UNICEF GUINEA-BISSAU Review of Malnutrition Prevention and Management Project
March 2018
Table of Contents
Table of Figures ...... 1 Executive Summary ...... 2 Acknowledgements ...... 4 Introduction ...... 5 Objectives ...... 5 Key definitions ...... 5 Background and Context ...... 6 Evaluation ...... 8 Challenges and Suggestions for the Future ...... 20 Bibliography ...... 22 Appendix A: Human Interest Stories ...... 23 Appendix B: Methodology ...... 25 Appendix C: Project Team ...... 27 Appendix D: Contact Details ...... 28
Table of Figures
Figure 1: CRN Treatment outcomes (Bafata) ...... 8 Figure 2: CRN Treatment outcomes (Gabu) ...... 10 Figure 3: Percentage of patients tested for HIV ...... 11 Figure 4: Percentage of patients tested for HIV by type of treatment centre (Bafata) ...... 13 Figure 5: Percentage of patients tested for HIV by type of treatment centre (Gabu) ...... 13 Figure 6: Percentage of patients who test HIV-positive who are referred to a CTA (Bafata) ...... 14 Figure 7: Treatment outcomes of children who test HIV-positive (Bafata) ...... 14 Figure 8: Treatment outcomes of children who test HIV-positive (All regions) ...... 15 Figure 9: Percentage of parents of CRN patients who have heard of HIV tests (by region) ...... 16 Figure 10: Percentage of parents of CRN patients who have been tested for HIV (by region) ...... 17 Figure 11: Water Source (%, by region) ...... 17 Figure 12: Percentage who treat water (by region) ...... 18 Figure 13: Type of water treatment (by region, multiple responses allowed) ...... 18
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Executive Summary
Background In October 2014, UNICEF Guinea-Bissau launched an initiative for more effective prevention of chronic malnutrition and management of Severe Acute Malnutrition (SAM) in nutrition rehabilitation centres across the country. As part of efforts to shift towards integrated planning and monitoring through the creation of convergence and programmes linkages, Nutrition integrated HIV and WASH into its interventions in three nutrition rehabilitation centres managed by Caritas.
Purpose To review the Malnutrition and Management project implemented at Nutritional Rehabilitation Centres (CRNs) and Casa das Mães in the regions of Gabú, Bafatá and Cacheu.
Identified best practices Feedback from beneficiaries indicates that participation in the project has positively influenced their practices and behaviours, especially relating to WASH, Nutrition, and Breastfeeding practices, notably improving the health of children at the CRN. Both beneficiaries and Key Informants at the CRNs expressed project satisfaction. Specific identified best practices include:
Overall
• Programme effectiveness due to addressing of three intricately interrelated issues at the grassroots level in Guinea-Bissau: nutrition, hygiene and HIV/AIDS. Effective resource use due to complementarity and cross- fertilisation effects of interventions. • Community visits by animators and supervision allowing for follow-up of patients increased reach and effectiveness of the programme and was considered a best practice by CRN staff. • The multiplier effect of awareness raising and training of parents on best nutritional, health and hygiene practices as those directly involved transmitted knowledge onto their families and neighbours.
Nutrition • Improvements in treatment outcomes at the CRN in Bafatá thanks to a combination of factors, including, good coordination between CRENI and CRENAG and better resourced and staffed CRNs, • Success in awareness-raising of nutritional practices thanks to better trained staff and the provision of graphic teaching materials (in Cacheu and Gabú).
HIV/AIDS • Improvements in HIV testing and CTA referral rates in Bafatá thanks, at least partly, to better staff awareness and training and increased coordination between CRENI, CRENAG and CTA. • High levels of awareness of CRN patients regarding availability and importance of HIV testing in all three regions as a result of training of CRN staff
WASH • Success in awareness-raising of water and sanitation practices thanks to better trained staff and the provision of graphic teaching materials (in Cacheu and Gabú).
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Identified challenges
Overall Main overall challenges preventing the project from achieving its key objectives included:
• Lack of coordination between centres in all three regions; insufficient financing for supervision field visits; inadequate training of all health professionals; • Inadequate and inconsistent data collection methods and serious ruptures to stocks of supplies.
Nutrition • Fall in ongoing treatment and an increase in treatment abandonment at the CRN in Bafatá. The CRN have had to stop field visits due to financial constraints which may be impacting these results, there is a need for action to ensure patients finalise their treatment. • Worsening treatment outcomes at the CRN in Gabú, and a sharp rise in unconfirmed abandonment, again potentially due to lack of supervision visits.
HIV/AIDS • Decrease in testing rates in Gabú, likely due to deficiencies in data collection and data sharing by the centre and the regional hospital. • Difficult to gauge success of HIV/AIDS awareness-raising as the topic remains a taboo subject when discussed in public. • As project was implemented via a catholic organisation (CRN Caritas) the use of preservatives to prevent HIV transmission was not being taught as a key awareness message in Cacheu.
WASH • Respondents in Gabú and Cacheu are more likely to use methods that are not adequate to ensure water is safe for human consumption. • Severe constraints in access to water in parts of Cacheu.
Sustainability • Lack of project awareness and training amongst health workers in hospitals, potentially due to the high rotation of staff in the Guinea-Bissau public health system. • Stop-start nature of donor funds impedes the on-going, prolonged efforts in raising-awareness that the project requires to achieve positive results and leads to waste, most notably of human capital. • MSF will exit Bafatá hospital, this may negatively impact the success in testing rates by the CRENI service.
Key recommendations 1. Improve coordination and communication amongst the Centres within regions, and between UNICEF and the Centres. 2. Provide regular monitoring, supervision and support by UNICEF nutrition, HIV and WASH teams to the Centres. 3. Tackle treatment abandonment issues by providing financial means to allow regular field visits by the Centres to the Tabankas and invest in data collection methods. 4. Provide updated and regular training sessions to health workers and key personnel. 5. Make efforts to address the regular stock breaks in tests, medicines, and nutrition supplies.
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Acknowledgements
This work would not have been possible without the financial support of UNICEF Guinea-Bissau and the guidance and feedback provided by their staff. The authors would particularly like to thank UNICEF Representative, Christine Jaulmes and her team, specially Dr. Jadranka Mimica, Dr. Paulo Rabna, Ademonkoun Rodolphe Missinhoun, Marion Cabanes, Iama Sanha and Bessa Vitor da Silva.
The fieldwork carried out for this evaluation would not have been possible without the cooperation, enthusiasm and generosity of CRN staff. We would especially like to thank Irma Ivanilda (CRENAG Bafata), Joao da Costa (CRENAG Bafata), Dr. Matias Saez Osorio (CRENI Bafata), Maria Pedro Gomes (Casa das Maes Bafata), Irma Adriana (CRENAG Gabu), Rebeka Sultana (CRENAG Gabu), Irma Solange Lussi (CRENAG Cacheu), Francisco Biai (CRENI Cacheu) and Francisca Mie (CRENI Cacheu) for their availability and openness to discuss and provide very insightful input regarding the achievements of the project and the challenges they continue to face in carrying out their extremely valuable, and often life-saving, work.
In addition, we would like to express our gratitude to the Minstry of Health of Guinea-Bissau for their cooperation, without which this evaluation would not have taken place. We are particularly grateful to Vany Moreira for supporting the project and providing us with access to mangers and staff in regional hospitals. We would also like to thank frontline health staff in Bafata, Gabu and Cacheu for their availability and kindness, and in particular Larisa Carol Pereira (CTA Bafata), Gam Jose Bock (CTA Gabu) and Herasmo de Barros (CTA Canchungo).
We would also like to thank Bandim Health Project, and particularly Dr. Amabelia Rodrigues and Dr. Cesario Martins, for their administrative, technical and logistical support.
Finally, the authors would like to express immense gratitude to, and admiration for, the mothers who took part in the focus groups and personal interviews. They, through their openness and warmth, despite the difficult circumstances many found themselves in, provided us with invaluable input for the success of the project and made the fieldwork a very enjoyable experience.
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Introduction
In October 2014, UNICEF Guinea-Bissau launched an initiative for more effective prevention of chronic malnutrition and management of Severe Acute Malnutrition (SAM) in nutrition rehabilitation centres across the country. As part of efforts to shift towards integrated planning and monitoring through the creation of convergence and programmes linkages, Nutrition integrated HIV and WASH into its interventions in three nutrition rehabilitation centres managed by Caritas. Approximately, 4,400 mothers and caregivers were counselled on optimal Infant and Young Child Feeding (IYCF) practices1, inclusive of hygiene and sanitation, HIV screening and rapid referral to care with support from Community Health Workers (CHW) and 40 Mother Support Groups. The centres were also supported with improved water and sanitation facilities as the connection between malnutrition and environmental health is increasingly recognised.
Objectives
To review the Malnutrition and Management project implemented at Nutritional Rehabilitation Centres (CRNs) and Casa das Mães in the regions of Gabú, Bafatá and Cacheu:
• Identify and understand the best practices of the project activities implementation; what worked and what did not work to reach expected outcomes in nutrition, HIV/AIDS and WASH; • Assess the complementarity and cross-fertilisation potentials of the different activities of the project. (i.e. whether or not each of the program component benefited from each other); • Assess the sustainability of interventions and the degree to which the knowledge and skills delivered through the project were retained in regular service delivery; • Understand the feedback of beneficiaries to the degree to which the participation in the project influenced their practices and behaviours.
The review will cover the main three programmatic areas of the project that are nutrition, HIV/AIDS and WASH and assess how the activities complement each other to reach the expected results. For each programmatic area, the review should inform on the following:
• Nutrition: assess the extent to which the project implementation was successful (or not) in improving the knowledge of caregivers at Centres covered by the project and mothers in terms of nutrition. It should highlight the factors that may be considered in future projects. • HIV/AIDS: assess if the project led to increased uptake of HIV testing, and referral to treatment for HIV infected children and mothers. • WASH: assess the extent to which WASH messages have been understood and applied by caregivers and mothers.
Key definitions
HIV stands for the human immunodeficiency virus which infects cells of the immune system, destroying or impairing their function. Infection with the virus results in progressive deterioration of the immune system, leading to "immune deficiency." The immune system is considered deficient when it can no longer fulfil its role of fighting
1 Source: UNICEF Guinea-Bissau (2016), UNICEF Annual Report 2015: Guinea Bissau, Bissau.
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infection and disease. Infections associated with severe immunodeficiency are known as "opportunistic infections", because they take advantage of a weakened immune system (World Health Organization, 2017).
AIDS stands for Acquired immunodeficiency syndrome, and is a term which applies to the most advanced stages of HIV infection. It is defined by the occurrence of any of more than 20 opportunistic infections or HIV-related cancers (World Health Organization, 2017).
WASH typically refers to activities aimed at improving access to and use of safe drinking-water and sanitation as well as promoting good hygiene practices (UNICEF, World Health Organization, 2015).
Malnutrition refers to all forms of nutrition disorders caused by a complex array of factors, including dietary inadequacy (deficiencies, excesses or imbalances in macronutrients or micronutrients), and includes both undernutrition and over nutrition and diet-related non-communicable diseases (UNICEF, World Health Organization, 2015).
Undernutrition occurs when the body’s requirements for nutrients are unmet as a result of under-consumption or impaired absorption and use of nutrients. Undernutrition commonly refers to a deficit in energy intake from macronutrients (fats, carbohydrates and proteins) and/or to deficiencies in specific micronutrients (vitamins and minerals) (UNICEF, World Health Organization, 2015).
CRENAG are Centres for Recovery and Nutrition Education for Severe Malnutrition without medical/clinical complications. In these Centres existence of a trained health worker (not necessarily a doctor) is sufficient.
CRENAM are Centres for Recovery and Nutrition Education for preventing Severe Malnutrition. They are present in Hospitals, and Health Centres. Requires only a person with nutritional and good feeding practical skills to provide counselling and give practical feeding demonstrations, not specifically a doctor or nurse. CRENAM occur mostly in health centres and casa das mães.
CRENI are Centres for Recovery and Nutrition Education in Intensive Regime. They are present in Regional Hospitals. Need for a qualified doctor to treat complications that may be the consequence of the severe malnutrition.
CTA are Centres dedicated to the follow-up of people with HIV (adults and children) under antiretroviral treatment.
Casa das Mães offer services for pregnant women and women with young children.
Caritas is a Faith-based Non-Governmental Organization established in Guinea-Bissau in 1982, with a strong presence at national level, working in 24 nutritional rehabilitation centres.
CRN are Nutritional Recovery Centres.
Background and Context
Guinea-Bissau has faced consistent political instability and a lack of stable social and economic institutions for more than two decades. A small state (36,125 km2), situated on the West Coast of Africa, with a population of 1.52 billion in 2015 (INE) and GDP income per capita of US$590 (2015), life expectancy is just 55 years, below the regional average (59 years). There are eight diseases that account for over 70% of deaths and DALYs (Disability-Adjusted Life Years): Malaria, HIV, neonatal disorders, lower respiratory infections, diarrheal diseases, nutritional deficiencies, injuries, and cardiovascular disease. According to the last Multi Indicators Cluster Survey (MICS) the maternal mortality rate (MMR) in Guinea-Bissau is estimated at 900 maternal deaths per 100,000 live births, one of the highest
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rates in the world (Anon n.d.). The country’s health system faces persistent challenges in providing services, related to a severe shortage of health workers, low public spending, poor infrastructure and weak governance. The density of doctors, nurses and midwives is 0.98 per 1,000 population, well below various recommended targets. Available health workers are concentrated in urban areas, mainly the capital city Bissau, leaving the remote regions without a minimum health team. In 2013 the per capita spending on health was US$37, below the average per capita among West African countries (US$65.3). Government spending accounts for about 20% of total health spending and is mostly to pay staff salaries, yet budget execution is very weak. Donors finance nearly 90% of the recurrent costs of the sector, including medicines and other critical health inputs. Out-Of-Pocket (OOP) payments represent the largest source of health sector financing (49.5%).
The burden of HIV/AIDS in Guinea-Bissau is among the highest in West Africa and is increasingly affecting children. Although most women are tested during pregnancy, the uptake of diagnostic testing for children is very low. The national prevalence of acute malnutrition (wasting, defined as weight for height lower than two standard deviations below the mean) is 6%, reaching approximately 8% in some areas, while the prevalence of stunting among children under five years is 27.6% (UNICEF, 2015).
HIV/AIDS and Nutrition
There are many studies indicating the high prevalence of malnutrition observed in HIV-infected children compared with HIV-uninfected children (Poda, Hsu, & Chao); (Bruno F Sunguya, 2011); (Anna M Rose, 2014). Such studies stress the need for nutritional assessment and support to be included in paediatric HIV management. Moderate or severe malnutrition can also be a sign for untested HIV-infected children; the WHO Paediatrics Clinical Staging system for HIV identifies a progression sequence from least to most severe (1 to 4) – the higher the clinical stage, the poorer the prognosis, with both stage 3 and stage 4 identifying malnutrition as a key symptom (World Health Organization , 2011). The strong relationship between HIV/AIDS and malnutrition in children highlights the potential in programme integration.
WASH and Nutrition
Both undernutrition and lack of safe water and sanitation are major global challenges, yet proven nutrition and wash interventions exist and have been successfully implemented, for example: early initiation of breastfeeding, appropriate complementary feeding practices, use of improved household toilets or latrines, and improved water supply. Existing evidence shows that a lack of access to WASH can affect a child’s nutritional status in at least three direct pathways: diarrheal diseases, intestinal parasite infections and environmental enteropathy (UNICEF, World Health Organization, 2015).
WASH and HIV/AIDS
Often regions with poor water and sanitation conditions are also regions with high HIV/AIDS prevalence. People living with HIV/AIDS are at greater risk of developing diarrheal disease, have it more frequently, have more severe episodes, and are more likely to die from it. Unsafe drinking water presents a particular threat to people living with HIV/AIDS (PLHIV) due to the increased risk of opportunistic infections, diarrheal-associated malabsorption of essential nutrients, and increased exposure to untreated water for children of HIV-positive mothers who use replacement feeding to reduce the risk of HIV transmission (Rachel Peletz, 2012).
Nutrition, HIV/AIDS and WASH
Given that HIV in children impacts malnutrition, undiscovered HIV could be the underlying cause to malnutrition, however this could also be due to poor hygiene. The relationship between HIV/AIDS, poor water and sanitation, and
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nutritional status is complex and interlinking, and points to the need for a thoroughly integrated approach to prevention. To the authors knowledge there does not exist any literature on the simultaneous integration of HIV/AIDS and WASH into Nutrition practices.
Evaluation Nutrition
Improving health and nutritional outcomes at CRNs is at the centre of the project. Guinea-Bissau has a very high burden of malnutrition, which directly correlates with maternal and child mortality (World Bank , 2016). The World Food Programme (WFP) national food security assessment conducted in 2013 revealed that only 7% of the population is food-secure.
CRN Treatment Outcomes
Treatment outcomes at the CRNs in Bafatá improved between 2015 and 2017 with cured or successfully treated patients rising in both absolute terms, from 183 patients in 2015 to 698 patients in 2017, and in relative terms, from 67 per cent in 2015 to 75 per cent2 of total patients in 2017. However, the proportion of patients with ongoing treatment fell from 13 per cent to 1 per cent, which could partly explain the increase in successfully treated cases. In addition, the proportion of patients who abandoned their treatment increased from 7 to 12 per cent in the same period, which signals a need for action to ensure patients finalise their treatment.
Figure 1: CRN Treatment outcomes (Bafatá)
0% 10% 20% 30% 40% 50% 60% 70% 80%
67% Cured/Succesfully treated 75% 7% Confirmed abandonment 12% 6% Death 6% 13% Ongoing treatment 1% 7% N/A 3% 0% Other 3%
2015 2017
This improvement in outcomes could be at least partly attributed to the successful integration of nutrition, HIV and WASH interventions which in turn leads to improved nutritional and health results through better quality care, more appropriate nutritional, hygiene and sanitation behaviours, and enhanced HIV prevention, diagnosis and treatment.
Results from a Human-Interest Story undertaken at the CRN in Bafatá highlights both the satisfaction of service at the Centre, and the success of nutrition awareness efforts in improving the knowledge of mothers.
2 Out of a total of 272 patients treated in 2015 and a total of 934 patients treated in 2017.
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“I am very happy to have come and received the awareness-raising information, I really liked it, thank you, and I would like it to be repeated more often so that we have good health so that we can treat our children…”
Human Interest Story, CRN, Bafatá
“They taught us to give the children tap water to avoid diarrhoea, they gave us serum that I put in a litre and a half of water and give to my child. They taught us to throw child stools not in the trash but in the bathroom, to keep the bathroom clean to avoid flies, as they are not good. When they give us food we sit here for a djumbai where they teach us using a large book.”
Human Interest Story, CRN, Bafatá
The service beneficiaries who participated in the focus group discussions were able to explain clearly both nutritional and WASH practices that they have learnt at the centre. More than half of the group gave precise examples of the practices which they now apply in their homes.
"After we receive the midday treatment, we arrive home and bath the children with soap and water; the dishes on which the food is served are also bathed with soap and water; the jugs of water are also washed with water and soap .... "
Service Beneficiary, CRN, Bafatá
Interviews with key informants adhered to field visits as one of the most effective tools in both monitoring practices and patients. The increase in the proportion of patients who abandoned treatment may be linked to the difficulties the Centre is facing in financing field visits.
"Often we want to visit the field in order to raise awareness but that requires means ... We have no means of vising the field where we would be able to get the job done."
Key Informant Interview, CRN, Bafatá
Regular supervision visits to the Tabankas could provide the follow-up needed to prevent abandonment and help in ensuring patients finalise their treatment.
Treatment outcomes in CRNs in Gabú have deteriorated with the proportion of cured and successfully treated patients falling from 53 per cent (46 of 87 patients) in 2015 to 26 per cent (18 of 70 patients) in 2017. Moreover, unconfirmed abandonments have risen sharply from 14 per cent of patients (12 of 87 patients) in 2015 to 49 per cent of patients (34 of 70 patients) in 2017, reflecting a worrying trend of the CRNs losing track of their patients before they finish their treatment without even confirming if they have abandoned the treatment voluntarily.
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Figure 2: CRN Treatment outcomes (Gabú)
0% 10% 20% 30% 40% 50% 60%
53% Cured/Succesfully treated 26% 3% Confirmed abandonment 0% 14% Unconfirmed abandonment 49% 3% Death 4% 17% Ongoing treatment 10% 0% N/A 4% 9% Other 7%
2015 2017
With the closure of the CRENI in the regional hospital, the CRN in Gabú has informally assumed its role. A potentially larger volume of patients, and no means to undertake supervision work, point to underlying causes of the rate of unconfirmed abandonment. This may relate to the deterioration of treatment outcomes. Factors such as exhaustion from hospital visits negatively impact parents’ willingness to return to Centre and facilities for their child’s treatment, thus contributing to falling success rates.
"We have a boy who is here now, he stayed two months recovering for being HIV positive and started treatment, he stayed two months at home as she took the medication but she did not come for control, nor to the centre, nor to get the medicine, then two months the child returned with everything that he had recovered from, and now he is starting all over again, now we know if a mother is two months away from home, a hospital environment is very exhausting, tiring, they already want to leave, but then the whole process starts over again."
Key Informant Interview, CRN, Gabú
HIV Testing, Treatment and Awareness
Moderate or severe malnutrition can be a sign of a child being HIV-infected, thus establishing if a child is HIV positive is a key element in determining treatment and is crucial to improving nutritional and overall health outcomes. In consequence, increasing testing rates of children admitted at a CRN to 100 per cent was one of the central objectives of the integrated initiative.
HIV Testing Rates
Data collected from medical records in CRNs across four regions show an increase in testing between 2015 and 2017, with 46 per cent of patients (345 out of 744 patients) tested for HIV in 2015 rising to 73 per cent (954 out of 1298 patients) by 2017. However, the results differ significantly between regions and particularly between the two regions covered by the integrated intervention for which data is available. Data for Bafatá shows a significant increase in testing, from 47 per cent (188 out of 399 patients) in 2015 to 77 per cent (694 out of 907 patients) in 2017, while testing rates in Gabú decreased from 28 per cent (23 out of 82 patients) to 19 per cent (19 out of 101 patients) of patients admitted to a CRN. At the same time, testing rates in the region of Oio, which was not covered by the programme, nearly doubled from 42 per cent (79 out of 189 patients) in 2015 to 80 per cent (172 out of 216 patients) in 2017.
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The qualitative interviews highlight some of the key constraints in HIV testing, for example a lack of materials at the CRN in Bafata prevents testing from occurring at the Centre.
“If we had materials, forms and medicines we could do it [HIV testing] here”
Key Informant Interview, CRENAG, Bafata
Two Key Informant Interviews in Gabu refer to key challenges facing the health centres which likely negatively impact the ability to achieve high HIV testing rates, for example: frequent stock breaks and difficulties in integrating and communicating with other implementers.
“The biggest challenge is with stock breaks, it is not only with the medicine that we have stock break but sometimes also the test”
Key Informant Interview, CRN/Caritas, Gabu
“…and often difficult times when there is a stock break and the organization of the health system itself often prevents functioning, detecting a child, admitting for treatment, and after the treatment is continued, there are difficulties, it has to be a joint work...”
Key Informant Interview, CTA, Gabu
Qualitative data from the Cacheu region also highlight the issue of stock breaks and inefficiencies in the supply chain which prevent HIV testing.
“We have had a stock break in type 2 medication since August / October; and even in December the quantity they brought was few; the health authorities asked for more because the number of patients type 2 was higher…” Key Informant Interview, CTA, Cacheu
“It [responding to re-stock request] is not fast, it is slow, it takes so long. Last time it arrived I think it was like a month after the request.” Key Informant Interview, CRENI, Cacheu
Figure 3: Percentage of patients tested for HIV
98% 100% 93%
80% 77% 80% 73%
60% 47% 46% 42% 40% 28% 19% 20%
0% Bafata Biombo Gabu Oio Total
2015 2017
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The HIV testing numbers point towards very different results of the project in Gabú and Bafatá and an analysis of the causes behind these differences could help shed light on the best practices to increase coverage of HIV testing, and conversely, the strategies that yielded less satisfactory results. However, these results must be interpreted cautiously, as they are dependent on the quality and completeness of the data collection efforts.
Despite the quantitative data showing a decrease in testing rates in Gabú, the Key Informant Interviewee at the CRENAG in Gabú ensured that all children that enter the centre are now tested for HIV. Previously it was offered only to those cases that were clinically suspect. The interviewee shed light on data collection deficiencies.
"All the children who arrive take the test .... we do the tests, and we send children that tested positive to the CTA, but we do not pass on the monthly number of children tested. On a monthly basis we deliver a report, but the report has only that data referring to nutrition, and the name of the malnourished children, there are no children who have been certified, so we do not pass on the data, so it is also our fault that we should pass on separately the number of children who were tested, because we referred those who were positive for CTA, but the number of tests performed we do not pass."
Key Informant Interview, CRENAG, Gabú
There is scope to improve data collection and coordination between centres in order to gain from the benefits of effective data registration which would help to keep track of patients and undertake supportive monitoring and evaluation.
HIV Testing Rates by Type of Treatment Centre
A more detailed analysis of the rate of HIV testing according to the type of Centre shows significant differences in testing rates at CRENIs and CRENAGs. In Bafatá, the CRENI saw a very sharp increase in the proportion of tested patients, going from 68 per cent (132 of 194 patients) in 2015 to virtually testing every patient (96%) (691 of 721 patients) by 2017. The CRENI in Bafatá’s regional hospital is supported by Doctors without Borders (MSF), dedicated to ensuring all children are tested:
"One of the positive models of MSF in CRENI is the 100 percent test rate of children, plus the measles vaccination."
Key Informant Interview, CRENI/MSF, Bafatá
The MSF team are due to leave the regional hospital which could negatively impact the high testing rates and raises sustainability issues. A clear exit strategy is needed to ensure the continuity of testing all children for HIV at the CRENI in Bafatá.
The CRENAG however went from testing 36 per cent of patients (28 of 78 patients) in 2015 to merely 1 per cent of patients (2 of 213 patients) in 2017. The CRENAG service at the CRN do not currently have adequate means to test patients, despite doing so in the past, and instead refer all patients to the CTA. However due to stock shortages, the CTA often refers patients to the MSF laboratory, which is seen by the CTA as a comfortable backup, and thus explains the difference in testing rates. Again, the planned exit of MSF from the regional hospital raises concerns for the continuity of testing.
"We test the children here if we have the material, if we do not have the material we send them to the laboratory, because Doctors without Borders can test in the laboratory"
Key Informant Interview, CTA, Bafatá
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Figure 4: Percentage of patients tested for HIV by type of treatment centre (Bafatá)
96% 100%
80% 68%
60%
36% 40%
20% 1% 0% 2015 2017
CRENAG CRENI
In Gabú, the proportion of tested CRENAG patients also fell sharply, while 18 per cent (13 of 72 patients) were tested in 2015 only 7 per cent (5 of 70 patients) were tested in 2017. No data for the CRENI is available because it has not been functioning due to the lack of a doctor and organisation issues. The absence of a functioning CRENI has meant that many of its functions have had to be taken over by the CRENAG, which underscores the gravity of such low rates of HIV testing at the CRENAG. This means that most children, even those with acute malnutrition and complications, might not be getting tested and might not be receiving adequate treatment because of a lack of an adequate diagnosis. As mentioned above, the CRENAG admitted to weaknesses in their record keeping, such as only passing on data for children that were HIV-positive.
Figure 5: Percentage of patients tested for HIV by type of treatment centre (Gabú)
100%
80%
60%
40% 18% 20% 7%
0% 2015 2017
CRENAG
CTA Referral Rates for HIV-Positive Patients
All patients that test HIV-positive should be referred to their nearest CTA to confirm the diagnosis, receive advice and guidance as well as antiretroviral treatment. The referral process, including information-sharing between the CRN and the CTA, should be clear and easy to follow for the patient’s parent or guardian to ensure the best care is given to HIV-positive patients. CRNs in Bafatá have seen a significant improvement in their CTA referral rates, with the percentage of HIV-positive patients who are referred increasing from 40 per cent (4 of 10 patients) in 2015 to 85 per cent (94 of 110 patients) in 2017. Some of this improvement could also be down to better record keeping, as 60% of HIV-positive patients in 2015 have no data regarding their referral to a CTA. Despite the improvement, much remains to be done, as it is of capital importance that one hundred per cent of HIV patients are referred to a CTA.
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Despite an improvement in Bafatá, issues in the referral process were highlighted in Cacheu. This may be due to a lack of training received by the staff currently working at the hospitals. For example, at the end of the interview with staff from the CRENI, the nurse asked the interviewers whether it is obligatory to test all children with malnutrition for HIV. Further, the doctor working at the CTA pointed to a lack of communication as the key reason preventing all children with malnutrition from being referred to be tested. The Guinea-Bissau health system suffers from high rotation of health workers, in the short-term it may be necessary to ensure regular, up-to date training sessions, and to improve the coordination between centres, even those within the same physical building.
Figure 6: Percentage of patients who test HIV-positive who are referred to a CTA (Bafatá)
100% 85%
80%
60% 60%
40% 40%
20% 10% 5% 0% 0% NO YES N/A
2015 2017
Treatment Outcomes of HIV-Positive Patients
Treatment outcomes of HIV-positive patients have improved since the project started, in Bafatá the proportion of those successfully treated or cured has increased from 60 per cent (6 of 10 patients) in 2015 to 69 per cent (76 of 119 patients) in 2017 while those who are confirmed to have abandoned treatment have decreased from 20 per cent to four per cent in the same period. Higher rates of HIV testing and CTA referral in CRNs in Bafatá could be factors behind the improvement in treatment outcomes, as HIV cases are detected earlier, and patients receive adequate care and guidance at the CTA.
Figure 7: Treatment outcomes of children who test HIV-positive (Bafatá)
0% 10% 20% 30% 40% 50% 60% 70% 80%
60% Cured/Succesfully treated 69%
20% Confirmed abandonment 4%
2015 2017
Treatment outcomes across all regions, including those not covered by the project, improved by a smaller margin from 61 per cent (28 of 46 patients) to 64 per cent (99 of 154 patients) of successfully treated or cured patients and 7 per cent to 5 per cent for confirmed abandonment of the treatment.
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Figure 8: Treatment outcomes of children who test HIV-positive (All regions)
0% 10% 20% 30% 40% 50% 60% 70%
61% Cured/Succesfully treated 64%
7% Confirmed abandonment 5%
2015 2017
Increasing awareness of HIV transmission, testing and treatment among parents is crucial to any strategy to fight HIV among children and was one of the objectives of the programme. A survey carried out by UNICEF in 2016 among parents of CRN patients shows very high levels of awareness regarding the availability and importance of HIV testing, particularly in Cacheu and Gabú. In fact, 100 per cent of respondents in Gabú said they have heard of HIV tests, with this proportion decreasing to 95 per cent in Cacheu and to 82 percent in Bafatá.
During the focus group discussions with service beneficiaries at the CRNs, all respondents that were questioned were able to explain clearly some of the key hygiene and nutritional practices that they learnt from the centre. When questioned about HIV prevention and transmission, although many respondents were able to correctly identify key transmission methods of HIV such as sexual transmission or that of a blade, some responses were less clear and at times inaccurate. This may be due to HIV/AIDS being somewhat of a ‘taboo’ subject when discussed in public. Often, once pushed for answers the respondents were able to explain facts. It should also be noted that prevention messages via the use of preservatives is not a tool used by the Casa das Mães, due to it being a Catholic organisation. Given that sexual activity is the most common cause of HIV transmission, the absence of condoms in the awareness- raising may want to be taken into consideration for future projects.
"They told me about other things, but they never spoke about AIDS in my presence."
Service Beneficiary, CRN, Bafatá
"Have you ever heard of HIV?” “No, they never spoke of it in my presence."
Human Interest Story, CRN, Cacheu
According to doctors in all three regions there are persistent cultural and religious beliefs that can prevent successful HIV treatment, in particular once a patient is starting to feel better these beliefs can lead to abandonment of treatment.
"Sometimes, especially those who have HIV-associated malnutrition, because as I have just said, they often rely more on religious practices, and say there are monkeys or cats, so when they go to their Tabanka and hear others influence, they end up giving up the treatment."
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Key Informant Interview, CRENI, Cacheu
"… well the lack of awareness that can be, but the people are really quite informed, I think it's the culture of Guineans once they have taken the medicine, that's when the treatment ends…”
Key Informant Interview, CTA, Gabú
"Others comply until a certain point, when they improve they are quick to abandon the treatment and it soon becomes difficult because they fall. This occurs even when we explain that the treatment should continue forever despite improvements to health."
Key Informant Interview, CTA, Bafatá
Parents of CRN Patients Awareness of HIV tests
Higher awareness should also lead to increased testing, in both adults and children. In the context of a family unit, early HIV testing and antiretroviral therapy initiation can play a role in not only reducing morbidity and mortality but also in reducing infectiousness and, therefore, onward transmission of the virus (van Rooyen, et al., 2016). Therefore, higher rates of HIV testing among parents can be a significant factor in reducing transmission risk for their children.
Figure 9: Percentage of parents of CRN patients who have heard of HIV tests (by region)
100% 100% 95% 90% 82% 80% 70% 60% 50% 40% 30% 20% 10% 0% Bafata Cacheu Gabu
Parents of CRN Patients Tested for HIV
According to the 2016 survey of the parents of CRN patients, nine in ten (90%) respondents in Cacheu declared having been tested for HIV in the past. However, the proportion of tested respondents in Gabú and Bafatá are much lower, with 48 per cent and 35 per cent respectively, which could increase the risk of transmission for children.
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Figure 10: Percentage of parents of CRN patients who have been tested for HIV (by region)
100% 90% 90% 80% 70% 60% 48% 50% 40% 35% 30% 20% 10% 0% Bafata Cacheu Gabu
Despite not having data per sex of parent, it is likely, at least in Gabú, that more mothers are being tested than fathers. A greater push to bring fathers to be tested may be required.
"...more women are tested, because they come to the hospital more than the men, and they, more than the men, are the ones who accept to do test. Sometimes we ask the woman to bring her husband but not many bring the husband. "
Key Informant Interview, CTA, Gabú
Water, Sanitation and Hygiene
Existing evidence shows that a lack of access to WASH can affect a child’s nutritional status in at least three direct pathways: diarrheal diseases, intestinal parasite infections and environmental enteropathy. Therefore, improved access to clean water as well as better sanitation and hygiene practices was one of the pillars of the project due to its potential to improve nutritional outcomes.
Water Source
A survey of CRN patients’ parents or guardians carried out by UNICEF in 2016 shows that respondents in Bafatá had better water infrastructure than in Cacheu and Gabú. Six per cent of respondents in Bafatá reported having running water with the remaining 94 per cent obtain water from a well with a pump. In contrast, in Gabú 70 per cent of respondents use a traditional well as their main source of water.
Figure 11: Water Source (%, by region)
100% 90% 80% 48% 70% 70% 60% 50% 94% 40% 30% 52% 20% 19% 10% 11% 0% 6% Bafata Cacheu Gabu
Running water Well with pump Traditional well
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Water Treatment
Conversely, respondents in Bafatá were least likely to treat water, with 82 per cent reporting they do, compared to 95 per cent in Cacheu and 100% in Gabú. Higher quality water sources in Bafatá could result in a lower need to treat water.
Figure 12: Percentage who treat water (by region)
100% 100% 95% 90% 82% 80% 70% 60% 50% 40% 30% 20% 10% 0% Bafata Cacheu Gabu
However, respondents in Gabú and Cacheu are more likely to use methods that are not adequate to ensure water is safe for human consumption. All respondents in Gabú and 81 per cent of respondents in Cacheu reported using filtering water with a cloth as a water treatment method. While some respondents might be using this method in tandem with a more adequate method such as boiling the water or using chlorine, many still appear to be using it as a stand-along water treatment solution.
Figure 13: Type of water treatment (by region, multiple responses allowed)
100% 100%
90% 81% 80% 65% 70% 62% 60% 52% 50% 40% 35% 30% 18% 20% 14% 10% 10% 4% 0% Bafata Cacheu Gabu
Boiling Chlorine Filter with cloth Leaves to settle
WASH Awareness-raising
Service beneficiaries in all three regions were able to explain key WASH messages learnt from the CRN during the focus group discussions.
“When you leave the bathroom, you have to wash your hands before you pick up anything, even if you do not do anything, if you leave the bathroom, you have to wash your hands."
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Service Beneficiary, CRN, Cacheu
Materials provided by UNICEF, such as visual boards, were useful tools used in awareness-raising especially in regions with low alphabetization or where multiple languages are spoken.
"We have posters donated by UNICEF that have part hygiene, part HIV-AIDS, that we show to the women even if they cannot read, they can see from the images what they mean and what they should do."
Key Informant Interview, CRN, Bafatá
However high rotation rates of women, as noted in the group in Gabú, can make it difficult to change individual hygiene habits. Changes are noticed in those women that stay for longer periods.
"... the group changes a lot, so to understand the scope is very difficult, especially with hygiene, but we try to change some, to be very sincere, we realize that there is a transformation change when they have been here for a month, yes, already receiving care, for example with the child's bed-bowl, with the bowl, after you have still to eat to wash your hands, to make the children cleaner, they understand."
Key Informant Interview, CRN, Gabú
Despite success in raising awareness, the following constraints were stressed as preventing beneficiaries from practicing at home what they learnt at the centre. Firstly, the strong link between poverty and hygiene.
"Hygiene is always linked, for example the issue of extreme poverty, because even if we tell them the information, yes some are already able to surround the fire with bits, to prevent the entry of animals, but always that matter of eating on the floor, they do not have a table, they do not have a seat…"
Key Informant Interview, CRN, Cacheu
Secondly, some areas of Cacheu are situated at the edge of the sea and at sea level. Despite teaching hygiene lessons, it is evident that there still exist large barriers preventing such practices from being implemented at home in Cacheu region due mainly to difficulties in accessing portable drinking water, and difficulties in digging for latrines, especially during the rainy season.
"No, you cannot dig the latrines in that area, you end up breaking in, there are no possibilities, you cannot just dig the pit because in the rainy season you end up breaking in, we cannot, and we are asking you for help because we are bad over there."
Service Beneficiary, CRN, Cacheu
“We do not always have clean water, there is little here, we walk miles to look for water because in our zone we are at the edge of the sea, if we dig, we will only have salt water so here we cannot. Women use water only to do horticulture, that is why we are always asking for support, to help us with a tube because there is pipeline here, to help us to get water to our area so we can have clean water because our women go to fetch water in a place far away… “
Service Beneficiary, CRN, Cacheu
Finally, it is hard to be certain that the messages learnt are passed on at home given financial restrictions preventing the supervision visits which were used as a monitoring tool. This would be a more effective means of following up.
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“Now it’s hard to do a follow-up to see this in their house, because we cannot happily follow post-discharge to visit their house to know if what they are doing continues at home."
Key Informant Interview, CRN, Gabú
Challenges and Suggestions for the Future
The following key issues highlight the challenges and suggestions for going forward that were made apparent during the Key Informant Interviews and Focus-Group Discussions:
Coordination and Communication
In order to integrate the three programmes a collaborative approach is necessary. A lack of communication and coordination was repetitively referred to across all regions and across all centres. More specifically: bottlenecks in communication between Centres; lacking communication between UNICEF and the Centres; and a general sentiment that coordination between all partners and key stakeholders could be improved.
"... the challenge, is that often for us to do this integration, it is not only our job, we have to integrate our work together with that of the hospital, with CTA, and it is often difficult due to stock breaks, and the health system as an organization itself often impedes, that to detect a child, admit treatment, after the treatment is continued, these I see as the greatest difficulties, because it has to do joint work, to integrate these three areas it has to be joint work, and many times we cannot do it. To do this communication is necessary, to achieve this, greater integration with the hospital and with the authorities is needed… "
Key Informant Interview, CRN, Gabú
Supervision Field Visits
Field visits were presented as one of the most effective ways in ensuring continued treatment, and in monitoring the up-take of awareness messages in the Tabankas. Currently there are financial constraints preventing such visits.
"...to have more frequent supervision, more than just two or three times a year, this helps in communication and development of our work."
Key Informant Interview, CRN, Gabú
"We make efforts to go to the Tabankas but with difficulty, we bring a lot of people back to the Centre and we do not have enough to give them, so I think that UNICEF has to help with the issue of transportation and means to welcome those that come."
Key Informant Interview, CRN, Bafatá
It is believed that such supervision, and/or the use of CHWs, should be explored further for the continuation of integrating all three areas at the homes of the beneficiaries. The potential to use the local radio to raise awareness was also highlighted.
"CHWs are directly connected with these cases of malnutrition, first they can detect and pass on, and second they can effectively give much better sanitary education than is done within hospitals and health centres…
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It is much more effective when a CHW has adequate training and supervision. They can also follow up on the cases of those that do not come back. "
Key Informant Interview, CRENI/MSF, Bafatá
"…and another issue that is also a challenge, as we are not normally able to do, is to do the radio shows, local radio helps a lot"
Key Informant Interview, CRN, Cacheu
Disruptions to Stock
Repetitively, issues surrounding stock and disruptions to stock were raised. Efforts by UNICEF to coordinate with other partners and the Ministry to ensure that all centres have sufficient equipment, materials and stock should be of priority. The unavailability of stock, in particular of HIV drugs, greatly hinders the efforts made in raising- awareness and promoting testing.
“What makes work difficult is that we have frequent stock breaks”
Key Informant Interview, CRN, Gabú
“There is another who died yesterday in paediatrics because of drug rupture, I believe, because the mother said the child had a fever and so brought her in. I asked her about the medication. She said that it was over and that she came to her and there was no medicine and so the next day they went to the paediatrics and they stayed their 5 days and then the child died.”
Key Informant Interview, CTA, Bafatá
Sustainability The sustainability of the project largely links to issues regarding human resources and donor funding. Knowledge of the project was varied across public health professionals, in all regions at least one medical professional was not informed of the project, and many had not received the training. For a continued effort within the hospitals regular training and frequent visits are necessary, especially to combat the high rate of rotation of health workers in the public health system. This would ensure that all staff on duty are aware of the project and make daily efforts to pursue the projects objectives.
"The most fundamental challenge, is that first of all, us doctors here have never received training about malnutrition ..."
Key Informant Interview, CRENI, Cacheu
“I have been here since 2014 but I have not been informed about this, but one day I saw my boss speaking with people from WFP about UNICEF.”
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Key Informant Interview, CTA, Bafatá
The stop-start nature of donor funding can also impact the sustainability of the project. This can hinder a project of this nature which requires on-going, prolonged efforts in raising-awareness to achieve positive results. Implementing the project via the CRNs has helped minimize this issue given that the Centres are well-known in the community, have been active for a number of years, and make continued efforts to continue raising awareness and applying best practices even when donor funding fluctuates. However, such centres are facing financial difficulties, particular in their ability to provide a constant supply of nutritional provisions and in engaging in follow-up visits in Tabankas.
Staff at the CRNs in all three regions were aware of the project, most of whom were present for all stages from elaboration to implementation.
"The project in 2014/2015 was a request that helped a lot, if we are able to get new initiatives, to be able to integrate these three missions, we would have good results."
Key Informant Interview, CRN, Gabú
Staff were both satisfied with the project and would like for it to be continued in the future.
Bibliography Anna M Rose, C. S.-A. (2014). Aetiology and management of malnutrition in HIV-positive children. Archives of Disease in Childhood . Bruno F Sunguya, K. C. (2011, November). Undernutrition among HIV-positive children in Dar es Salaam, Tanzania: antiretroviral therapy alone is not enough. BMC Public Health. Poda, G. G., Hsu, C.-Y., & Chao, J. C.-J. (n.d.). Malnutrition is associated with HIV infection in children less than 5 years in Bobo-Dioulasso City, Burkina Faso: A case-control study. Rachel Peletz, M. S. (2012). Assessing Water Filtration and Safe Storage in Households with Young Children of HIV-Positive Mothers: A Randomized, Controlled Trial in Zambia. PLOS ONE . Rotheram-Borus, M., Flannery, D., Rice, E., & Lester, P. (2005). Families living with HIV. AIDS Care, 978- 987. UNICEF. (2015). Multiple Indicator Cluster Survey (MICS5), 2014. UNICEF. UNICEF, World Health Organization. (2015). Improving nutrition outcomes with better water, sanitation and hygiene: practical solutions for policies and programmes. World Health Organization. van Rooyen, H., Essack, Z., Rochat, T., Wight, D., Knight, L., Bland, R., & and Celum, C. (2016). Taking HIV Testing to Families: Designing a Family-Based Intervention to Facilitate HIV Testing, Disclosure, and Intergenerational Communication. Front Public Health, 154. World Bank . (2016). Guinea-Bissau Health Sector Diagnostic . World Health Organization . (2011). Manual on paediatric HIV care and Treatment for District Hospitals. World Health Organization. (2017). HIV/AIDS Online Q&A. Retrieved from http://www.who.int/features/qa/71/en/
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Appendix A: Human Interest Stories Mariama Sano
It is a clear and sunny morning in Bafatá, Guinea-Bissau, as a group of about 30 people, composed of mostly mothers with their children, gather under a gazebo waiting to be seen by the staff of the Nutritional Recovery Centre (a CRENAG in this case). In a region where 24 per cent of children under the age of five are underweight and more than a third (34%) suffer from stunting due to poor nutrition (UNICEF, 2015), many families rely on the support of these UNICEF-supported centres to, not only monitor the health and nutritional status of their children, but also provide nutritional supplementation, advise on best nutritional and hygiene practices and, in critical malnutrition cases, provide life-saving treatment and care.
Mariama Sano, a mother of two girls aged five and three from Gam Taure village is, at 23 years of age, one of the youngest and most outspoken members of the group. She explains that her younger daughter started having regular fevers from a very young age. A few months ago, her health was deteriorating rapidly, she appeared weaker by the day and refused to eat. Mariama became increasingly worried and decided to take her to the CRENI at the hospital in Bafatá where, after being examined and having a blood-test to rule out HIV, was diagnosed with severe malnutrition and admitted to hospital for urgent treatment.
Mariama and her 3-year-old daughter spent two weeks in hospital where staff “would come by every morning to check-up on her, provide her with chocolate and help feed her when she refused to eat.” After two weeks her daughter’s health had visibly improved and they were finally able to go home.
They were referred to the CRENAG, where they have been coming, along with many others, every Wednesday for the last 2 months. Mariama explains that she was “told to bring her here every week so that they can monitor her weight and health and provide me with food for her so that her health improves”. She adds that “every week, I can come here and receive food for my child, such as chocolate, rice and peanuts.”
As well as receiving food, and as part of a UNICEF pilot project, the staff at the centre provide training to parents on preparing more nutritious food, good hygiene practices and HIV prevention. Mariama explains that she now knows the importance of “keeping the house and toilet clean and disposing of rubbish in an appropriate manner to stop flies from coming to my house” and adds that “I should only give my daughter treated clean water from the tap, including the water I use to prepare her food.” This initiative, however, reaches beyond the parents who accompany their children to the centre every week because as Mariama explains, apart from the field visits from centre staff to provide information and training in the villages, she now advises other mothers in the village to “keep their houses clean and take their children to hospital if they have diarrhoea because it can be dangerous.”
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As Mariama leaves the centre, she expresses her satisfaction with the care and attention received and expresses her gratitude to the centre “for having treated my daughter who is now in much better health” adding that the advice parents receive “enables us to take better care of our children, which makes us very happy.” Finally, she thanks the UNICEF evaluation team and expresses her desire for the project to continue “because we are all benefiting greatly from it.”
Salimatu Baldé
It is a surprisingly cool December morning in Gabú, normally one of the hottest regions in Guinea- Bissau, as the group of 21 mothers with their children currently staying at the CRENAG, try to keep warm while getting on with their morning routine; most breastfeed their children while the rest prepare breakfast with the assistance of a staff member. There is a sense of community, which is not surprising given the fact that most of these mothers have been staying at the centre several weeks, if not months, while their children are slowly nurtured back to strength from, in most cases, severe malnutrition.
In a region where 19 per cent of children under the age of five are underweight and nearly a third (30%) suffer from stunting due to poor nutrition (UNICEF, 2015), many families rely on the support of these UNICEF-supported centres to, not only monitor the health and nutritional status of their children, but also provide nutritional supplementation, advise on best nutritional and hygiene practices and, in critical malnutrition cases, provide life-saving treatment and care. This is particularly the case in Gabú, where the hospital ward specialised in severe malnutrition cases (CRENI) has not been functional for several years due to the lack of a qualified doctor, poor organisation and lack of resources. As a result, the CRENAG, which should take care of less severe cases requiring only ambulatory care, is having to fill that gap.
Salímatu Baldé, a 22-year-old mother, tends to her only child while she actively participates in the activities of the group. In total, she has spent more than three months at the centre after her child started showing symptoms of severe malnutrition shortly after his birth. Salimatu explains that his stomach was swollen, he would refuse to eat and his bowel movements would be few and far between. At the centre, both blood and stool tests were performed to assess the cause of his malnutrition, but the results of both were inconclusive. Due to the gravity of his condition, they were evacuated to the capital, Bissau, where more tests were performed, but again they were inconclusive. After this, she returned to the centre in Gabú, where thanks to the assistance from the staff, he has been gradually improving. Salimatu explains that while her child “is doing better, he has more appetite and has regained weight”, he still requires significant care.
The mothers staying at the centre do not only receive care for their children, but are also given information and training on preparing nutritious
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food with local inexpensive ingredients, on good hygiene practices and on HIV prevention. Salimatu says that she is now more aware of the importance of “making sure children are clean and protected from the cold and that the house is clean” and adds that “it is important to work with clean water and dispose of dirty water”, making sure that she disinfects water with 3 drops of chlorine and washes her hands with soap.
As the UNICEF evaluation team are about to leave, Salimatu expresses her gratitude for the help received and says that “they have helped my child a lot, now during the cold season they have provided him with warm clothes, a hat and socks.”
Appendix B: Methodology
The table below details the methods used in carrying out the research.
Activity Approach Used
1. Desk review of project reports and - Review existing partner’s progress and final report as well as background documents. progress data and indicators on malnutrition, HIV/AIDS and WASH projects. - Review data from secondary sources such as the 2015 Situation Analysis and the 2014 MICS. - Draft brief literature and data review to serve as a theoretical and empirical basis and inform the methodology in the inception report and the conclusions of the final report. 2. Analysis and review of existing - Review existing data, cleaning and preparing databases for quantitative data analysis as necessary. - Identify best practices, synergies and ideal target beneficiaries by carrying out bivariate analysis to identify the causal relationships between demographics/project interventions and nutritional, hygiene, sanitary and HIV/AIDS related behaviours and satisfaction with service. - Assess sustainability by tracking causal relationships between demographics/interventions and behaviours over time by comparing baseline data with mid-term and project-end reviews. Identify best practices for knowledge/skills retention. - Determine best practices by carrying out cross sectional comparison of centres to identify best performers and short- list them for further analysis through the collection of qualitative data. - Throughout the analysis, identify salient themes, best performers and outliers to underpin the sampling for the quantitative data collection and inform the preparation of discussion guides for the focus groups and the interviews. - Produce tables and charts to visualize important data points and support key narrative themes in final report and other UNICEF materials, as necessary. 3. Qualitative data collection (1) – Focus - Three focus groups, were carried out, one in each region Groups (Bafatá, Gabú and Cacheu), between December 12-15, 2017. The choice of location and sampling was driven by a combination of empirical (from the quantitative data), geographical and convenience factors and decided in close collaboration with CRNs and UNICEF, to ensure adequate participation, inclusion of most relevant participants in line
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Activity Approach Used
with quantitative findings and adequate representation of different populations and Centres. - A discussion guide/script outlining the structure and content of the sessions was prepared and shared with UNICEF in advance. It included 4 key questions designed to provide deeper insight on findings from the quantitative analysis and better understand the level of satisfaction of service beneficiaries, as well as the knowledge retained and their behavioural changes as a result of the interventions. - A monetary incentive of 3.000 CFA francs was offered to each participant to cover attendance costs and ensure participation. In addition, drinks and snacks were offered to participants during the session. - Participants were informed of the objectives of the session, of the recording arrangements and were asked to provide consent both verbally and in writing. - The demographic details of the participants were collected at the end of the discussion. - Focus groups were moderated jointly by the lead consultant and the local consultant with the aim of, not only facilitating a free-flowing discussion, but also to ensure that it stays on point and is meaningful. All participants were given a voice. - Focus groups were recorded in their entirety for subsequent transcription and analysis. 4. Qualitative data collection (2) – Key - Ten Key Informant Interviews were carried out between informant interviews December 12-17, 2017 across the three regions covered. All interviewees occupy positions of significant responsibility in - A discussion guide/script outlining the structure and content of the interviews was prepared. It was comprised of 10 questions designed to provide deeper insight on findings from the quantitative analysis and a better understanding of successes, opportunities and challenges on the project implementing side, including in relation to programme synergies. The questions were focused, clear, to the point and geared to incentivise open-ended answers that provided additional and unique insight. - Interviews were recorded in their entirety for subsequent transcription and analysis. 5. Qualitative data collection (3) – Human - Interviews with one participant in each region, selected from interest stories Service Beneficiaries, was carried out with the aim of producing three human interest stories across Gabú, Bafatá and Cacheu. - Pictures of the interviewees were taken to further illustrate their personal context and stories. - Interviews were recorded in their entirety for subsequent transcription and analysis. 6. Qualitative data transcription and - Recordings of focus groups and interviews were transcribed in analysis (4 days) in full and translated to Portuguese where appropriate.
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Activity Approach Used
- The collected data was analysed using a constant comparison analysis approach3, which consists of three key stages: coding the data into small units and attaching a descriptor or code to each unit, followed by grouping the codes into relevant categories and finally identifying key themes. This approach provides insight, not only into the themes of unearthed in a particular focus group, but also common themes across focus groups, providing for conclusions that are more generalisable. - An Excel file was created with the coding and classification of all relevant interventions/responses into themes and categories. 7. Prepare first draft of review report - A preliminary report presenting the first quantitative and presenting first quantitative and qualitative findings was drafted for initial review and feedback qualitative findings from UNICEF stakeholders to ensure final report analysis and narrative is aligned with their varying objectives.
8. Draft final review report, including - A final report that weaves together the qualitative analysis human interest studies. and qualitative data and insight from focus groups was produced. Key informant interviews and human-interest stories were incorporated into a compelling narrative setting out the project outcomes including: identifying and understanding best-practices, assessing the complementarity and cross-fertilisation potential of project activities, assessing the sustainability of interventions and capacity generation, and understanding the feedback of beneficiaries and the impact of the project on their behaviour.
Appendix C: Project Team The organisation
Bandim Health Project (BHP) is a health and demographic surveillance system (HDSS) site situated in Guinea-Bissau, it was founded in 1978 by Danish anthropologist Peter Aaby. BHP is formally placed under the National Institute of Public Health in Guinea-Bissau (INASA) and is a member of the Indepth Network, a global network of health and demographic surveillance system (HDSS) field sites in Africa, Asia and Oceania.
BHP follows a population of more than 200,000 individuals in urban and rural Guinea-Bissau. This provides a Unique platform for conducting health research. More than 150 local assistants, nurses, doctors and supervisors work for BHP, making it one of Guinea-Bissau’s biggest employers. Most people in the city of Bissau know the project and someone who has a relation to it.
3 Leech, N. L., & Onwuegbuzie, A. J. (2007). An array of qualitative data analysis tools: A call for qualitative data analysis triangulation. School Psychology Quarterly, 22, 557–584
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BHP has a good reputation with the government, international partners and local community. BHP has extensive experience conducting top quality health research, including the evaluation of health interventions.
The project supervisor
Dr Amabelia Rodrigues is the Director of Research at BHP- She is also the former president of the new National Institute of Public Health in Guinea Bissau. She received her PhD at the University of Copenhagen in 2001, concentrating on the epidemiology of cholera. She has done research on cholera, rotavirus, malaria and vaccines.
The lead consultants
The implementation of the project has been led by two consultants:
Jorge Retana de la Peza, is an economist and behavioural research professional with six years’ experience producing quantitative and qualitative analysis (including organising focus groups and in-depth interviews) for the Bissau- Guinean government, the World Bank and the financial sector. You can find his CV attached with this proposal.
Mr. Retana de la Peza has lived in Guinea-Bissau for over 2 years, where he was worked as an Advisor at the Ministry of Economy and Finance and produced policy analysis reports for the Minister, including a study of public spending on fighting HIV, TB and Malaria that served as key evidence to certify counterpart financing compliance and prevent a 15% (€5 million) cut to Global Fund grants. In addition, during his time in Guinea-Bissau he has supported UNICEF- WASH data analysis efforts on a voluntary basis.
Nichola Kitson is a development economist, graduated from the University of Oxford, with 2 years’ experience working as a technical assistant for the Ministry of Health of both Mozambique and Guinea-Bissau.
Local consultant for qualitative fieldwork
One local consultant assisted the team during the qualitative data collection:
Cadija Mane has more than 10 years’ experience working with the health sector in Guinea-Bissau and has extensive experience conducting qualitative fieldwork. She has previously worked with UNICEF and taken a leading role in the facilitation and moderation of focus groups and key informant interviews.
Appendix D: Contact Details Bandim Health Project
Address: Projeto de Saúde Bandim, Zona Sete, Bissau, Guinea-Bissau.
E-mail: bandim@ssi-dk
Phone: +245 201672
Dr Amabélia Rodrigues
E-mail: [email protected]
Phone: +245 966078659
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Jorge Retana de la Peza
Address: Prédio Esteves, Rua Vitorino Costa, Bissau, Guinea-Bissau.
E-mail: [email protected]
Phone: +245 95545513 / +34 662113882
Nichola Kitson
Address: Prédio DJ Mangui, Avenida do Brasil, Bissau, Guinea-Bissau.
E-mail: [email protected]
Phone: +245 956136254 / +44 7804504448
BANDIM HEALTH PROJECT – REVIEW OF MALNUTRITION PREVENTION AND MANAGEMENT RESEARCH 29