeks preceding the survey Percentage of children age 2-59 months with cough and difficult or rapid breathing (suspected pneumonia) in the two weeks 47.8 62.1 12 14.3 0.0153 preceding the survey who had their (40.8 - 54.9) (51.9 - 71.4) respiratory rate counted to assess fast breathing Sick child assessment by CORP Percentage of children age 2-59 months with fever in the two weeks preceding the 77.1 13 0.0 77.1 0.0003 survey who had a finger or heel stick by a (67.6 - 84.4) CORP Percentage of children age 2-59 months for whom their caregiver received the results of the malaria diagnostic test of the 90.3 14 0** 90.3 na children who had a finger or heel stick by (0.8 - 1.0) a CORP in the two weeks preceding the survey Percentage of children age 2-59 months with cough and difficult or rapid breathing (suspected pneumonia) in the two weeks 23.5 55.8 15 32.3 0.1252 preceding the survey who had their (4.1 - 69.1) (44.1 - 67.0) respiratory rate counted to assess fast breathing by a CORP Sick child treatment Percentage of children age 2-59 months who received ACT treatment the same or next day following the onset of fever 56.9 73.9 16 17 0.0123 among all children with fever who had a (46.5 - 66.8) (64.7 - 81.4) positive malaria diagnostic test result in the two weeks preceding the survey Percentage of children age 2-59 months who received both ORS and zinc among 12.8 74.0 17 61.2 0.0000 all children who had diarrhea in the two (8.9 - 18.2) (63.6 - 82.3) weeks preceding the survey

RAcE Niger State, Nigeria Endline Survey Final Report vi Baseline Endline % point Indicator p-value % (CI %) % (CI %) change Sick child treatment by CORP Percentage of children age 2-59 months who received ACT treatment from a CORP the same or next day following the 60.6 18 onset of fever among all children with 0.0 60.6 0.0000 (50.0 - 70.4) fever who had a positive malaria diagnostic test result in the two weeks preceding the survey Percentage of children age 2-59 months who received both ORS and zinc from a 1.1 66.3 19 CORP among all children who had 65.2 0.0000 (0.4 - 2.7) (55.5 - 75.7) diarrhea in the two weeks preceding the survey First dose and counseling by CORP Percentage of children age 2-59 months who received the first dose of treatment in the presence of a CORP among those who received prescription medicines for an iCCM condition from a CORP in the two weeks preceding the survey 63.3 73.0 Overall 9.7 0.4223 20 (39.1 - 82.3) (63.7 - 80.7) 38.5 74.0 Fever (ACT) 35.5 0.0772 (10.6 - 76.7) (64.6 - 81.6) 68.8 Diarrhea (ORS and zinc) 0** 18.8 na (57.7 - 78.2) Cough with fast or difficult breathing 92.3 77.5 -14.8 0.1974 (Amoxicillin) (66.3 - 98.7) (64.9 - 86.5) 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 an iCCM condition from a CORP in the two weeks preceding the survey 70.0 97.6 21 Overall 27.6 0.0000 (56.3 - 80.8) (95.5 - 98.7) 76.9 97.5 Fever (ACT) 20.6 0.0009 (46.3 - 92.8) (93.1 - 99.1) 97.0 Diarrhea (ORS and zinc) 0** -3.0 na (93.5 - 98.6) Cough with fast or difficult breathing 53.9 98.6 44.7 0.0000 (Amoxicillin) (33.9 - 72.7) (94.3 - 99.7) Sick child referral and follow-up Percentage of sick children age 2-59 who were referred to a health facility by a 82.1 93.4 22 CORP in the two weeks preceding the 11.3 0.0419 (63.9 - 92.3) (87.2 - 96.8) survey whose caregiver adhered to referral advice Percentage of sick children age 2-59 months who sought care from a CORP in 56.3 80.6 23 24.3 0.0022 the two weeks preceding the survey who (40.2 - 71.1) (73.9 - 85.9) received a follow-up visit from an CORP na = not applicable * Includes only caregivers who were aware of a community case management-trained CORP in their community. ** There were no cases or the number of cases was too small to calculate a percentage.

RAcE Niger State, Nigeria Endline Survey Final Report vii 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 RAcE Project Background in Niger State, Nigeria Over the past three decades, Nigeria has made progress in reducing child mortality. According to the 2013 Nigeria Demographic and Health Survey,1 from 2003 to 2013 infant mortality decreased from 100 to 69 deaths per 1,000 live births, and mortality for children under the age of five decreased from 201 to 128 deaths per 1,000 live births This progress, however, falls far short of the targets set under the Millennium Development Goals: 30 deaths per 1,000 live births for infant mortality and 64 deaths per 1,000 live births for mortality for children under the age of five.2 In an effort to improve the health of children, the Government of Nigeria developed Nigeria’s National Strategic Health Development Plan, which harmonized several efforts to address high child mortality rates: the National Child Health Policy, the Integrated Maternal Newborn and Child Health Strategy, the Integrated Management of Childhood Illnesses, Community Management of Acute Malaria, and the Integrated Community Case Management of Malaria.3 The country has based these policies, strategies, and documents on the continuum-of-care principle— integrated care from the household, through the community, to the health facility, and referral care. In 2013, Nigeria adopted an iCCM strategy with the goal of further reducing the number of deaths among children under the age of five by improving access within their homes and communities to treatment of common childhood illnesses.

1 National Population Commission (NPC) [Nigeria] and ICF International. 2014. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International. 2 Office of the Senior Special Assistant to the President on Millennium Development Goals. 2015. Nigeria 2015: Millennium Development Goals, End Point Report. Available at: file:///C:/Users/31279/Downloads/Nigeria_MDGs_Abridged_Sept30.pdf 3 Government of Nigeria. National iCCM Guidelines.

RAcE Niger State, Nigeria Endline Survey Final Report 1 Malaria Consortium was funded by WHO in 2013 to implement the RAcE project in Niger State, Nigeria. Malaria Consortium leads the project implementation in partnership with the Niger State Ministry of Health (SMOH) and the State Primary Health Care Development Agency (PHCDA). RAcE Niger State aims to increase coverage of diagnostic, treatment, and referral services for children under the age of five through capacity building, training, and operational support to community-oriented resource persons (CORPs), Nigeria’s community health workers, and community health extension workers (CHEWs) who supervise the CORPs. RAcE is implemented in six local government areas (LGAs) in Niger State: Edati, Lapai, Mariga, Paikoro, Rafi, and Rijau. In the first project year (November 2013–October 2014), 704 CORPs were trained, and 673 of those were equipped and deployed to provide iCCM services in Lapai, Paikoro, and Rijau. The project expanded to Edati, Mariga, and Rafi in the second project year (November 2014–October 2015), during which 848 CORPs were trained, and 684 of those were equipped and deployed to provide services. Overall, a total of 195 out of 1,552 trained CORPs were not equipped because they could not meet the minimum performance level after the training assessment. A total of 1,381 CORPs and 154 CHEWs in all 6 LGAs were retrained in the third quarter of the third project year (November 2015–October 2016). Out of 1,357 equipped, only 1,321 were functional in terms of service provision and submission of reports. About 2.6 percent (36) CORPs were non-functional due to relocation or death. In the third year of project implementation, CORPs assessed 196,775 children under the age of five. The baseline household survey was conducted in March 2014 by Malaria Consortium, the Niger SMOH, and the Niger State PHCDA, with technical support from ICF. The endline household survey was conducted in February 2017 by Malaria Consortium, the Niger SMOH, and the Niger State PHCDA, with technical support from ICF; further details are provided in subsequent sections of this report.

1.3 RAcE 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 State 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 CORPs services, and we used the information to make inferences about project accomplishments.

RAcE Niger State, Nigeria Endline Survey Final Report 2 2 SURVEY METHODS

2.1 Survey Implementation and Partnership Malaria Consortium, together with the Niger SMOH and the Niger State PHCDA, conducted the RAcE endline survey, with technical assistance from ICF. Malaria Consortium worked with ICF to finalize the questionnaire. ICF conducted a training of trainers (TOT), and Malaria Consortium led the step-down training of enumerators, data entry operators, and supervisors. Malaria Consortium also provided oversight to the entire implementation process. The survey protocol received ethical approval from ICF’s Institutional Review Board and from Nigeria’s National Health Research Ethics Committee. 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 fast breathing. All primary caregivers of children aged 2–59 months reported to have experienced diarrhea, fever, or cough with rapid breathing in the two weeks prior to interview were considered eligible for inclusion in the survey. ICF developed standardized sampling guidance for all RAcE projects, which was adapted for Niger State, Nigeria. To be able to detect a 20 percent difference in the sick child indicators that include all sick children for a specific illness (fever, diarrhea, or cough with difficult or fast breathing) between baseline and endline at 90 percent power with a two-tailed test and 95 percent confidence using cluster sampling, 263 cases were needed for each illness. 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 household survey used a 30x30 multi-stage cluster sampling methodology. At baseline, the target population comprised the RAcE project area: communities that are more than five km from a functional primary health care facility. At baseline, 30 clusters were selected using probability proportional to size (PPS). In the initial proposed sampling design for the endline survey, the same clusters visited for the baseline survey were proposed to be included in the endline survey. However, discussions with Malaria Consortium identified that 21 of the 30 clusters selected at baseline did not ultimately receive iCCM through the RAcE project The clusters were excluded from initially mapped communities for iCCM services either due to the presence of a health facility within 5 km or failure of selected CORPs to meet the minimum performance level after training. Because of this, ICF redrew 30 new clusters using the same PPS methodology used for the baseline using an updated sampling frame that included only the communities where RAcE activities were implemented. The endline sample is provided in Annex B. Within each cluster, 10 interviews were conducted for each of the 3 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.

RAcE Niger State, Nigeria Endline Survey Final Report 3 At each household, the enumerator first determined whether 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. 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. If multiple children in the same household were reported to have symptoms in the preceding two weeks but had different caregivers, interviewers could interview multiple caregivers, as long as not more than one child from each household was included for each iCCM condition.

2.3 Survey Questionnaire ICF developed a standard household survey questionnaire for all RAcE grantees to use for their baseline surveys. Each grantee adapted the questionnaire to fit the iCCM program and country context, such as using appropriate local terminology for community health workers, care-seeking locations, and treatment options. The same questionnaire used for the baseline survey was used at endline, with some additional questions added to the endline questionnaire: two questions were added to each of the illness modules to gather information about whether caregivers sought care for their sick child and whether they sought care from a CORP. 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 collected 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. Annex C contains the survey household questionnaire.

2.4 Selection and Training of Survey Staff ICF conducted an endline survey TOT in Abuja from January 24 to 27, 2017 for 12 participants from Malaria Consortium and the Niger SMOH. A WHO Nigeria representative joined for one day of the training. The training used a participatory approach and focused on preparing survey teams to conduct the survey and supervise the implementation. The approach focused on ensuring a shared understanding of the technical aspects of the RAcE endline survey and establishing specific details needed for implementation, such as assigning responsibilities for household and respondent selection, adjusting definitions of households to reflect actual family structures in Niger State, and defining steps for solving problems that might arise during implementation. The TOT workshop was followed by a five-day cascade training of two groups of enumerators conducted concurrently: one for the three northern LGAs (Mariga, Rafi, and Rijau) and one for the three southern LGAs (Edati, Lapai, and Paikoro). The five-day training included four days of classroom

RAcE Niger State, Nigeria Endline Survey Final Report 4 training and one day of field practice. There was one day of training provided for the data manager to provide information on the study protocol and the data collection instruments. The data manager used the opportunity to familiarize himself with the data entry template developed by ICF. The data manager conducted a 1-day training on data entry using CSPro for 10 data clerks by test-running the data entry template. ICF provided additional clarification and support on the use of the template for effective and efficient data entry process. In addition to the training of data clerks, the data manager provided supportive supervision and further data management by making corrections and merging all entries. The training schedule is provided in Annex D.

2.5 Data Collection Endline survey data collection took place from February 13 through 25. A total of 12 survey teams, each composed of 1 supervisor and 4 enumerators, conducted the data collection. Data collection first took place in the three southern LGAs (Edati, Lapai, and Paikoro), followed by data collection in the northern LGAs (Mariga, Rafi, and Rijau). Data collection in the southern LGAs went smoothly, and survey teams found adequate number of cases of illness in each cluster. In five of the clusters in the northern LGAs, survey teams had to go to the nearest neighboring community to get an adequate number of cases of illness. Written informed consent was obtained from each caregiver prior to interview. Participation in the study was voluntary, and there was no penalty for non-participation. Survey respondents were not compensated for their time away from income-earning activities or daily duties for participating in the data collection. The questionnaire took approximately 40 minutes to administer per caregiver interviewed. Quality control procedures during field work included daily spot checks by supervisors, during which they observed at least one interview per enumerator per day and also reviewed all completed questionnaires they received. In addition, one monitor was assigned to each LGA to ensure team compliance with the survey protocol and to provide further logistical, material, and technical support to the supervisors. These monitors were Malaria Consortium personnel who participated in all the trainings, including the TOT. A detailed account of the survey implementation process is documented in the RAcE Endline Survey Process Report, prepared by Malaria Consortium and provided in Annex E. The fieldwork schedule is provided in Annex F.

2.6 Data Entry and Management Data entry took place from February 27 through March 7. Data entry operators double-entered the survey data into a database using a CSPro tool developed by ICF for the baseline and endline surveys. After the data entry operator entered the data separately for a cluster, the data entry supervisor ran a quality check built into the CSPro tool to compare the first and second entries for the cluster. If the check found any discrepancies, the data entry operator used the paper questionnaires to verify the correct values and then resolved the discrepancies using the CSPro tool. The supervisor again ran the quality check, and if it resulted in no discrepancies, the data for the cluster were considered clean. Names of participants were collected only for purposes of listing but were not used during any stage of data analysis. Data entered could not be traced back to the individuals. Access to data was restricted to

RAcE Niger State, Nigeria Endline Survey Final Report 5 authorized personnel only. After data for all clusters were entered and validated, Malaria Consortium stripped the final dataset of any identifying information prior to sending it to ICF for analysis.

2.7 Data Analysis ICF analyzed the survey data using Stata v14 and Microsoft Excel. The ICF analyst imported the baseline and endline CSPro data files into Stata and merged them into one file for the analysis. The ICF analyst calculated survey indicator point estimates and 95 percent confidence intervals accounting for cluster effects. Pearson’s chi-squared test was used 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.

2.8 Survey Indicators The household survey collected data on 23 key indicators related to caregiver knowledge of CORPs and child illnesses; caregiver perceptions of CORPs; 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.

2.9 Survey Limitations The survey provides estimates for the RAcE project area as a whole. The survey was not powered to provide LGA-level estimates. There are also known potential biases and limitations with the 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 Section 3, Findings.

RAcE Niger State, Nigeria Endline Survey Final Report 6 3 FINDINGS

The findings for the baseline and endline household survey are organized and presented below by the key topic areas covered in the survey. The first section presents key background characteristics of the sick children and their caregivers. This is followed by the key findings related to household decision-making about income and care-seeking; caregiver knowledge and their perceptions of CORPs; continued feeding and care-seeking practices for sick children; assessment and treatment coverage for fever, diarrhea, and cough with difficult or fast breathing; administration of and counseling on treatment by CORPs; and CORP referral and follow-up practices.

3.1 Characteristics of Sick Children and Caregivers Tables 2 and 3 present the background characteristics of the sick children and their caregivers included in the survey. Overall, there was an equal representation of sick children by sex and an even distribution of age groups at baseline and endline (see Table 2). An equal number of cases of fever, diarrhea, and cough with difficult or fast breathing were captured at endline. The majority of caregivers were between the ages of 25 to 34 years and had no education, and nearly all were married or living with a partner as if married (see Table 3). The primary mode of transportation that caregivers reported taking to a health facility changed from walking at baseline (56 percent) to motorbike at endline (77 percent). The majority of caregivers reported that it takes less than 30 minutes to get to the health facility, with most living within less than 9 km of the nearest health facility (see Table 4). Among those who walk to a facility, the majority (61 percent) at endline reported that it takes less than 30 minutes to walk. Because it is unlikely that anyone can walk even 5 km in 30 minutes or less, there is likely significant misunderstanding of the question or flawed estimation by caregivers in responding to this question.

Table 2. Characteristics of sick children included in the survey

Baseline Endline Child characteristic % (CI %) % (CI %) Sex of sick children included in survey 50.5 49.9 Male, % (47.0 - 54.0) (45.0 - 54.7) 49.5 50.2 Female, % (46.0 - 53.0) (45.3 - 55.0) Age (months) of sick children included in survey 20.2 15.0 2–11, % (17.5 - 23.3) (12.2 - 18.4) 21.1 22.1 12–23, % (18.7 - 23.9) (19.7 - 24.6) 17.1 22.1 24–35, % (14.3 - 20.4) (19.7 - 24.6) 17.1 20.0 36–47, % (14.3 - 20.4) (17.1 - 23.3) 19.7 19.4 48–59, % (16.8 - 22.9) (16.5 - 22.7) Two-week history of illness of sick children included in survey 58.3 57.9 Had fever, % (52.9 - 63.5) (53.9 - 61.9) 47.9 46.9 Had diarrhea, % (47.0 - 57.1) (43.1 - 50.8)

RAcE Niger State, Nigeria Endline Survey Final Report 7 Baseline Endline Child characteristic % (CI %) % (CI %) 43.2 51.2 Had cough with fast breathing, % (38.1 - 48.4) (47.7 - 54.7) Average number of illnesses, N 1.5 1.6 Total number of sick children 899 680 included in survey Cases of illness included in survey Fever, N 413 301 Diarrhea, N 374 300 Cough with fast breathing, N 343 301 Total number of illness cases among 1,130 902 sick children included in survey

Table 3. Caregiver characteristics Baseline Endline Caregiver characteristic % (CI%) % (CI %) Age (years) 16.5 18.8 15–24 (13.2 - 20.4) (14.3 - 24.3) 60.8 58.2 25–34 (55.8 - 65.5) (52.9 - 63.4) 16.5 20.6 35–44 (13.1 - 20.5) (16.2 - 25.8) 2.8 2.4 45+ (1.6 - 4.7) (1.3 - 4.2) Mean age (years) 29 years 29 years Education 83.6 83.3 None (77.7 - 88.2) (76.2 - 88.6) 11.1 12.4 Primary (8.3 - 14.7) (8.8 - 17.1) 5.3 4.3 Secondary or higher (2.8 - 9.7) (2.0 - 9.2) Marital status Currently married or living with 94.3 99.6 partner as if married (91.2 - 96.4) (98.4 - 99.9) 5.7 0.4 Not in union (3.7 - 8.8) (0.1 - 1.6) Partner living with caregiver (among those in union)* 95.4 97.1 Yes (93.1 - 97.0) (93.9 - 98.6) Total number of caregivers 721 510 * There were 680 caregivers in a union at baseline, and 508 caregivers in a union at endline.

RAcE Niger State, Nigeria Endline Survey Final Report 8 Table 4. Reported distance and mode of transport to nearest health facility Baseline Endline Travel to nearest facility % (CI%) % (CI%) Distance to nearest facility 68.9 33.3 < 5 km (57.2 - 78.6) (22.3 - 46.5) 19.5 39.2 5–9 km (13.9 - 26.6) (25.3 - 55.1) 6.3 4.3 10–14 km (3.1 - 12.6) (2.1 - 8.8) 5.3 3.7 15–29 km (2.5 - 11.1) (1.2 - 11.0) 1.8 30+ km 0 (0.3 - 8.7) 17.7 Don’t know 0 (9.4 - 30.8) Mean distance 3.9 km 6.0 km Number of caregivers 678 510 Mode of transport 56.0 19.3 Walk (44.5 - 66.9) (11.9 - 29.6) 40.8 77.6 Motorbike (31.1 - 51.3) (67.9 - 85.0) 3.2 3.1 Other (1.1 - 9.3) (1.2 - 7.8) Number of caregivers 652 509 Time to nearest facility (among those who go to the facility) 76.8 65.8 < 30 minutes (67.4 - 84.2) (54.3 - 75.7) 12.2 23.2 30–59 minutes (8.7 - 17.0) (15.4 - 33.3) 5.8 8.1 1–< 2 hours (3.2 - 10.2) (4.3 - 14.6) 5.2 3.0 2 hours or more (2.1 - 12.2) (0.9 - 9.6) Mean time 29 minutes 32 minutes Number of caregivers 678 509 Time to nearest facility (among those who walk to the facility) 83.2 61.2 < 30 minutes (72.6 - 90.3) (39.1 - 79.5) 9.1 30.6 30 – 59 minutes (4.7 - 16.9) (15.8 - 51.0) 2.8 8.2 1 – < 2 hours (1.2 - 6.0) (4.3 - 14.9) 5.0 2 hours or more 0 (1.9 - 12.1) Mean time 21 minutes 29 minutes Number of caregivers 364 98 Note: Communities were selected for inclusion in the RAcE project based on a Geographic Information System mapping exercise conducted by Malaria Consortium at the start of the project. This exercise mapped all health facilities in RAcE project LGAs and identified communities falling outside the 5 km radius of each facility.

RAcE Niger State, Nigeria Endline Survey Final Report 9 3.2 Decision-Making Decision-making about household income and care-seeking at both baseline and endline was made predominantly by the caregiver’s husband or partner (see Table 5). However, there was a significant increase in joint decision-making for both income decisions and care-seeking decisions over the course of the project. At baseline, only 7 percent of income decisions were made jointly by the caregiver and partner; this increased to 29 percent at endline. At baseline, only 5 percent of care-seeking decisions were made jointly; this increased to 29 percent 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, overall joint decision-making to seek care for the sick child with a husband or partner increased significantly over the course of the project, from 60 percent at baseline to 75 percent at endline (p<0.05). This trend of significant increase for joint decision-making was also found for each illness.

Table 5. Usual decision-maker in household about income and care-seeking Income decisions Care-seeking decisions Decision-maker Baseline Endline p-value Baseline Endline p-value % (CI%) % (CI%) % (CI%) % (CI%) 12.1 2.8 11.6 2.8 Caregiver alone (7.3 - 19.3) (1.5 - 4.9) (7.1 - 18.4) (1.6 - 4.6) Caregiver’s husband or 79.1 66.1 80.7 67.9 partner (71.3 - 85.2) (55.6 - 75.3) (72.3 - 87.0) (57.8 - 76.6) Caregiver and partner 7.1 29.3 5.4 28.7 0.0000 0.0000 jointly (3.2 - 14.8) (21.0 - 39.3) (2.0 - 13.9) (20.6 - 38.6) 1.8 1.8 2.2 0.6 Other (0.7 - 4.2) (0.5 - 6.4) (1.0 - 4.7) (0.1 - 2.6) Total number of 678 508 680 508 caregivers in a union

Table 6. 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 %) 60.0 74.9 Overall 0.0065 1075 898 (52.2 - 67.4) (66.9 - 81.6) 60.6 77.7 Fever 0.0081 398 301 (52.0 - 68.5) (68.1 - 85.1) 58.2 72.2 Diarrhea 0.0088 359 298 (50.1 - 65.9) (63.3 - 79.6) Cough with fast or difficult 61.3 74.9 0.0297 318 299 breathing (52.0 - 69.9) (65.7 - 82.3)

3.3 Caregiver Knowledge and Their Perception of CORPs Findings from the 721 caregivers sampled at baseline and the 510 caregivers sampled at endline show that in the RAcE project areas, caregiver knowledge of childhood illness increased over the course of the project. Caregiver knowledge of two or more childhood illness danger signs increased significantly, from 56 percent at baseline to 68 percent at endline (p<0.05) (see Table 7). Knowledge of the cause of malaria increased significantly, from 61 percent at baseline to 78 percent at endline, but knowledge of fever as a sign of malaria did not change significantly. Caregiver knowledge of correct malaria treatment (artemisinin-based combination therapy [ACT]) increased significantly between baseline and endline, from 26 percent at baseline to 73 percent at endline (p<0.0001). Caregiver knowledge of correct

RAcE Niger State, Nigeria Endline Survey Final Report 10 diarrhea treatment (oral rehydration solution [ORS] and zinc) also increased significantly, from 5 percent at baseline to 54 percent at endline (p<0.0001).

Table 7. Caregiver knowledge of childhood illnesses Baseline Endline Caregiver illness knowledge p-value % (CI %) % (CI %) 55.9 68.2 Knows 2+ child illness signs 0.0463 (45.9 - 65.4) (58.9 - 76.3) 61.2 77.8 Knows cause of malaria 0.0154 (52.5 - 69.2) (68.8 - 84.8) 57.7 63.9 Knows fever is a sign of malaria 0.3194 (49.8 - 65.2) (54.9 - 72.1) 25.5 72.9 Knows malaria treatment 0.0000 (20.3 - 31.5) (63.7 - 80.6) 4.9 53.5 Knows diarrhea treatment (ORS + zinc) 0.0000 (2.8 - 8.4) (42.2 - 64.5) Total number of caregivers 721 510 At baseline, 56 caregivers (8 percent of those surveyed) reported knowing the iCCM-trained CORP working in their community. This increased to 93 percent of caregivers at endline (see Table 8). At baseline, CORPs had not yet been trained and deployed in communities to provide iCCM. The quality control team for the baseline survey determined that the 56 respondents who reported knowing the CORP likely misidentified CHEWs and Junior CHEWs in the community as CORPs. Of those caregivers who reporting knowing the CORP, the percentage of caregivers who know the location of the CORP increased significantly, from 57 percent at baseline to 97 percent at endline. The percentage of caregivers who could identify at least two curative services provided by the CORP increased significantly over the course of the project, from 14 percent at baseline to 78 percent at endline. This increase in knowledge of the role of the CORP is expected with the rollout of iCCM services provided by CORPs in communities over the course of the project.

Table 8. Caregiver knowledge of CORP

Caregiver knowledge of iCCM-trained Baseline Endline Baseline Endline p-value CORP % (CI %) % (CI %) N N Knows iCCM-trained CORP works in 7.8 92.9 0.0000 721 510 community (5.0 - 12.0) (85.6 - 96.7) 57.1 96.8 Knows location of iCCM-trained CORP* 0.0000 56 474 (38.3 - 74.1) (93.3 - 98.5) Knows role of iCCM-trained CORP 14.3 78.1 0.0000 56 474 (identified 2+ curative services)* (7.4 - 25.8) (69.7 - 84.6) *Only asked of caregivers who stated that there was a CORP in their community

Overall, caregivers had positive perceptions of CORPs at both baseline and endline, with positive perceptions increasing significantly in all dimensions at endline. Table 9 shows that at endline, 94 percent of caregivers view CORPs as trusted health care providers, and 96 percent believe that CORPs provide quality services, cite CORPs as a convenient source of treatment, and found the CORP at the first care-seeking visit.

RAcE Niger State, Nigeria Endline Survey Final Report 11 Table 9. Caregiver perceptions of iCCM-trained CORP Baseline Endline Baseline Endline Caregiver perception of CORP p-value % (CI %) % (CI %) N N Views the CORP as a trusted health care 76.8 94.1 0.0033 56 474 provider (59.6 - 88.1) (88.1 - 97.2) 67.9 95.6 Believes the CORP provides quality services 0.0000 56 474 (48.7 - 82.5) (89.7 - 98.2) Cites the CORP as a convenient source of 85.7 96.0 0.0314 56 474 treatment (68.4 - 94.3) (90.7 - 98.3) Found the CORP at first visit (for all 85.7 96.1 instances of care-seeking included in 0.0015 35 410 (75.9 - 91.9) (93.7 - 97.6) survey)* * Includes only caregivers who report seeking care from a CORP for at least one sick child

3.4 Care-Seeking Overall, care-seeking from an appropriate provider increased significantly, from 75 percent at baseline to 91 percent at endline (p<0.001) (see Table 10). Care-seeking from an appropriate provider also increased significantly for each iCCM illness over the course of the project: from 78 percent to 94 percent for cases of fever (p<0.01), from 72 percent to 91 percent for cases of diarrhea (p<0.01), and from 76 percent to 89 percent for cases of cough with difficult or fast breathing (p<0.05). Care-seeking practices also changed substantially in terms of the provider over the life of the project, with caregivers selecting to seek care from CORPs in their communities for the majority of cases of all illnesses experienced by their children at endline. Among all cases of illness for which care was sought at baseline, the majority of cases of illness sought care at a hospital (42 percent) or a health center (29 percent); by endline, the majority of cases of illness sought care from CORPs (84 percent), followed by health centers (21 percent). These results reflect multiple sources of care for some cases of illness. The first source of care sought for all cases of illness followed the same trend, with a hospital (39 percent) as the most commonly reported first source of care at baseline, followed by a health center (24 percent). At endline, the most commonly reported first sources of care were a CORP (82 percent) and a health center (9 percent). At endline, more than two-thirds of all cases of illness among children aged 2–59 months were taken to a CORP as the first source of care (see Table 10). When assessing care-seeking from CORPs among only sick child cases for whom care was sought, approximately 82 percent of cases were taken to a CORP; this was consistent across all illnesses (see Table 11). For approximately 21 percent of all cases of illness among children aged 2–59 months in the two weeks preceding the survey, caregivers reported not seeking any care for their child’s illness episode at both baseline and endline (see Table 12). Among the caregivers who did not seek care at endline (N=63), the majority (58 percent) reported not seeking care because they did not have money for transport or care; 21 percent reported that they could treat the condition at home or with medicines already on hand. There were 138 caregivers who sought care but not from a CORP. Nearly all of these caregivers (95 percent) reported not seeking care from a CORP because they did not trust the CORP to provide care and they believed that the CORP did not have medicines or supplies; 94 percent thought that their child’s condition was too serious for the CORP to treat.

RAcE Niger State, Nigeria Endline Survey Final Report 12 Table 10. Source of care by illness Sought care from CORP was first source of appropriate provider* p- care p- Baseline Endline Illness Baseline Endline value Baseline Endline value N N % (CI%) % (CI%) % (CI%) % (CI%) 75.5 91.4 1.6 76.6 Overall 0.0000 0.0000 1,130 902 (68.3 - 81.5) (87.2 - 94.3) (0.6 - 4.0) (65.9 - 84.8) 78.0 94.0 1.7 78.4 Fever 0.0001 0.0000 413 301 (70.6 - 83.9) (88.8 - 96.9) (0.6 - 4.9) (66.3 - 87.0) 71.9 91.3 0.8 75.7 Diarrhea 0.0000 0.0000 374 300 (64.3 - 78.5) (86.7 - 94.4) (0.1 - 5.9) (64.8 - 84.0) Cough with 76.4 88.7 2.3 75.8 fast or difficult 0.0110 0.0000 343 301 (68.1 - 83.1) (82.3 - 93.0) (0.9 - 6.1) (64.4 - 84.4) breathing * Appropriate providers include hospital, health center, health post, clinic, CORP, or pharmacy

Table 11. Care-seeking from CORPs CORP was first source of care among those who sought any p- Baseline Endline Illness care value N N Baseline Endline % (CI %) % (CI %) 2.1 82.4 Overall 0.0000 869 839 (0.8 - 5.2) (71.5 - 89.7) 2.2 82.2 Fever 0.0000 325 287 (0.7 - 6.1) (70.6 - 89.9) 1.1 82.0 Diarrhea 0.0000 274 277 (0.1 - 8.1) (70.5 - 89.6) Cough with fast or difficult 3.0 82.9 0.0000 270 275 breathing (1.1 - 7.7) (71.7 - 90.3)

Table 12. Cases of illness for which no care was sought Baseline Endline Baseline Endline Illness p-value % (CI %) % (CI %) N N Did not seek care 21.3 7.0 Overall 0.0000 1,130 902 (17.3 – 30.1) (4.6 – 10.4) 21.3 4.7 Fever 0.0000 413 301 (15.4 - 28.7) (2.5 - 8.6) 26.7 7.7 Diarrhea 0.0000 374 300 (20.4 - 34.2) (4.8 - 12.0) 21.3 8.6 Cough with fast or difficult breathing 0.0013 343 301 (15.2 - 29.0) (5.5 - 13.4) Sought care but not from CORP 26.7 26.7 Overall 0.0000 869 839 (20.4 - 34.2) (20.4 - 34.2) 94.8 16.4 Fever 0.0000 325 287 (89.5 - 97.5) (8.7 - 28.7) 94.9 17.0 Diarrhea 0.0000 274 277 (89.4 - 97.6) (9.8 - 27.9) 93.7 16.0 Cough with fast or difficult breathing 0.0000 270 275 (86.1 - 97.3) (9.1 - 26.7)

RAcE Niger State, Nigeria Endline Survey Final Report 13 3.5 Assessment Overall, over the course of the project, the percentage of cases of fever in the two weeks preceding the survey who had a blood test increased significantly, from 34 percent at baseline to 77 percent at endline (p<0.001) (see Table 13). Similar improvements were observed in the percentage of caregivers who received the result of the blood test, which increased significantly, from 66 percent at baseline to 88 percent at endline (p<0.01), and the percentage of children who received ACT after being confirmed for malaria, which increased significantly, from 65 percent at baseline to 88 percent at endline (p<0.01). Among cases of fever who sought care from a CORP at endline, 77 percent received a blood test from the CORP, 90 percent of their caregivers reported receiving the result of the test from the CORP, and 89 percent received ACT from the CORP after being confirmed for malaria. Among children with fever who sought care from a provider other than a CORP at endline, 57 percent received a blood test from the provider, 41 percent of their caregivers reported receiving the result of the test from the provider, and 48 percent received ACT from the provider after being confirmed for malaria. These results indicate overall better assessment and management of fever cases by CORPs, compared to all cases that were managed by various other providers. 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 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.”4

Table 13. Malaria assessment among children with fever Baseline Endline Baseline Endline Malaria assessment p-value % (CI %) % (CI %) N N All fever cases Child had blood drawn by any 33.9 76.7 0.0000 413 301 provider (27.6 - 40.8) (69.3 - 82.8) Caregiver received result of blood 65.7 87.5 0.0028 140 231 test (54.7 - 75.3) (79.3 - 92.7) 78.3 93.1 Blood test positive for malaria 0.0039 92 202 (64.3 - 87.8) (86.9 - 96.5) Received ACT after positive blood 65.2 87.6 test, among those who had a 0.0017 92 202 (51.9 - 76.5) (80.2 - 92.5) positive blood test Fever cases in which care was sought from CORP 77.1 Child had blood drawn by CORP** 0 0.0003 17 240 (67.6 - 84.4) Caregiver received result of blood 90.3 0* na 0 185 test (0.8 - 1.0) 92.8 Blood test positive for malaria 0* na 0 167 (0.9 - 1.0)

4 Maternal and Child Health Integrated Program. 2013. Indicator guide: Monitoring and evaluating integrated community case management. Washington, DC: John Snow Inc., Karolinksa Institute, Save the Children, Uppsala University, and the World Health Organization.

RAcE Niger State, Nigeria Endline Survey Final Report 14 Baseline Endline Baseline Endline Malaria assessment p-value % (CI %) % (CI %) N N Received ACT after positive blood 89.0 test, among those who had a 0* na 0 155 (0.8 - 1.0) positive blood test Fever cases in which care was sought from providers other than CORP Child had blood drawn by other 99.4 57.1 0.0000 318 112 provider** (95.3 - 99.9) (40.9 - 72.0) Caregiver received result of blood 27.9 40.6 0.0797 316 64 test (21.1 - 35.8) (28.8 - 53.6) 79.6 96.2 Blood test positive for malaria 0.0708 88 26 (65.0 - 89.1) (73.8 - 99.6) Received ACT after positive blood 68.6 48.0 test, among those who had a 0.0546 70 25 (53.1 - 80.8) (28.0 - 68.7) positive blood test na = not applicable * There were no cases or the number of cases was too small to calculate a percentage. ** Malaria assessment provider missing for six cases at baseline and four cases at endline. Table 14 presents the findings on coverage of respiratory rate assessment among cases of cough with fast or difficult breathing in the two weeks preceding the survey. The percent of cases that had their respiratory rate assessed increased significantly, from 48 percent at baseline to 62 percent at endline (p<0.05). Among those cases that sought care from a CORP, 56 percent reported having their respiratory rate counted at endline. It is likely that some caregiver respondents did not understand or correctly recall the diagnostic procedure implemented by the CORP. Routine monitoring data collected using lot quality assurance sampling showed that 98 percent of the 2,208 fast breathing cases assessed by CORPs in November 2016 had their respiratory rates counted. There was a significant decrease (p<0.05) in cases of cough with fast or difficult breathing who sought care from providers other than a CORP who had their respiratory rate counted. Among caregivers who sought care from providers other than a CORP, 57 percent reported having their respiratory rate counted at baseline, and this decreased to only 41 percent at endline.

Table 14. Respiratory rate assessment Baseline Endline Baseline Endline Fast breathing assessment p-value % (CI %) % (CI %) N N All cough with fast or difficult breathing cases 47.8 62.1 Respiratory rate assessed 0.0153 343 301 (40.8 - 54.9) (51.9 - 71.4) Cough with fast or difficult breathing cases in which care was sought from CORP* 23.5 55.8 Respiratory rate assessed 0.1252 17 231 (4.1 - 69.1) (44.1 - 67.0) Cough with fast or difficult breathing cases in which care was sought from provider other than CORP 57.4 42.3 Respiratory rate assessed 0.0161 256 102 (50.0 – 64.5) (30.9 – 54.3) Note: Some cases sought care from multiple providers, which is why the sum of the endline N for those assessed by CORP and those assessed by other providers (333) is larger than endline N that had respiratory rate assessed (301). *Provider of fast breathing assessment missing for 13 cases at baseline and 5 cases at endline.

3.6 Treatment Coverage Treatment of fever cases (N=301), by any provider, with ACT the same or next day following the onset of fever increased significantly over the course of the project, from 27 percent at baseline to 65 percent at endline (see Table 15). Among confirmed malaria cases (N=188), the percentage of children who received ACT within the same or next day following the onset of fever also increased significantly, from

RAcE Niger State, Nigeria Endline Survey Final Report 15 57 percent at baseline to 74 percent at endline (p<0.05). It is important to note that results of treatment of confirmed malaria are based on caregiver recall of receiving a finger or heel stick (rapid diagnostic test [RDT] or microscopy, depending on the provider), which can be poor and therefore can affect the results of a malaria diagnosis and receipt of treatment.5 For cases of diarrhea, treatment with ORS and zinc by any provider increased significantly, from 13 percent at baseline to 74 percent at endline (p<0.001), and for cases of cough with difficult or fast breathing, treatment with amoxicillin by any provider increased significantly from 29 percent at baseline to 61 percent at endline (p<0.001).6 Table 16 presents the findings on receipt of treatment by a CORP among the cases that sought care from a CORP, and receipt of treatment by providers other than CORP that sought care from other providers. At endline, among children aged 2–59 months who sought care from a CORP, 68 percent of fever cases (N=240) were treated with ACT the same or next day after fever onset, and 74 percent of confirmed malaria cases (N=155) were treated with ACT the same or next day after fever onset. Treatment of fever and confirmed malaria by CORPs (68 and 74 percent) is comparatively much higher than that by providers other than CORPs (22 percent and 40 percent), among the cases that sought care from other providers. Among cases of diarrhea that sought care from CORPs, 82 percent were treated with ORS and zinc by CORPs. Among cases of cough with fast or difficult breathing who sought care from CORPs, 61 percent were treated with amoxicillin by the CORPs. As shown in Table 16, treatment of both diarrhea and cough with fast or difficult breathing by other providers, among those who sought care from other providers, was lower at endline that treatment by CORPs.

5 Maternal and Child Health Integrated Program. 2013. Indicator guide: Monitoring and evaluating integrated community case management. Washington, DC: John Snow Inc., Karolinksa Institute, Save the Children, Uppsala University, and the World Health Organization. 6 Treatment of cough with difficult or fast breathing must be interpreted with caution. Pneumonia treatment, for which this indicator is a proxy, is globally recognized to have validity issues* because diagnosis of “suspected” pneumonia, which is based on the presence of cough accompanied by difficult or rapid breathing, is often inaccurate in comparison with clinical diagnosis of pneumonia at health facilities. The survey did not collect information on whether the child was classified as having fast breathing for his or her age according to a respiratory rate assessment; there is no validated household survey question to capture this, and there are better methods of collecting this information. The results of this indicator, therefore, should not be interpreted as appropriate treatment for pneumonia, because there are likely cases of cough with difficult or fast breathing captured in it that are not actual pneumonia cases. Careful interpretation is needed for decision-making regarding actions to take regarding assessment, diagnosis, and treatment of sick child cases with antibiotics. * Campbell H, el Arifee 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 State, Nigeria Endline Survey Final Report 16 Table 15. Treatment coverage Baseline Endline Baseline Endline Illness (treatment) p-value % (CI %) % (CI %) N N Received treatment Fever (ACT same or next day following 27.4 64.5 0.0000 413 301 the onset of fever) (22.1 - 33.3) (56.3 - 71.9) Confirmed malaria (ACT same or next 56.9 73.9 0.0123 72 188 day following the onset of fever)* (46.5 - 66.8) (64.7 - 81.4) 68.2 88.3 Diarrhea (ORS) 0.0000 374 300 (59.5 - 75.7) (81.9 - 92.7) 15.0 77.0 Diarrhea (zinc) 0.0000 374 300 (10.5 - 20.9) (66.8 - 84.8) 12.8 74.0 Diarrhea (ORS and zinc) 0.0000 374 300 (8.9 - 18.2) (63.6 - 82.3) Cough with difficult or fast breathing 28.6 60.5 0.0000 343 301 (amoxicillin) (21.6 - 36.7) (50.2 - 69.9) Received treatment from CORP Fever (ACT same or next day following 2.2 55.5 0.0000 413 301 the onset of fever) (0.8 - 5.7) (46.6 - 64.0) Confirmed malaria (ACT same or next 60.6 0 0.0000 72 188 day following the onset of fever)* (50.0 - 70.4) 3.2 75.3 Diarrhea (ORS) 0.0000 374 300 (1.3 - 7.7) (63.9 - 84.0) 1.1 68.3 Diarrhea (zinc) 0.0000 374 300 (0.4 - 2.7) (57.5 - 77.5) 1.1 66.3 Diarrhea (ORS and zinc) 0.0000 374 300 (0.4 - 2.7) (55.5 - 75.7) Cough with difficult or fast breathing 3.8 47.2 0.0000 343 301 (amoxicillin) (1.5 - 9.5) (36.3 - 58.3) Received treatment from provider other than CORP Fever (ACT same or next day following 25.2 9.0 0.0015 413 301 the onset of fever) (20.0 - 31.2) (4.5 - 17.1) Confirmed malaria (ACT same or next 56.9 13.3 0.0000 72 188 day following the onset of fever)* (46.5 - 66.8) (7.1 - 23.4) 65.0 13.0 Diarrhea (ORS) 0.0000 374 300 (55.5 - 73.4) (7.6 - 21.4) 12.8 9.7 Diarrhea (zinc) 0.3157 374 300 (9.0 - 18.0) (6.4 - 14.3) 11.8 7.7 Diarrhea (ORS and zinc) 0.1541 374 300 (8.1 - 16.8) (4.5 - 12.7) Cough with difficult or fast breathing 24.8 13.3 0.0212 343 301 (amoxicillin) (18.0 - 33.1) (8.1 - 21.0) * Denominator for confirmed malaria is restricted to those with a positive malaria diagnostic test result.

Table 16. Treatment by CORPs and other providers among those who sought care Baseline Endline Baseline Endline Illness (treatment) p-value % (CI %) % (CI %) N N Received treatment from CORP among those who sought care from CORP Fever (ACT same or next day following 41.2 68.3 0.0157 17 240 the onset of fever) (23.4 - 61.6) (61.1 - 74.8) Confirmed malaria (ACT same or next 73.6 0* na 0 155 day following the onset of fever)** (64.0 - 81.3) 35.7 93.0 Diarrhea (ORS) 0.0000 14 230 (14.3 - 65.0) (87.7 - 96.2) 21.4 83.9 Diarrhea (zinc) 0.0000 14 230 (7.3 - 48.6) (76.0 - 89.6) 21.4 82.2 Diarrhea (ORS and zinc) 0.0000 14 230 (7.3 - 48.6) (74.2 - 88.1) Cough with difficult or fast breathing 68.4 61.2 0.5664 19 232 (amoxicillin) (42.3 - 86.5) (49.2 - 72.0)

RAcE Niger State, Nigeria Endline Survey Final Report 17 Baseline Endline Baseline Endline Illness (treatment) p-value % (CI %) % (CI %) N N Received treatment from provider other than CORP among those who sought care from other providers Fever (ACT same or next day following 32.1 22.4 0.2227 324 116 the onset of fever) (25.8 - 39.1) (11.8 - 38.4) Confirmed malaria (ACT same or next 55.7 40.0 0.1898 70 25 day following the onset of fever)** (44.6 - 66.3) (20.0 - 64.0) 69.2 29.7 Diarrhea (ORS) 0.0002 273 111 (59.6 - 77.5) (18.6 - 43.9) 12.8 18.9 Diarrhea (zinc) 0.2792 273 111 (8.3 - 19.2) (11.9 - 28.7) 11.4 17.1 Diarrhea (ORS and zinc) 0.2849 273 111 (7.0 - 17.8) (9.9 - 27.9) Cough with difficult or fast breathing 31.6 29.5 0.8114 269 105 (amoxicillin) (22.9 - 41.8) (18.3 - 44.0) na = not applicable * There were no cases or number of cases was too small to calculate a percentage. ** Denominator for confirmed malaria is restricted to those with a positive malaria diagnostic test result. In the survey, caregivers were asked to report on their continued feeding practices during their child’s latest diarrhea illness episode. Caregiver practice of providing both continued fluids and feeding to children with diarrhea increased significantly from baseline to endline (see Table 17). At baseline, 19 percent of diarrhea cases were provided continued fluids, and this increased to 28 percent at endline (p<0.05). Only 11 percent of diarrhea cases were provided continued feeding at baseline, and this increased to 20 percent at endline (p<0.05).

Table 17. Continued fluids and feeding during illness Sick child care Baseline Endline Baseline Endline p-value (diarrhea cases only) % (CI %) % (CI %) N N 18.5 27.7 Continued fluids 0.0439 374 300 (12.3 - 26.7) (20.5 - 36.2) 11.0 20.0 Continued feeding 0.0404 374 300 (6.8 - 17.3) (14.7 - 26.6)

3.7 First Dose of Treatment and Counseling from CORP CORP treatment protocols indicate that the first dose of treatment should be provided by the CORP at the time of assessment as a form of demonstration that the caregiver can subsequently follow, and that the CORP should counsel the caregiver on how to provide treatment to her child. Overall, among cases of illness treated by a CORP at endline, 73 percent received the first dose of treatment in the presence of the CORP (see Table 18). The administration of the first dose of treatment varied slightly across the different treatments provided at endline, with approximately 74 percent of fever cases treated by a CORP receiving the first dose of ACT in the presence of the CORP, 69 percent of diarrhea cases receiving the first dose of ORS and zinc in the presence of the CORP, and 78 percent of cases of cough with fast or difficult breathing receiving amoxicillin from a CORP. Among all cases of illness treated by a CORP, nearly all (98 percent) received counseling from the CORP on how to administer the provided treatment to the child at home (see Table 19), with no notable differences observed by type of treatment provided.

RAcE Niger State, Nigeria Endline Survey Final Report 18 Table 18. First dose of treatment from CORP First dose received in presence of CORP Baseline Endline Illness (treatment) p-value Baseline Endline N N % (CI %) % (CI %) 63.3 73.0 Overall* 0.4223 30 541 (39.1 - 82.3) (63.7 - 80.7) 38.5 74.0 Fever (ACT) 0.0772 13 200 (10.6 - 76.7) (64.6 - 81.6) 66.7 72.6 Diarrhea (ORS) 0.7481 12 226 (27.9 - 91.2) (62.1 - 81.0) 75.0 77.1 Diarrhea (zinc) 0.9269 4 205 (21.4 - 97.1) (67.9 - 84.3) 50.0 68.8 Diarrhea (ORS and zinc)** 0.4466 4 199 (11.1 - 88.9) (57.7 - 78.2) Cough with fast or difficult 92.3 77.5 0.1974 13 142 breathing (amoxicillin) (66.3 - 98.7) (64.9 - 86.5) * Includes cases in which the child received ACT, both ORS and zinc, or amoxicillin from a CORP. ** Includes only cases in which the child received both ORS and zinc.

Table 19. Counseling on treatment administration by CORP Counseled on treatment administration by CORP Baseline Endline Illness (treatment) p-value Baseline Endline N N % (CI %) % (CI %) 70.0 97.6 Overall* 0.0000 30 541 (56.3 - 80.8) (95.5 - 98.7) 76.9 97.5 Fever (ACT) 0.0009 13 200 (46.3 - 92.8) (93.1 - 99.1) 91.7 96.0 Diarrhea (ORS) 0.4122 12 226 (66.5 - 98.4) (91.9 - 98.1) 99.0 Diarrhea (zinc) 100 0.8449 4 205 (95.8 - 99.8) 97.0 Diarrhea (ORS and zinc)** 100 0.7076 4 199 (93.5 - 98.6) Cough with fast or difficult breathing 53.9 98.6 0.0000 13 142 (amoxicillin) (33.9 - 72.7) (94.3 - 99.7) * Includes cases in which child received ACT, both ORS and zinc, or amoxicillin from a CORP. ** Includes only cases in which child received both ORS and zinc.

3.8 CORP Referrals and Referral Adherence CORPs referred 58 percent of cases of illness at baseline and 39 percent of cases at endline. The reasons referrals were made are not known. Among sick child cases that received a referral, nearly all (93 percent) reported adhering to the referral at endline. This high rate of referral adherence is surprising and likely due to reporting bias, because caregivers probably responded with what they felt was the correct answer regardless of the action they actually took. Evidence from routine data for the last quarter showed an overall referral adherence rate of 19 percent, although in two LGAs adherence was 88 percent, because the referral was assisted due to ongoing research. Caregivers who did not adhere to the referral were asked why they did not go to the health facility as advised. The main reasons noted by these caregivers for not following the referral were that they went somewhere else (28 percent), the child improved (22 percent), and the facility was too far away (17 percent). The survey did not measure whether CORPs followed up to verify whether the cases they referred adhered to the referral.

RAcE Niger State, Nigeria Endline Survey Final Report 19 Table 20. Referral by CORP and adherence to CORP referral Baseline Endline Baseline Endline Illness p-value % (CI %) % (CI %) N N Referred by CORP 58.3 39.1 Overall 0.0713 48 701 (41.6 - 73.4) (28.4 - 50.9) 47.1 38.8 Fever 0.5959 17 240 (21.9 - 73.8) (27.6 - 51.3) 71.4 35.2 Diarrhea 0.0063 14 230 (45.9 - 88.1) (24.4 - 47.8) Cough with fast or difficult 58.8 43.3 0.2902 17 231 breathing (35.3 - 78.9) (31.4 - 56.0) Adhered to CORP referral 82.1 93.4 Overall 0.0419 28 274 (63.9 - 92.3) (87.2 - 96.8) 87.5 95.7 Fever 0.3776 8 93 (39.2 - 98.7) (86.4 - 98.7) 80.0 88.9 Diarrhea 0.3319 10 81 (47.3 - 94.7) (78.4 - 94.6) Cough with fast or difficult 80.0 95.0 0.1330 10 100 breathing (35.1 - 96.7) (86.3 - 98.3)

3.9 CORP Follow-Up with Sick Child According to the national iCCM protocol, CORPs are trained to conduct a follow-up visit to sick children within three days of the initial visit. Overall, across all cases of illness among children aged 2–59 months, 81 percent received a follow-up visit from a CORP at endline; this was consistent across all three illnesses.

Table 21. CORP follow-up with sick child CORP follow-up with sick child Baseline Endline Illness Baseline Endline p-value N N % (CI %) % (CI %) 56.3 80.6 Overall 0.0022 48 701 (40.2 - 71.1) (73.9 - 85.9) 47.1 80.0 Fever 0.0306 17 240 (17.7 - 78.6) (71.5 - 86.5) 64.3 81.7 Diarrhea 0.1172 14 230 (38.0 - 84.1) (74.5 - 87.3) Cough with fast or difficult 58.8 80.1 0.0985 17 231 breathing (29.3 - 83.1) (71.7 - 86.5)

3.10 Illness Management and Diagnostics by Sex Table 22 presents endline survey results of select indicators by sex. There is a significant difference at endline in the treatment of diarrhea cases, by any provider, with both ORS and zinc. A significantly (p<0.05) higher percentage of female children with diarrhea (79 percent) received treatment with both ORS and zinc than male children with diarrhea (69 percent).This difference was not measured for diarrhea treatment by CORPs. There were no other differentials between male and female children.

RAcE Niger State, Nigeria Endline Survey Final Report 20 Table 22. Select endline indicators by sex Male Female % point Indicator p-value % (CI %) % (CI %) difference Sick child care-seeking Percentage of children age 2-59 months who have been sick in the two weeks 92.3 90.4 1 preceding the survey for whom advice or 1.9 0.3161 (87.6 - 95.3) (85.2 - 93.9) treatment was sought from an appropriate provider Percentage of children age 2-59 months who were sick in two weeks preceding the 77.4 75.8 2 1.6 0.7577 survey taken to a CORP as first source of (64.3 - 86.7) (63.9 - 84.7) care Sick child assessment Percentage of children age 2-59 months 76.0 77.6 3 with fever in the two weeks preceding the -1.6 0.7211 (66.6 - 83.3) (68.5 - 84.7) survey who had finger or heel stick Percentage of children age 2-59 months for whom their caregiver received the 87.5 87.4 4 results of the malaria diagnostic test of the 0.1 0.9771 (78.9 - 92.9) (76.3 - 93.7) children who had had finger or heel stick in the two weeks preceding the survey Percentage of children age 2-59 months with cough and difficult or rapid breathing 59.2 65.1 5 in the two weeks preceding the survey -5.9 0.4061 (45.3 - 71.8) (54.0 - 74.8) who had their respiratory rate counted to assess fast breathing Sick child assessment by CORP Percentage of children age 2-59 months with fever in the two weeks preceding the 75.2 79.3 6 -4.1 0.4406 survey who had finger or heel stick by a (64.2 - 83.7) (67.4 - 87.6) CORP Percentage of children age 2-59 months for whom their caregiver received the results of the malaria diagnostic test of the 89.7 90.9 7 -1.2 0.7223 children who had had finger or heel stick (80.1 - 95.0) (76.7 - 96.8) by a CORP in the two weeks preceding the survey Percentage of children age 2-59 months with cough and difficult or rapid breathing 52.1 59.7 8 in the two weeks preceding the survey -7.6 0.3282 (37.1 - 66.8) (47.1 - 71.1) who had their respiratory rate counted to assess fast breathing by a CORP Sick child treatment Percentage of children age 2-59 months who received ACT treatment the same or next day following the onset of fever 71.0 77.3 9 -6.3 0.3567 among all children with fever who had a (61.2 - 79.2) (63.2 - 87.0) positive malaria diagnostic test result in the two weeks preceding the survey Percentage of children age 2-59 months who received both ORS and zinc among 69.2 78.6 10 -9.4 0.0478 all children who had diarrhea in the two (57.1 - 79.1) (67.3 - 86.7) weeks preceding the survey

RAcE Niger State, Nigeria Endline Survey Final Report 21 Male Female % point Indicator p-value % (CI %) % (CI %) difference Sick child treatment by CORP Percentage of children age 2-59 months who received ACT treatment from a CORP the same or next day following the 59.0 62.5 11 onset of fever among all children with -3.5 0.6162 (46.4 - 70.5) (49.4 - 74.0) fever who had a positive malaria diagnostic test result in the two weeks preceding the survey Percentage of children age 2-59 months who received both ORS and zinc from a 61.6 70.8 12 CORP among all children who had -9.2 0.0718 (49.2 - 72.8) (59.2 - 80.2) diarrhea in the two weeks preceding the survey First dose and counseling by CORP Percentage of children age 2-59 months who received the first dose of treatment in the presence of a CORP among those 71.6 74.4 13 -2.8 0.5747 who received prescription medicines for a (59.5 - 81.2) (64.7 - 82.1) CCM condition from a CORP in the two weeks preceding the survey Percentage of sick children age 2-59 months for whom their caregivers received counseling on how to provide the 97.4 97.8 14 treatment(s) among those who received -0.4 0.7332 (93.9 - 98.9) (94.7 - 99.1) prescription medicines for a CCM condition from a CORP in the two weeks preceding the survey Sick child referral and follow-up Percentage of sick children age 2-59 who were referred to a health facility by a 93.0 93.9 15 CORP in the two weeks preceding the -0.9 0.6990 (84.9 - 96.9) (87.0 - 97.3) survey whose caregiver adhered to referral advice Percentage of sick children age 2-59 months receiving treatment from a CORP 79.9 81.3 16 in the two weeks preceding the survey -1.4 0.6916 (72.1 - 85.9) (73.2 - 87.4) who received a follow-up visit from a CORP according to country protocol

RAcE Niger State, Nigeria Endline Survey Final Report 22 4 DISCUSSION iCCM was introduced in Nigeria in late 2013, with Abia and Niger States selected as sites to pilot the iCCM program through the WHO RAcE project. Overall, the findings from the RAcE project in Niger State demonstrate substantial improvements in caregiver knowledge and care-seeking, assessment, and treatment coverage for the three main illnesses addressed through iCCM among children under five— fever, diarrhea, and cough with difficult or fast breathing. Overall, appropriate treatment of iCCM illnesses increased significantly over the course of the project, with 69 percent of all illness cases receiving appropriate treatment, from any provider, at endline. Caregiver knowledge of signs of childhood illness increased significantly, as did knowledge of correct treatment for malaria and diarrhea. Caregiver knowledge of location and role of CORPs also increased significantly over the course of the project. Notably, caregivers had highly positive perceptions of CORPs at endline: 94 percent of caregivers view CORPs as trusted health care providers, and 96 percent believe that CORPs provide quality services and cite CORPs as a convenient source of treatment. The increase in knowledge of caregivers on signs and correct treatment for childhood illnesses and their confidence in the ability of CORPs to treat the illnesses was probably enhanced by the demand-generation activities of the RAcE project. The project developed a behavioral change communication strategy that targeted the caregivers as the primary audience and aimed to improve their knowledge on childhood illnesses and promote uptake of services provided by CORPs. The strategy guided the development of appropriate messages and materials as well as innovative multi-channels to reach the caregivers and other key audiences. Overall, care-seeking from an appropriate provider increased significantly, from 75 percent at baseline to 91 percent at endline. Care-seeking practices changed substantially in terms of the provider over the life of the program, with caregivers selecting to seek care from CORPs in their communities for the majority of cases of all illnesses (84 percent) experienced by their children at endline. More than two-thirds of all cases of illness among children aged 2–59 months were taken to a CORP as the first source of care. The choice of CORPs as the first source of care may be due to proximity of the CORPs to the caregivers. iCCM guideline stipulates that for a community to be selected for CORP services, the health facility should not be within a radius of 5 km to the community. One of the key factors that affect care-seeking behavior of caregivers of children under five is the distance to the health facility because this constitutes difficulty for the caregivers to get to health facility.7 However, it should be noted that 12 percent of caregivers surveyed at endline still did not seek any care for their sick child. There were 138 caregivers, out of 510, who sought care for their child’s episode of illness but not from a CORP. Nearly all of these caregivers (95 percent) reported not seeking care from a CORP because they did not trust the CORP to provide care and they believed that the CORP did not have medicines or supplies; 94 percent thought that their child’s condition was too serious for the CORP to treat. The percentage of cases of fever in the two weeks preceding the survey who had a blood test increased significantly over the course of the project, from 34 percent at baseline to 77 percent at endline. Among

7 Adedokun ST, Adekanmbi VT, Lilford RJ. (2017). Contextual factors associated with health care service utilization for children with acute childhood illnesses in Nigeria. PLoS ONE 12 (3): e0173578. https://doi.org/10.1371/journal.pone.0173578

RAcE Niger State, Nigeria Endline Survey Final Report 23 cases of fever that sought care from a CORP at endline, 77 percent received a blood test from the CORP, compared to only 57 percent of cases that sought care from providers other than a CORP receiving a blood test for malaria. For confirmed malaria cases, the percentage of children who received ACT within the same or next day after the onset of fever improved significantly, from 57 percent at baseline to 74 percent at endline. Of those cases managed by a CORP, 73 percent of malaria cases received ACT. Of cases managed by other providers, 40 percent of malaria cases received ACT. These results indicate overall better assessment and management of fever cases by CORPs, compared to all cases that were managed by various other providers. Of the percentage of cases of cough with difficult or fast breathing that sought care from a CORP, 56 percent reported having had their respiratory rate counted at endline. Among cases of cough with difficult or fast breathing that sought care from providers other than a CORP, 41 percent reported having had their respiratory rate counted at endline. For cases of cough with difficult or fast breathing that sought care from a CORP, 61 percent were treated with amoxicillin at endline. Among cases that sought care from other providers, only 30 percent received amoxicillin. The indicator measuring treatment for cough with difficult or fast breathing is independent of whether the child was classified as having fast breathing for his or her age according to a respiratory rate assessment, however, and therefore must be interpreted with caution. Among the cases of diarrhea that sought care from a CORP, 82 percent received ORS and zinc, compared to only 17 percent of cases of diarrhea managed by other providers. CORPs referred 39 percent of cases of illness at endline. The reasons that referrals were made are not known, because they were not captured in the questionnaire. Among sick child cases that received a referral, nearly all (93 percent) reported adhering to the referral at endline. This could, however, be due to a response bias because routine data from the project show that less than 20 percent of caregivers actually adhere to referrals except where the referral is assisted. Overall, across all cases of illness among children aged 2–59 months, 81 percent received a follow-up visit from a CORP at endline; this was consistent across all three illnesses and in line with that national iCCM protocol. The RAcE project in Niger State provided a series of quality assurance measures that likely contributed to the adherence with iCCM protocols and perceived improvements in quality of care measured at endline. These measures spanned the entire case management process of assessment, classification, treatment, counseling, referral, and follow-up. Adequate training and tools—data collection forms and tools, and diagnostic tools including timers, malaria RDTs, and visual job-aids—were provided for the CORPs to aid case assessment and treatment. These included malaria RDTs for malaria confirmation and timers for breathing rate classification as well as chart booklets that served as job aids for case management. On a continuous basis, CORPs were supervised by CHEWs through regular one-on-one interactions, review meetings, and clinical mentoring. These interactions focused on quality and were informed by findings from bi-annual competency and data quality audits carried out on the CORPs. The project also implemented an effective supply chain system that ensured a smart push of commodities for regular supply and replenishment of CORPs’ stocks.

RAcE Niger State, Nigeria Endline Survey Final Report 24 ANNEX A. PEOPLE INVOLVED IN THE SURVEY

The following table provides a list of people involved in the survey and their roles.

S/N Name Organization Role 1 Jennifer Winestock Luna ICF Trainer 2 Dr. Kolawole Mazwell Malaria Consortium Management oversight 3 Dr. Olusola Oresanya Malaria Consortium Technical oversight 4 Dr. Jonathan Jiya Malaria Consortium Management oversight 5 Olatunde Adesoro Malaria Consortium Technical oversight 6 Ibrahim Ndaliman Malaria Consortium Field Monitor 7 Seyi Olujimi Malaria Consortium (Consultant) Field Coordinator 8 Olalekan Onitiju Malaria Consortium (Consultant) Data Manager 9 Obaje Hawa Malaria Consortium Workshop Assistant (TOT) 10 Sadiyat Ibrahim Malaria Consortium Workshop Assistant (Cascade) 11 Prince Malaria Consortium Workshop Assistant (Cascade) 12 Asiyah A. Ndaman School of Health Technology, Minna Trainer/Field Supervisor 13 Mercy Dawaba Niger State Ministry of Health Trainer/Field Supervisor 14 Fatima Ibrahim Niger State Ministry of Health Trainer/Field Supervisor 15 Hamza T. Yahaya Niger State Ministry of Health Trainer/Field Supervisor 16 Ibrahim Idris Niger State Ministry of Health Trainer/Field Supervisor 17 Gimba Patrick Niger State Ministry of Health Trainer/Field Supervisor 18 Inuwa Junaidu Niger State Primary Healthcare Trainer/Field Supervisor Development Agency 19 Jummai Idris Mohammed Niger State Primary Healthcare Trainer/Field Supervisor Development Agency 20 Amina Ibrahim Wamba Mariga LGA Enumerator 21 Maryamu Jibo Jatau Mariga LGA Enumerator 22 Umar Hassan Mariga LGA Enumerator 23 Shehu Sule Mariga LGA Enumerator 24 Tukur S Mohoro Mariga LGA Enumerator 25 Abubakar Suleiman B Mariga LGA Enumerator 26 Aliyu Suleiman Mariga LGA Enumerator 27 Bilal M Suleiman Mariga LGA Enumerator 28 Safinatu Shehu Mariga LGA Enumerator 29 Hanatu Bello Mariga LGA Enumerator 30 Aliyu B Aishatu Mariga LGA Enumerator 31 Saratu Ibrahim Mariga LGA Enumerator 32 Bala Zaharadeen Rafi LGA Enumerator 33 Usman Wanzan Rafi LGA Enumerator 34 Amina Abdullahi Rafi LGA Enumerator 35 Ibrahim Rahinatu Rafi LGA Enumerator 36 Jafar Dan'sabe Kushariki Rafi LGA Enumerator 37 Abubakar Ibrahim Rafi LGA Enumerator 38 Awwal Abdulmumin Rafi LGA Enumerator 39 Hussaina Hameedah Habeeb Rafi LGA Enumerator 40 Mohammed Aliyu Rijau LGA Enumerator 41 Abubakar N Shambo Rijau LGA Enumerator 42 Yakubu Adamu Rijau LGA Enumerator 43 Ketura Sunday Rijau LGA Enumerator 44 Aishatu Hanya Rijau LGA Enumerator 45 Ibrahim Umar Rijau LGA Enumerator 46 Salamatu Mohammed Rijau LGA Enumerator 47 Anas Umar Rijau LGA Enumerator 48 Abdulkarim Awwal LAPAI LGA Enumerator 49 Fatima Mohammed LAPAI LGA Enumerator 50 Ibrahim Aminu Tumigi LAPAI LGA Enumerator

RAcE Niger State, Nigeria Endline Survey Final Report 25 S/N Name Organization Role 51 Usman Ibrahim Muhammed LAPAI LGA Enumerator 52 Yahaya Garba Magaji LAPAI LGA Enumerator 53 Muhammed Ibrahim LAPAI LGA Enumerator 54 Muhammed Jadeeq LAPAI LGA Enumerator 55 Abdulmalik Aliyu Kudu LAPAI LGA Enumerator 56 Maryam Kolo Mathew Edati LGA Enumerator 57 Aishatu Mohammed Edati LGA Enumerator 58 Mohammed N Aliyu Edati LGA Enumerator 59 Andrew Gana Edati LGA Enumerator 60 Damion Gimba Paikoro LGA Enumerator 61 Emebo Chika Paikoro LGA Enumerator 62 Nasir Garba Paikoro LGA Enumerator 63 Samaila Musa Paikoro LGA Enumerator 64 Ibrahim Danlami Paikoro LGA Enumerator 65 Aisha Musa Ahmed Paikoro LGA Enumerator 66 Aishetu Isa Paikoro LGA Enumerator 67 Abdulazeez Umar Paikoro LGA Enumerator 68 Muhammad Zubairu Malaria Consortium (Consultant) Data Clerk 69 Adamu Idris Malaria Consortium (Consultant) Data Clerk 70 Isah Habila Malaria Consortium (Consultant) Data Clerk 71 Limanko Muhammad Malaria Consortium (Consultant) Data Clerk 72 Randa S. Kingsley Malaria Consortium (Consultant) Data Clerk 73 Ahmad L. Yusuf Malaria Consortium (Consultant) Data Clerk 74 Ibrahim Saba Sojeko Malaria Consortium (Consultant) Data Clerk 75 Abubakar H. Abubakar Malaria Consortium (Consultant) Data Clerk 76 Atolagbe G. Abayomi Malaria Consortium (Consultant) Data Clerk 77 Raji Adamu Bala Malaria Consortium (Consultant) Data Clerk

RAcE Niger State, Nigeria Endline Survey Final Report 26 ANNEX B. ENDLINE SURVEY SAMPLE

LGA Community Population Edati Emi Zhitsu 125 Edati Yagbindi 811 Lapai Hamdallahi 303 Lapai Kemi 695 Lapai Ndawashi 950 Lapai Tanaye 618 Mariga Ang Climo 660 Mariga Dinalko 990 Mariga Funa Funan Yidi 1,310 Mariga Mai Saje 615 Mariga Matseri 1,000 Mariga Rijawa 1,530 Mariga Ung Gada 920 Mariga Ung Makura 1,040 Mariga Ung Yahala 1,000 Mariga Ung Baituwa 270 Paikoro Butu 1,075 Paikoro Jullu 1,005 Paikoro Kwashi 116 Paikoro Shunagba 1,335 Paikoro Tumbi 400 Rafi Sabon Gida Sambaro 255 Rafi Un/Karma 550 Rafi Ung/Bigude 115 Rafi Ung/Kura 1,125 Rafi Ung/Tambari 795 Rijau Abaran Ushe 442 Rijau Babade 681 Rijau Genu Daji 88 Rijau Kudabo 2 600

RAcE Niger State, Nigeria Endline Survey Final Report 27 ANNEX C. ENDLINE SURVEY QUESTIONNAIRE

See attachment.

RAcE Niger State, Nigeria Endline Survey Final Report 28 ANNEX D. ENDLINE SURVEY TRAINING SCHEDULE

Training Agenda (TOT)

Agenda—Day 1  Session 1  Introductions—clarification of expectations  Objectives of training  Session 2  Overview of RAcE survey & survey material  Overview of the survey protocol  Session 3—Survey Ethics  Ethical approval and management  Confidentiality  Proper behavior while in the field  Session 4—Sampling  Explanation of sample size and cluster selection  Session 5—Participant Selection  Selecting respondents within a household . Definition of household . Definition of head of household . Developing algorithm

Agenda Day 2—Household Selection  Session 1—Selecting Households in a Cluster  Developing algorithm  Session 2—Questionnaire and Key Forms  Review of Questionnaire Modules:  Basic instructions  Cover sheet, consent form, and child identifier modules  Caregiver’s background, decision-making, CORP and caregiver knowledge modules  Diarrhea, fever and cough with rapid breathing modules  Review of key interviewing forms  Quality control checklist  Interviewer assignment sheet

RAcE Niger State, Nigeria Endline Survey Final Report 29  Session 3—Role Play and Discussion  Practice:  Interviewing  Observing  Filling out quality control sheet; filling out interviewer assignment sheet  Discuss problems and solutions . Details to include in standard operating procedures . Corrections to questionnaires

Agenda Day 3—Translation  Session 1  List of key terms to be translated.  Agreement of translation of key terms  Agreement of translation of consent form Agenda—Day 3—Organizing Field Work  Session 2—Team Organization and Management  Supervisor and interviewer roles  Field work communication  Preparation checklist before leave for field site  Preparations before visit next household  Supervisor sheet Agenda—Day 3—Organizing Field Work  Session 3—Data Quality Procedures  Questionnaire checking, giving feedback  Ensuring enough completed interviews . Call backs  Problem solving procedures  Daily team meetings Agenda—Day 3—Practice Interviewing  Session 4—Practice with Standard Translations

Agenda—Day 4  Session 1—Respondent Selection Practice  Using child identifier module

RAcE Niger State, Nigeria Endline Survey Final Report 30  Session 2—Practice Household Selection  Using algorithm  Session 3—Enumerator Training Preparation  Session 4—Logistics Preparation  Session 5—Completing Unfinished Business  Adjusting algorithms and standard operating procedures  Session 6—Conclusion

TRAINING AGENDA (Training of Enumerators) Day 1—Tuesday January 24, 2017  Objectives of endline survey  Sampling method and sample size determination  Selection of clusters  Sample size determination for survey  Probability proportionate to size (PPS)  Determination of choice of clusters using:  Development of algorithm for identification of eligible respondents  Obtaining of respondents’ consent

Day 2—Wednesday January 25, 2017  Recap of Day 1 activities  Development of algorithm for selection of dwellings/HH  Review of questionnaire—participants were paired; one to act as respondent and the other to act as interviewer Day 3—Thursday January 26, 2017 i. Review of questionnaire continued—participants were paired; one to act as respondent and the other to act as interview ii. Interviewing a. Concerns about questionnaires and role play from Day2 b. List of key terms to be translated. c. Agreement of translation of key terms d. Agreement of translation of consent form iii. Organization of the field a. Supervisor and interviewer roles b. Field work communication c. Preparation checklist before leave for field site

RAcE Niger State, Nigeria Endline Survey Final Report 31 d. Preparations before visit next household e. Supervisor sheet iv. Data quality procedures a. Questionnaire checking, giving feedback b. Ensuring enough completed interviews c. Call backs d. Problem solving procedures e. Daily team meetings v. Field work communication a. How will you communicate with interviewers before first day of field work? b. How will you communicate with interviewers while in a cluster? c. How will you communicate with interviewers to manage number of illness modules administered? d. How will you let interviewers know that you will observe an interview? e. How will you communicate with home office while in the field? Who will you communicate with? vi. Data Quality Procedures a. Questionnaire checking b. Ensuring enough completed interviews c. Call backs d. Problem solving procedures e. Daily team meetings vii. Practice interviewing

Day 4—Friday January 27, 2017  Role play  Child identifier module  Six scenarios on identification of caregivers for interviews  Housekeeping  Vote of thanks

RAcE Niger State, Nigeria Endline Survey Final Report 32 ANNEX E. RACE ENDLINE SURVEY PROCESS REPORT

PROCESS REPORT OF RAcE ENDLINE SURVEY,

NIGER STATE, NIGERIA

By

Seyi Olujimi (Lead Consultant) Dr Olusola Oresanya Dr Jonathan Jiya Olatunde Adesoro Ibrahim Ndaliman

Mar 2017

RAcE Niger State, Nigeria Endline Survey Final Report 33 Final Approval

Report signed off by:

Date Initials

For Final 2nd May 2017 O.O

RAcE Niger State, Nigeria Endline Survey Final Report 34 Table of Contents

Section Page No. Section 1 Title Page 1 Table of Contents 3 Abbreviations and Acronyms 4 Acknowledgements 5 Section 2 Executive Summary (summary of findings and 7 recommendations) Section 3 3.1 Background & Introduction 8 3.2 Key Activities 8 3.3 Approach and Methodology 10 3.4 Key Findings and analysis 10 3.5 Recommendations and next steps 11 3.6 Conclusions 11

Section 4 Annexes: 12 Annex 1 Terms of reference Annex 2 List of clusters Annex 3 Survey Personnel Selection Criteria Annex 4 Training Schedule Annex 5 List of survey personnel Annex 6 Survey schedule Annex 7 Algorithm for selecting dwelling place Annex 8 Algorithm for selecting respondents

RAcE Niger State, Nigeria Endline Survey Final Report 35 Abbreviations and Acronyms

CORPs Community Oriented Resource Persons GoN Government of Nigeria HH Household iCCM Integrated Community Case Management LGA Local Government Area MC Malaria Consortium PPS Probability Proportionate to Size RAcE Rapid Access Expansion RBM Roll Back Malaria SMOH State Ministry of Health TOT Training of Trainers

RAcE Niger State, Nigeria Endline Survey Final Report 36 Acknowledgements The Project Manager and the entire RAcE team members in Minna and the Country Office are acknowledged for this support for this assignment. I appreciate the SMoH and all members of the survey team for their commitment to this work as well as all the respondents in the communities surveyed.

RAcE Niger State, Nigeria Endline Survey Final Report 37

The contents of this report are the sole responsibility of its authors and do not necessarily reflect the views of the Partnership managing the programme.

RAcE Niger State, Nigeria Endline Survey Final Report 38 SECTION 2 – EXECUTIVE SUMMARY This report documents the conducting of the RAcE endline survey carried out in 6 LGAs in Niger State where the iCCM program was implemented by the Malaria Consortium. Protocol development and training of trainers was led by ICF while cascade training of data collectors, cluster selection, data collection process and data entry and cleaning where implemented by MC with technical support from ICF. The survey activities began with the recruitment of required study personnel, namely the Lead Consultant, field supervisors, enumerators, data analyst, data entry clerks and logistics assistants. Preparatory meetings were held at critical stages of the survey to plan for activities and resolve technical and logistic issues. The first planning meeting was held on Monday January 23, 2017 between MC officials and ICF to review all survey activities and provide technical direction. Other planning meetings held were for the enumerators’ training, data collection in southern and northern LGAs. To acquaint key study personnel with the nature of the study, its technical approach and protocol, two levels of training were conducted. The first was for trainers/field supervisors held between January 24 and 27, 2017 in Valentia Hotel, Abuja led by ICF. The trainer/supervisors later cascaded training to enumerators between February 6 and 10, 2017. The trainings were held concurrently in Kontangora (for northern LGAs) and Bida (for southern LGAs). Prior to field data collection and in line with the study protocol, 30 clusters were selected using the Probability Proportionate to Size methodology. Eleven of the selected clusters fell within the southern LGAs of Edati, Lapai and Paikoro; while the remaining 19 fell in the northern LGAs – Mariga, Rafi and Rijau. For each cluster selected, 30 interviews were conducted equally split between three categories of caregivers, namely those with children under 5 years who had been sick with fever, diarrhoea or cough with difficulty or fast breathing in the last two weeks before the survey. This gave a total of 900 interviews. The training of the enumerators was followed by data collection in the 11 clusters in southern LGAs of Edati, Lapai and Paikoro between February 13 and 18, 2017. After a review of the data collection in the southern LGAs, the exercise continued in the remaining 19 clusters in northern LGAs of Mariga, Rafi and Rijau between February 20 and 25, 2017. In all, the desired sample size of 900 caregivers was achieved. The major challenge with the exercise was the difficulty in accessing the clusters which slowed down the pace of work. Data quality assurance measures put in place included comprehensive training for personnel, daily supervision of enumerators, daily review and correction of questionnaires as well as double entry of data. Data generated were captured using the Census and Survey Processing software. The survey was carried out successfully with expectation that the data would be of high quality.

RAcE Niger State, Nigeria Endline Survey Final Report 39 SECTION 3

3.1 Background & Introduction Malaria Consortium (MC) was awarded a grant by Global Affairs Canada/WHO to lead the Rapid Access Expansion 2015 (RAcE) project, focused on catalyzing the implementation of integrated community case management of malaria, pneumonia and diarrhoea (iCCM) at scale in Niger State. This strategy is delivered by a pool of community oriented resource persons (CORPs) under the supervision of health workers, using life-saving curative interventions in areas where normal access to healthcare is a challenge. A cross sectional baseline survey was conducted in 2014 with the following objectives:  To assess of health seeking patterns and treatment options available to caregivers of children with suspected history of malaria, diarrhoea and pneumonia  To assess levels of knowledge, prevailing attitudes and practices as it relates to malaria, diarrhoea and pneumonia  To provide population representative data to feed into modelling work by ICF Macro RAcE is in its final year of implementation. Before the commencement of project activities, an assessment was conducted to generate baseline information in 6 LGAs of Niger State. As the project winds up, it is expedient to determine what impact (if any) the project has had. The endline survey is also important to determine if there have been changes to the baseline indicators attributable to the RAcE project activities. The purpose of this assignment is to coordinate the conduct endline survey for the RAcE iCCM project in Niger state in accordance with the survey protocol. Summarize the ToR and refer to annex 1 which is to include the final ToR. 3.2 Key Activities  Preparatory meeting (23/1/2017) organized by MC: The meeting was used to review schedule of survey activities; personnel categories and selection criteria; survey logistics; roles and responsibilities for all survey personnel and survey protocol and questionnaires as well as sampling procedure using Probability Proportionate to Size (PPS) approach. It was attended by representatives of ICF, MC and the Lead Consultant.  Survey personnel selection: Conducting a study of this nature and magnitude requires recruitment of different categories of individuals with required knowledge and skills. Six categories of personnel were recruited by Malaria Consortium to perform specific tasks including a national consultant, Field supervisors, Enumerators, Data Analyst, Data entry clerks and Logistic Assistants. Please see annex 3 for their specific tasks in the survey and the criteria for their selection.  Selection of clusters: Some of the mapped communities selected for baseline study were not eventually selected for participation in the project. The communities were excluded because they did not meet the criteria of absence of functional health facility within a reach of 5kms. For this reason, another sampling was done to select 30 out of 1, 303 communities in which CORPs were rendering iCCM services. The clusters were selected using PPS methodology. First, all the communities were arranged in alphabetical order, followed by the calculation of cumulative population of their sizes. The total population was divided by 30, the number of clusters required.

RAcE Niger State, Nigeria Endline Survey Final Report 40 The result was used as a sampling interval for selection of the clusters. Annex 2 shows the list of 30 clusters selected for data collection. The selection yielded 19 clusters in the northern LGAs of Mariga, Rafi and Rijau. The remaining 11 were in the southern LGAs of Edati, Lapai and Paikoro.  Training of trainers (ToT) was held between January 24 and 27, 2017 at the Valencia Hotel, Wuse II, Abuja: The participants included 8 officials from the Niger State ministry of health, 2 MC staff and 1 consultant (to coordinate field activities). Jennifer Winestock Luna of ICF facilitated the 4-day training. The trainers had the dual role of training enumerators and supervising the data collection. The training objective was to acquaint the trainers with the survey and its procedures. Topics covered included overview of RAcE, endline survey objectives and protocol as well as the survey instruments. The trainers developed algorithm for sampling and respondent selection. The trainers were also trained on facilitation and interview skills. Roles of research personnel were clarified and logistics for enumerator training finalized. List of trained trainers is in annex 4.  Cascade training: The cascade training was conducted concurrently in two sites: south (Bida) and north (Kotangora between 6th and 10th February, 2017. Bida training site had 26 enumerators from Paikoro, Lapai and Edati LGAs while Kotangora training site had 34 enumerators from Mariga, Rafi and Rijau LGAs. It was a 5-day training out of which 1 day was spent on the field for practice. Bida training site had four trainers while Kotangora training site had five trainers. Topics covered included objectives of the survey, consent taking, survey tools, including translation into local languages and interview skill as well as sampling procedure and respondent selection. The data quality assurance processes and logistics for field work were finalized. The field practice ensured that enumerators and supervisors practice out the algorithm for household and respondent selection, consent taking and interviews. The lessons from the field practice were used to correct mistakes, assess enumerators for final selection and further revise logistic plans. List of trained and selected enumerators is in annex 4.  Data collection: The data collection exercise was in 2 phases. The first, was in the southern LGAs (Edati, Lapai and Paikoro) was held between February 13 and 17, 2017. The required sample size of 330 for the 11 clusters in the area was achieved. The second phase was done in the northern LGAs – Mariga, Rafi and Rijau. Field work began on Monday February 20 and ended on Sunday 26th February with required sample of 570 achieved (annex 5). There were 12 survey teams in all headed by 12 supervisors; each composed of 4 enumerators working in pairs. For each of the clusters visited, the data collection team followed the algorithm developed for the selection of dwelling structures (annex 6). After the selection of the first dwelling structure, the second algorithm (annex 7) for selection of households was adopted. Process of consent taking was duly followed for all respondent selected before interviews were done. Sample size that could not be achieved in a cluster was extended to the neighbouring communities with iCCM service. This happened in clusters: 6, 8, 10, 13, 16 and 22. The next community to cluster 22 was chosen because security situation in cluster 22 did not allow interview to take place. Field schedule for data collection is in annex 5. In order to ensure quality of data, the trainers were made to supervise enumerators on a daily basis. One trainer/supervisor was assigned to a maximum of 4 enumerators working in same cluster. The enumerators worked in pairs for security and cultural reasons. In addition, one monitor was assigned to each LGA to ensure that teams comply with survey protocol and provide further logistic, material and technical support to the supervisors. These monitors were Malaria Consortium

RAcE Niger State, Nigeria Endline Survey Final Report 41 personnel that participated in all the trainings including ToT. The questionnaire took between 35 – 45 minutes to complete for a caregiver. During interviews, supervisors observed minimum of one interview per enumerator and had daily review meetings with his/her team of enumerators. The review meetings were used to assess completed questionnaires and resolve any challenges encountered on the field. The supervisors took safe custody of the completed questionnaires stored in sealed bags. A total of 900 interviews were completed.  Data management: CsPro software was used to enter data from the survey tools. The data manager was given a 1-day orientation on the survey objectives and instruments by the field coordinator. ICF developed the data entry template and provided further clarification and support to the data manager on its use. A total number of ten data clerks were recruited and trained by the data manager. The 1-day training was done on Monday 20th February 2017 by test-running the data template using completed questionnaires from the southern LGAs. Dataset from the test-run (training of data clerks) was discarded in order to start the main data entry afresh from 27th February to 7th March, 2017. Double entry approach was used for the data entry. The data manager provided supportive supervision for the data clerks, ran quality checks, made corrections and merged the data in a single file using internal controls of the software before transferring to ICF for analysis. 3.3 Approach and Methodology The process was guided by the survey protocol. Algorithm was developed and used for household and respondents’ selection for interview (annex 4). 3.4 Key Findings & Analysis  Eligibility for interview was case of disease condition (malaria, pneumonia and diarrhoea) within two weeks of the survey time. It was very difficult to get enough diarrhoea cases for interview in most of the clusters. This was probably due to improved hygiene of the people or the season when the survey happened.  During training, many enumerators found the survey questionnaire difficult to understand. Even those who claimed to have been involved in similar studies in the past could not cope with the demands of the document. Extra efforts were put in place to ensure that enumerators got better grasp of the questionnaire for a successful data collection. The field practice was also used to assess and select the final list of enumerators for the main survey  The training in Kontagora could not take off by 8am as planned due to late arrival of enumerators lodged outside the venue of the training venue due to insufficient rooms. Subsequently, better transport arrangement was made and the rest of the training ran smoothly.  Preparatory meetings were held at every stage of scheduled activities. This helped proper planning and smooth running of activities. Critical decisions were taken at these meetings and adequately followed up for execution and feedback.  The use of high ranking SMoH officials ensured good quality of inputs, however, their full participation at field could not be secured. Two out of eight SMoH officials could not participate fully in the field work.

RAcE Niger State, Nigeria Endline Survey Final Report 42  To further ensure quality data collection, the Lead Consultant was assigned to monitor and supervise the exercise. This involved visiting each of the clusters as field work progresses. It provided an opportunity for the consultant to ensure adherence to the survey protocol on field work, provision of additional materials (where necessary) and technical assistance.  Virtually all clusters were hard-to-reach and it took quite a long time to get transportation there. Provision of a Toyota Hilux for supervision and monitoring enabled accessibility into all the clusters. Appropriate means of transportation (motorcycle) was provided for the supervisors and enumerators. Difficulty in accessing the clusters slowed down the exercise.  LGA officials were very helpful in mobilizing community members for the survey and advising on security situations in the survey area. Due to security challenges in one of the clusters 12, the next community was selected.  The local language in Kudabo 2 (cluster 12) and Anguwan Gada (cluster 23) was different and none of the interviewers understood it. So the team had to rely on second person interpretation for interviews. 3.5 Recommendations & Next Steps In order to ensure proper data management, the data manager should be part of future ToT or training of enumerators. His/her participation would provide opportunity for him/her to ensure that the questionnaire for field data collection is in line with the data entry template. A situation where discrepancies between the questionnaire and the data entry template were discovered at the point of data entry creates setbacks and slows down data entry. 3.6 Conclusion The ToR for the assignment was adequately fulfilled as the RAcE endline survey was successfully carried out despite some challenges encountered which were adequately resolved. 3.7 Other Emerging Issue

None

RAcE Niger State, Nigeria Endline Survey Final Report 43 ANNEX 1: THE TERMS OF REFERENCE RAPIC ACCESS EXPANSSION (RAcE) PROJECT.

TERMS OF REFERENCE FOR END LINE SURVEY FOR INTEGRATED COMMUNITY CASE MANAGEMENT (iCCM), NIGER STATE.

Reference number: MC/RAcE/ToR/ Period of assignment: Jan‐Mar, 2017

Date of draft: 14 December 2016 Date of final:

Staff Technical Lead: RAcE M&E Officer CO Technical Lead: Country Technical Coordinator.

Background Malaria Consortium works with communities, government and non-government agencies, academic institutions, and local and international organisations, to ensure good evidence supports delivery of effective services, providing technical support for monitoring and evaluation of programmes and activities for evidence-based decision-making and strategic planning. The organisation works to improve not only the health of the individual, but also the capacity of national health systems, which helps relieve poverty and support improved economic prosperity. Malaria Consortium (MC) was awarded a grant by Global Affairs Canada/WHO to lead the Rapid Access Expansion 2015 (RAcE) project, focused on catalyzing the implementation of integrated community case management of malaria, pneumonia and diarrhoea (iCCM) at scale in Niger State. This strategy is delivered by a pool of community oriented resource persons (CORPs) under the supervision of health workers, using life-saving curative interventions in areas where normal access to healthcare is a challenge. A cross sectional baseline survey was conducted in 2014 with the following objectives:  To assess of health seeking patterns and treatment options available to caregivers of children with suspected history of malaria, diarrhoea and pneumonia  To assess levels of knowledge, prevailing attitudes and practices as it relates to malaria, diarrhoea and pneumonia  To provide population representative data to feed into modelling work by ICF Macro RAcE is in its final year of implementation. Before the commencement of project activities, an assessment was conducted to generate baseline information in 6 LGAs of Niger State. As the project winds up, it is expedient to determine what impact (if any) the project has had. The end line survey is also important to determine if there have been changes to the baseline indicators attributable to the RAcE project activities. The purpose of this assignment is to coordinate the conduct end line survey for the RAcE iCCM project in Niger state in accordance with the survey protocol.

RAcE Niger State, Nigeria Endline Survey Final Report 44 The objectives: To lead the process of endline survey for Race iCCM project in Niger state and generate evidence of impact of the project The Scope: The ToR covers the conduct of endline survey for RAcE project in 6 LGAs of Niger State.

Type of Consultants Required The following consultants will be required for this assignment: 1. A national consultant 2. Field supervisors 3. Enumerators 4. Data Analyst 5. Data entry clerks 6. Logistic Assistants

Specific Tasks Data Analyst:  Design data entry template for survey questionnaire using CSPro  Supervise data entry  Analyse data and present report in graphics and tables

Deliverables

Data Analyst:  An advanced degree in computer science or related field  Demonstrated expertise in development of health databases  Demonstrated expertise of CSPro is required.  Experience in design of relational menu driven computational databases using VBA and Microsoft Access.  Excellent ability in data analysis especially qualitative data analysis and interpretation.  Familiarity with iCCM project is desired

RAcE Niger State, Nigeria Endline Survey Final Report 45 Survey coordination Overall Project Manager management

Technical Quality spot Monitoring team – 2 Lead Consultant - 1 checks lead PM CI/SDO

Supervisors Quality Data Analyst - 1 control for 2/LGA data

Data entry Logistic Enumerators clerks- 10 Assistants - 2 8/LGA Data collection

RAcE Niger State, Nigeria Endline Survey Final Report 46 Timing of consultancy: (January – March, 2017)

Number of days needed for survey team members Data SN Tasks Lead Field Data Logistic Enumerators entry consultant supervisors analyst assistants clerks 1 Initial briefing/Planning 1 0 0 1 0 0 meeting for ToT 2 Development of data entry 1 0 0 2 0 0 template 3 Conduct training for 4 0 0 0 0 4 trainers/supervisors 4 Conduct training for field 6 7 0 0 0 6 enumerators, including planning meeting 5 Planning meeting for field 2 2 0 0 0 2 work 6 Field data collection 12 12 6 0 0 12 7 Data entry and analysis 0 0 0 4 10 0 8 Report writing 2 0 0 0 0 0 Total days 28 20 6 7 10 24 Number of Consultants 1 8 48 1 10 2 Total TA-days 28 160 288 7 100 48

RAcE Niger State, Nigeria Endline Survey Final Report 47 ANNEX 2: Lists of survey cluster

LGA Community Population Edati Emi Zhitsu 125 Edati Yagbindi 811 Lapai Hamdallahi 303 Lapai Kemi 695 Lapai Ndawashi 950 Lapai Tanaye 618 Mariga Ang Climo 660 Mariga Dinalko 990 Mariga Funa Funan Yidi 1,310 Mariga Mai Saje 615 Mariga Matseri 1,000 Mariga Rijawa 1,530 Mariga Ung Gada 920 Mariga Ung Makura 1,040 Mariga Ung Yahala 1,000 Mariga Ung Baituwa 270 Paikoro Butu 1,075 Paikoro Jullu 1,005 Paikoro Kwashi 116 Paikoro Shunagba 1,335 Paikoro Tumbi 400 Rafi Sabon Gida Sambaro 255 Rafi Un/Karma 550 Rafi Ung/Bigude 115 Rafi Ung/Kura 1,125 Rafi Ung/Tambari 795 Rijau Abaran Ushe 442 Rijau Babade 681 Rijau Genu Daji 88 Rijau Kudabo 2 600

RAcE Niger State, Nigeria Endline Survey Final Report 48 ANNEX 3: SURVEY PERSONNEL SELECTION CRITERIA

National Consultant Specific tasks for survey Skills, experience and capacity required for the tasks. Work with ICF and MC team in all aspect of the survey. An advanced degree in social, behavioral or health sciences or related disciplines Participate in central level training of master trainers Demonstrated expertise in rigorous quantitative and qualitative research design and implementation and analytical methods. Facilitate state-level training of field enumerators and At least 5 years’ experience in conduct and management supervisors surveys Coordinate the planning for data collection Willing to work under time pressure. Participate in the data collection as part of survey Excellent ability in data analysis especially qualitative data supervisory team, support the resolution of bottlenecks analysis and interpretation. ensure adherence to agreed procedures. Develop a comprehensive report of activities carried out Demonstrated report writing skills for qualitative study; Understanding of the context and setting of interventions in the north Basic Hausa language is desirable Field Supervisors Specific tasks for survey Skills, experience and capacity required for the tasks. Participate in central level training of trainers At least a university degree/higher diploma in social, behavioural or health sciences Facilitate state-level training of field enumerators and At least 5-year experience in conducting qualitative research supervisors in the health sector Assign field teams to sampled households/LGAs Full availability on ground in Niger is required throughout the study duration Supervise field teams during data collection Hausa language is highly desirable. Familiarity with iCCM trainings relevant Enumerators Specific tasks for survey Skills, experience and capacity required for the tasks. Participate in data collection training and planning An indigene of the LGA where he/she is to work, must have grown up there and understand the language, culture and geography of the area at first hand level Conduct household interviews using dedicated Educational qualification of a minimum of O’ Level with at questionnaires and record information collected using least a credit in English dedicated tools Collect and record quantitative data using dedicated tools Good communication skills, able to express himself/herself well in English and the local language of his/her LGA Previous experience in household survey. A candidate who has not experience of a previous survey but has other criteria must have a minimum educational level of HND or a university degree. Possession of a functioning mobile phone for use during training and fieldwork Data Analyst Specific tasks for survey Skills, experience and capacity required for the tasks. Design data entry template for survey questionnaire An advanced degree in computer science or related field using CSPro Supervise data entry Demonstrated expertise in development of health databases Analyze data and present report in graphics and tables Demonstrated expertise of CSPro is required. Experience in design of relational menu driven computational databases using VBA and Microsoft Access.

RAcE Niger State, Nigeria Endline Survey Final Report 49 Excellent ability in data analysis especially qualitative data analysis and interpretation. Familiarity with iCCM project is desired

Data Entry Clerks Specific tasks for survey Skills, experience and capacity required for the tasks. Review end line survey data At least an OND/NCE

Key in all questionnaire data on to dedicated CSPro Experience with data entry of survey/routine data platform Familiarity with data software such as Ms Excel, CSPro etc Logistics Assistants Specific tasks for survey Skills, experience and capacity required for the tasks. Provide administrative support for planning At least OND/NCE qualification meetings/trainings Provide logistic support for field work Experience in providing support to trainings and field activities

Facilitate production and distribution of materials for meetings/trainings and filed work

Facilitate collation and orderly arrangement/storage of all survey materials

Support documentation at survey activities including attendance sheets,, photographs etc.

RAcE Niger State, Nigeria Endline Survey Final Report 50 ANNEX 4: Training schedule Training Agenda (TOT)

Agenda—Day 1  Session 1  Introductions—clarification of expectations  Objectives of training  Session 2  Overview of RAcE survey & survey material  Overview of the survey protocol  Session 3—Survey Ethics  Ethical approval and management  Confidentiality  Proper behavior while in the field  Session 4—Sampling  Explanation of sample size and cluster selection  Session 5—Participant Selection  Selecting respondents within a household . Definition of household . Definition of head of household . Developing algorithm

Agenda Day 2—Household Selection  Session 1—Selecting Households in a Cluster  Developing algorithm  Session 2—Questionnaire and Key Forms  Review of Questionnaire Modules:  Basic instructions  Cover sheet, consent form, and child identifier modules  Caregiver’s background, decision-making, CORP and caregiver knowledge modules  Diarrhea, fever and cough with rapid breathing modules  Review of key interviewing forms  Quality control checklist  Interviewer assignment sheet  Session 3—Role Play and Discussion  Practice:

RAcE Niger State, Nigeria Endline Survey Final Report 51  Interviewing  Observing  Filling out quality control sheet; filling out interviewer assignment sheet  Discuss problems and solutions . Details to include in standard operating procedures . Corrections to questionnaires

Agenda Day 3—Translation  Session 1  List of key terms to be translated.  Agreement of translation of key terms  Agreement of translation of consent form Agenda—Day 3—Organizing Field Work  Session 2—Team Organization and Management  Supervisor and interviewer roles  Field work communication  Preparation checklist before leave for field site  Preparations before visit next household  Supervisor sheet Agenda—Day 3—Organizing Field Work  Session 3—Data Quality Procedures  Questionnaire checking, giving feedback  Ensuring enough completed interviews . Call backs  Problem solving procedures  Daily team meetings Agenda—Day 3—Practice Interviewing  Session 4—Practice with Standard Translations

Agenda—Day 4  Session 1—Respondent Selection Practice  Using child identifier module  Session 2—Practice Household Selection  Using algorithm  Session 3—Enumerator Training Preparation

RAcE Niger State, Nigeria Endline Survey Final Report 52  Session 4—Logistics Preparation  Session 5—Completing Unfinished Business  Adjusting algorithms and standard operating procedures  Session 6—Conclusion

TRAINING AGENDA (Training of Enumerators) Day 1—Tuesday January 24, 2017  Objectives of endline survey  Sampling method and sample size determination  Selection of clusters  Sample size determination for survey  Probability proportionate to size (PPS)  Determination of choice of clusters using:  Development of algorithm for identification of eligible respondents  Obtaining of respondents’ consent

Day 2—Wednesday January 25, 2017  Recap of Day 1 activities  Development of algorithm for selection of dwellings/HH  Review of questionnaire—participants were paired; one to act as respondent and the other to act as interviewer Day 3—Thursday January 26, 2017 i. Review of questionnaire continued—participants were paired; one to act as respondent and the other to act as interview ii. Interviewing a. Concerns about questionnaires and role play from Day2 b. List of key terms to be translated. c. Agreement of translation of key terms d. Agreement of translation of consent form iii. Organization of the field a. Supervisor and interviewer roles b. Field work communication c. Preparation checklist before leave for field site d. Preparations before visit next household e. Supervisor sheet

RAcE Niger State, Nigeria Endline Survey Final Report 53 iv. Data quality procedures a. Questionnaire checking, giving feedback b. Ensuring enough completed interviews c. Call backs d. Problem solving procedures e. Daily team meetings v. Field work communication a. How will you communicate with interviewers before first day of field work? b. How will you communicate with interviewers while in a cluster? c. How will you communicate with interviewers to manage number of illness modules administered? d. How will you let interviewers know that you will observe an interview? e. How will you communicate with home office while in the field? Who will you communicate with? vi. Data Quality Procedures a. Questionnaire checking b. Ensuring enough completed interviews c. Call backs d. Problem solving procedures e. Daily team meetings vii. Practice interviewing

Day 4—Friday January 27, 2017  Role play  Child identifier module  Six scenarios on identification of caregivers for interviews  Housekeeping  Vote of thanks

RAcE Niger State, Nigeria Endline Survey Final Report 54 ANNEX 5: LIST OF PEOPLE CONSULTED

S/N Names Organization Role 1 Debra Prosnitz ICF Technical lead 2 Jennifer Winestock Luna ICF Trainer 3 Dr. Kolawole Mazwell Malaria Consortium Management oversight 4 Dr. Olusola Oresanya Malaria Consortium Technical oversight 5 Dr. Jonathan Jiya Malaria Consortium Management oversight 6 Olatunde Adesoro Malaria Consortium Technical oversight 7 Ibrahim Ndaliman Malaria Consortium Field Monitor 8 Seyi Olujimi Malaria Consortium (Consultant) Field Monitor 9 Olalekan Onitiju Malaria Consortium (Consultant) Data Manager 10 Obaje Hawa Malaria Consortium Workshop Assistant (TOT) 11 Sadiyat Ibrahim Malaria Consortium Workshop Assistant (Cascade) 12 Prince Malaria Consortium Workshop Assistant (Cascade) 13 Asiyah A. Ndaman SHT Minna Trainer/Field Supervisor 14 Mercy Dawaba Niger State Ministry of Health Trainer/Field Supervisor 15 Fatima Ibrahim Niger State Ministry of Health Trainer (Kotangora) Field Supervisor 16 Hamza T. Yahaya Niger State Ministry of Health Trainer/Field Supervisor 17 Ibrahim Idris Niger State Ministry of Health Trainer/Field Supervisor 18 Gimba Patrick Niger State Ministry of Health Trainer/Field Supervisor 19 Inuwa Junaidu Niger State Primary Healthcare Trainer/Field Supervisor Development Agency 20 Jummai Idris Mohammed Niger State Primary Healthcare Trainer/Field Supervisor Development Agency 21 Amina Ibrahim Wamba Mariga LGA Enumerator 22 Maryamu Jibo Jatau Mariga LGA Enumerator 23 Umar Hassan Mariga LGA Enumerator 24 Shehu Sule Mariga LGA Enumerator 25 Tukur S Mohoro Mariga LGA Enumerator 26 Abubakar Suleiman B Mariga LGA Enumerator 27 Aliyu Suleiman Mariga LGA Enumerator 28 Bilal M Suleiman Mariga LGA Enumerator 29 Safinatu Shehu Mariga LGA Enumerator 30 Hanatu Bello Mariga LGA Enumerator 31 Aliyu B Aishatu Mariga LGA Enumerator 32 Saratu Ibrahim Mariga LGA Enumerator 33 Bala Zaharadeen Rafi LGA Enumerator 34 Usman Wanzan Rafi LGA Enumerator 35 Amina Abdullahi Rafi LGA Enumerator 36 Ibrahim Rahinatu Rafi LGA Enumerator 37 Jafar Dan'sabe Kushariki Rafi LGA Enumerator 38 Abubakar Ibrahim Rafi LGA Enumerator 39 Awwal Abdulmumin Rafi LGA Enumerator 40 Hussaina Hameedah Habeeb Rafi LGA Enumerator 41 Mohammed Aliyu Rijau LGA Enumerator 42 Abubakar N Shambo Rijau LGA Enumerator 43 Yakubu Adamu Rijau LGA Enumerator 44 Ketura Sunday Rijau LGA Enumerator 45 Aishatu Hanya Rijau LGA Enumerator 46 Ibrahim Umar Rijau LGA Enumerator 47 Salamatu Mohammed Rijau LGA Enumerator 48 Anas Umar Rijau LGA Enumerator 49 Abdulkarim Awwal LAPAI LGA Enumerator 50 Fatima Mohammed LAPAI LGA Enumerator 51 Ibrahim Aminu Tumigi LAPAI LGA Enumerator 52 Usman Ibrahim Muhammed LAPAI LGA Enumerator

RAcE Niger State, Nigeria Endline Survey Final Report 55 S/N Names Organization Role 53 Yahaya Garba Magaji LAPAI LGA Enumerator 54 Muhammed Ibrahim LAPAI LGA Enumerator 55 Muhammed Jadeeq LAPAI LGA Enumerator 56 Abdulmalik Aliyu Kudu LAPAI LGA Enumerator 57 Maryam Kolo Mathew Edati LGA Enumerator 58 Aishatu Mohammed Edati LGA Enumerator 59 Mohammed N Aliyu Edati LGA Enumerator 60 Andrew Gana Edati LGA Enumerator 61 Damion Gimba Paikoro LGA Enumerator 62 Emebo Chika Paikoro LGA Enumerator 53 Nasir Garba Paikoro LGA Enumerator 64 Samaila Musa Paikoro LGA Enumerator 65 Ibrahim Danlami Paikoro LGA Enumerator 66 Aisha Musa Ahmed Paikoro LGA Enumerator 67 Aishetu Isa Paikoro LGA Enumerator 68 Abdulazeez Umar Paikoro LGA Enumerator 69 Muhammad Zubairu Malaria Consortium (Consultant) Data Clerk 70 Adamu Idris Malaria Consortium (Consultant) Data Clerk 71 Isah Habila Malaria Consortium (Consultant) Data Clerk 72 Limanko Muhammad Malaria Consortium (Consultant) Data Clerk 73 Randa S. Kingsley Malaria Consortium (Consultant) Data Clerk 74 Ahmad L. Yusuf Malaria Consortium (Consultant) Data Clerk 75 Ibrahim Saba Sojeko Malaria Consortium (Consultant) Data Clerk 76 Abubakar H. Abubakar Malaria Consortium (Consultant) Data Clerk 77 Atolagbe G. Abayomi Malaria Consortium (Consultant) Data Clerk

RAcE Niger State, Nigeria Endline Survey Final Report 56 ANNEX 6: Field schedule

S/N Name of supervisor Cluster Name of cluster LGA Date number 1 Dr. Patrick Gimba 6 Emi Zhitsu (Lasagi & Edati 13 -17/2/2017 Nagimka) 30 Yagbindi (Benuko) 2 Dr. Inuwa Junaidu 9 Hamdallahi, Lapai 13 -17/2/2017 20 Tanaye 3 Mrs. Mercy Dawaba 11 Kemi 16 Ndawashi (Ungwan Gwari) 4 Dr. Fatima Ibrahim 4 Butu Paikoro 13 -17/2/2017 and Mrs. Asiyah Ndaman 5 Dr. Fatima Ibrahim 21 Tunbi 6 Mrs. Asiyah Ndaman 13 Gupashi or Kwashi (Wadata & Gurunku) 7 Dr. Ibrahim Idris 10 Jullu (Asu, Shakpere, Secudna & Sisi) 19 Shinagba 8 Dr. Fatima Ibrahim 1 Abaran Ushe Rijau 20-24 12 Kudabo 2 10 Dr. Patrick Gimba 8 Genu Daji (Tasha Mayaki) 20-24 3 Babade 12 Dr. Fatima Ibrahim 17 Rijawa Mariga 25-26 13 Dr. Patrick Gimba 25 Ung Yahala 25-26 14 Mrs. Mercy Dawaba 2 Ang Climo 20-26 7 Funa Funan Yidi 16 Mrs. Mercy Dawaba 24 Ung Makura and Yahaya Magaji 17 Yahaya Magaji 23 Ung Gada 5 Dinalko 14 Mai Saje 18 Mrs. Mercy Dawaba 15 Matseri 19 Dr. Ibrahim Idris and 26 Ung Baituwa 20-22 Asiyah Ndaman 20 Dr. Ibrahim Idris 18 Sabon Gida Sambaro, Rafi 24-26/2/2017 29 Ung/Tambari 21 Mrs. Asiyah Ndaman 22 Un/Maibaka, 20-26/2/2017 28 Ung/Kura 22 Dr. Ibrahim Idris and 27 Ung/Bigude 27/2/2017 Mrs. Asiyah Ndaman

RAcE Niger State, Nigeria Endline Survey Final Report 57 ANNEX 7: Algorithm for selecting dwelling place Are there more than 30 dwellings in this community?

Yes No Go to page (22) Move to the centre of the area, Divide into 4 quadrants Randomly select a quadrant using balloting

*Does the quadrant selected has more >30 dwellings?

Yes No

Stand at the apex of Stand at the apex of quadrant. the quadrant, divide it Choose the 3rd closest house as s t the 1 dwelling Are there caregivers with children 2-59 months that have… in the last 2 weeks Use balloting to select 1 of them

Is the selected half > 30 dwellings? Yes No

Conduct interviewsMove to the next house with Yes No front door closest to you Continue to next house

Do you have enough interviews?

No Yes

Move to the next randomly selected quadrant using balloting and start again @ *

RAcE Niger State, Nigeria Endline Survey Final Report 58 Finished

Are there more than 30 dwellings in this community? No

Move to the centre Ballot to choose a direction rd st Choose the 3 closest house as the 1

Are there caregivers with children 2-59 months that h ave ….. in the last 2 weeks

Yes No

Do interviews Move to the next door with front door closest to you

Continue next house with

Do you have enough

Yes No

Move to the next non- No allotted community, but within study area

RAcE Niger State, Nigeria Endline Survey Final Report 59 ANNEX 8: Algorithm for selecting respondent

ARE THERE CHILDREN 2-59 MONTHS IN THIS HOUSEHOLD?

No Yes

Move to the next household Are you the caregiver of any of the children?

Yes No

Are you the caregiver of all the children? Help identify the caregiver (s)

Yes No

Administer consent Are all other caregivers around?

Go to Module 1:CI Yes No

Revisit

RAcE Niger State, Nigeria Endline Survey Final Report 60 ANNEX F. ENDLINE SURVEY FIELDWORK SCHEDULE

S/N Name of supervisor Cluster Name of cluster LGA Date number 1 Dr. Patrick Gimba 6 Emi Zhitsu (Lasagi & Edati 13 -17/2/2017 Nagimka) 30 Yagbindi (Benuko) 2 Dr. Inuwa Junaidu 9 Hamdallahi, Lapai 13 -17/2/2017 20 Tanaye 3 Mrs. Mercy Dawaba 11 Kemi 16 Ndawashi (Ungwan Gwari) 4 Dr. Fatima Ibrahim 4 Butu Paikoro 13 -17/2/2017 and Mrs. Asiyah Ndaman 5 Dr. Fatima Ibrahim 21 Tunbi 6 Mrs. Asiyah Ndaman 13 Gupashi or Kwashi (Wadata & Gurunku) 7 Dr. Ibrahim Idris 10 Jullu (Asu, Shakpere, Secudna & Sisi) 19 Shinagba 8 Dr. Fatima Ibrahim 1 Abaran Ushe Rijau 20-24 12 Kudabo 2 10 Dr. Patrick Gimba 8 Genu Daji (Tasha Mayaki) 20-24 3 Babade 12 Dr. Fatima Ibrahim 17 Rijawa Mariga 25-26 13 Dr. Patrick Gimba 25 Ung Yahala 25-26 14 Mrs. Mercy Dawaba 2 Ang Climo 20-26 7 Funa Funan Yidi 16 Mrs. Mercy Dawaba 24 Ung Makura and Yahaya Magaji 17 Yahaya Magaji 23 Ung Gada 5 Dinalko 14 Mai Saje 18 Mrs. Mercy Dawaba 15 Matseri 19 Dr. Ibrahim Idris and 26 Ung Baituwa 20-22 Asiyah Ndaman 20 Dr. Ibrahim Idris 18 Sabon Gida Sambaro, Rafi 24-26/2/2017 29 Ung/Tambari 21 Mrs. Asiyah Ndaman 22 Un/Maibaka, 20-26/2/2017 28 Ung/Kura 22 Dr. Ibrahim Idris and 27 Ung/Bigude 27/2/2017 Mrs. Asiyah Ndaman

RAcE Niger State, Nigeria Endline Survey Final Report 61