Key Findings & Programmatic Implications by 83yAjVI


									Key Findings &
Programmatic Implications
        OVC Program Evaluations
          in Kenya & Tanzania

       Tonya Renee Thurman, MPH, PhD
   Tulane University School of Public Health &
    Tropical Medicine/ MEASURE Evaluation
   Dissemination Meeting, September 3rd, 2009
                Washington, DC

     Tulane University School of Public
     Health and Tropical Medicine

 What is the level of program coverage?

 What influence are interventions having on the well-being
  of children and guardians?

 Are there any unintended consequences?

 What does it all mean?
  Program Coverage

 A small number of beneficiaries confirmed
  that they received key interventions employed

 For example, while TSA sample were drawn
  from the Kids Club Registry:
   Only 27% reported attending
   57% indicated they had never heard of Kids Clubs

 Prevalence and frequency of home visits was
  also less than expected
Prevalence of Home Visiting

60                    49
40                               29
           Has a home visitor

     Allamano   CRS        Salvation Army
     Frequency of Visits

40              28
       Visited only a few times a year or less

         Allamano     CRS        Salvation Army
    Key Outcomes & Interventions
Key Outcomes
                                  Key Interventions
 HIV knowledge
                                   School-based HIV education
 Psychosocial well-being of
  children & guardians             Kids clubs

 Care & treatment of children     Home visits
 Physical health of children &    Guardian support groups

 Legal protection                 Distribution of goods: school
                                    supplies & food
 Children’s education
                                   Income-generating activities
 Household food security
                                   Community education: OVC
 Community support                 care & support
               Hypotheses Tested

 School-based HIV programs: Child HIV knowledge

 Kids clubs: Children’s HIV knowledge &
  psychosocial well-being

 Home visits: Children & guardians psychosocial
  wellbeing & physical health, child’s care and
  treatment, educational outcomes & legal protection

 Guardian support groups: Children & guardian’s
  psychosocial well-being, child care and treatment &
  legal protection
              Hypotheses Tested

 Distribution of goods: School supplies & children’s
  educational & psychosocial outcomes; food
  provision & food security

 Income-generating activities: Food security

 Community education, OVC Care & Support:
  Community support & child’s legal protection
                HIV Knowledge
 Heard of AIDS
 Number of known prevention methods
 Mistaken beliefs

Key Interventions
 School-based programs
 Kids Clubs
                 HIV Knowledge
 Two programs offered school-based HIV education
  (CRS & IAP)

 Both were associated with increased number of HIV
  prevention methods known by child participants

 However, gaps in knowledge remained
    Few mentioned sexually-related protective behaviors
    No difference in prevalence of children’s mistaken
                 HIV Knowledge

 Two programs offered Kids Clubs (Allamano & TSA)

 Better awareness of HIV among participants in one of
  the two Kids Clubs (TSA)

 But only one-third knew at least 1 prevention method
     Children’s Psychosocial Well-being

Outcomes                Key Interventions
 Self esteem            Kids Clubs
 Pro-social behavior    Home Visiting
 Emotional problems     Guardian Support Groups
 Total difficulties
 Adult support
 Social isolation
    Children’s Psychosocial Well-being

                          Kids Clubs
Outcomes              Allamano         TSA

Emotional symptoms     Effect      No Effect

Pro-social behavior    Effect      No Effect

Adult support          Effect      No Effect

Global self-esteem    No Effect    No Effect

Social isolation      No Effect    No Effect
    Children’s Psychosocial Well-being
         Three Programs offered Home Visiting &
          Two offered Guardian Support Groups

Child Outcomes         Home Visiting    Support Group
Pro-social behavior      No Effect          Effect
Total Difficulties        Effect             Effect
Adult support              Effect           No Effect
Global self-esteem         Effect           No Effect
Social isolation           Effect           No Effect

    Effects not consistent across programs– only one
     outcome affected by two programs
    No more than two outcomes per program
        Care and Treatment of Children &
        Guardian Psychosocial Well-being

Outcomes                   Key Interventions
Child Care & Treatment      Home Visiting
 Feelings Towards Child    Support groups
 Family Functioning
 Child Abuse
Guardian Psychosocial
 Marginalization
 Negative Feelings
 Positive Feelings
            Child Care and Treatment &
           Guardian Psychosocial Well-being

                     Home Visiting CRS Support   IAP Support
                     (3 programs)    Group          Group
Feelings re child     No Effect     No Effect     No Effect
Family Functioning   Effect (CRS)    Effect       No Effect
Child abuse           No Effect      Effect       No Effect
Negative Feelings     No Effect     No Effect      Effect
Positive Feelings     No Effect     No Effect     No Effect
Marginalization       No Effect      Effect       No Effect
     Support Groups & Home Visiting?
                One study demonstrated the added benefit
                of exposure to multiple interventions (CRS)

80                             72      11       9.56
                        67                              8.12    8.56
                  58                   9                                7.36
           46                          7
40                                     5
0                                      -1
         Good Family Functioning            Total Child Behavioral Difficulties

       Neither         Support Group         Neither           Support Group
       Home Visitor    SG + HV               Home Visitor      SG + HV
      Guardian Psychological Health

 How did they fare?
    Average scores of 2.3 -2.8 in Kenya and Tanzania
    Relative data from healthy adults in Zimbabwe: > 3.5

 Preliminary analyses also suggest it’s importance
    Between OVC to non-OVC guardians
    Impact of guardian psychological health on children’s
     psychological health
  Children & Guardian’s Physical Health

 Reported Health Status
 Use of needed health services

Key Interventions
 Home Visiting
 Referrals for Free Health Services
  Home Visiting & Physical Health

 None of the programs were associated with an
  improvement in the reported physical health status
  of guardians

 Only one program demonstrated an association
  between home visiting and better reported health
  status for children
  Health Referrals
 Frequency of Referral Use for Free Healthcare among program
    participants at one study site (CRS)



    20%                                               Child


             Always     Sometimes      Never

Uptake of referrals was fairly poor even if the service was free
                Legal Protection

Outcomes                Key Interventions
 Identity documents     Home Visiting
 Succession planning    Support Groups
                         Community education:
                          OVC Care & Support
                  Legal Protection

                    Home          Support    Community
                    Visiting      Groups     Education
                 (3 programs) (2 programs) (2 programs)
Identity              NS           NS          Effect
Succession            NS            NS             NS

   No effect of Home Visiting or Support Groups
   No effects on Succession Planning
                Legal Protection

 High prevalence of OVC lacking identity documents
   About 65% in Tanzania and nearly half in Kenya

 OVC found less likely to have such documents than
   60% of maternal orphans relative to 84% of other
    children; similar among other OVC groups

 Succession Planning was very low
   Less than 20% even among ill caregivers
     Children’s Educational Outcomes

Outcomes          Key Interventions
 Enrollment       Provision of School Supplies
 Attendance       Home Visiting
               Educational Outcomes

                                         Enrollment fairly high
                  Home Visiting           (> 95%) across each
             Allamano   CRS       TSA
                                         Provision of school
Enrollment     Effect    NS       NS
                                          supplies not
Attendance      NS      Effect    NS      associated with
                                          enrollment or

 Cross-cutting: Possession of school supplies was
  associated with better self-esteem across two program sites
  (Allamano & PACT)
        Household Food Security

Outcome             Key Interventions
 Food Security      Income generating
                     Food parcels
                   Food Insecurity
       Two programs aimed to enhance food security

               % of Food Insecurity
               in the Study Regions



           0      20      40      60       80        100

                       Moderate        Severe
                 Household Food Insecurity

Interventions:                          Reduced food insecurity?
      Food Parcels & IGA
Inconsistent Food Parcels (CRS)                 No effect

Consistent Food Parcels (Allamano)               Effect

IGA: Savings and Internal Lending
Committees (CRS)                                 Effect

IGA: Bio-intensive Gardening Training
with Supply Provision (Allamano)                 Effect
             Community Support

Outcomes              Key Intervention
 Perceived Stigma     Community education:
 In-kind support       OVC Care & Support
               Community Support
 Two programs had Community Education regarding
  OVC Care & Support (IAP & PACT)

 Guardians living in communities with a high
  concentration of OVC Care & Support Mtgs reported
  more receipt of in-kind support (PACT)

 Attendance at an OVC Care & Support Mtg associated
  with marginal effects on participants stigma concerning
  OVC and HIV affected families (IAP)

 Notably, children living in high stigma communities
  were found to be worse off (IAP)
         Unintended Consequences?

 In one study, guardians of Kids Club participants
  reported more negative feelings towards the child

 In another study, worse perceived stigma found
  among Kids Club participants and those with a
  home visitor

 High levels of perceived jealousy reported across
  almost all sites
         Jealousy of service provision
70                              67
        53                           52
50           45
40                  35 37
30                                          27
      Allamano       TSA        CRS          IAP

                  Guardians    Children

For PACT, perceived jealousy was significantly higher in the
Intervention Group
     Who is responsible for orphans?

     Extended   Community Government      NGOs

           Beneficiaries   Community sample
     Who is responsible for orphans?

40               34
30                        22
           Intervention   Comparison

                          Significant difference (p < .05)
           Summary: Service Provision
 Program exposure was lower than anticipated

 Beneficiaries may not always capitalize on services
  available to them

 Services targeting one domain of well-being may affect
  another domain

 Exposure to multiple interventions has additive effects

 Emerging unintended consequences of program
            Summary: Key Interventions

 Kids Clubs and distribution of school supplies can have a
  positive influence on children’s psychosocial wellbeing

 Home visiting had more effects on children’s outcomes
  than guardian outcomes and inconsistent effects across

 Support groups for guardians associated with positive
  child, guardian and family outcomes

 Meeting basic needs consistently can be effective
    But are they sustainable?

 Income generating can build the family’s capacity to
  support themselves
              Summary: Unmet Needs
 Comprehensive HIV education remains necessary for

 Stigma is powerful influence on child outcomes and
  remains largely unaddressed

 Guardian’s psychological health unaffected across each of
  the interventions

 No effects on child & guardian’s physical health

 Limited influence on children’s legal protection,
  particularly succession planning
         Programmatic Implications

            What does it all mean for the
          improvement of OVC programs?

 Drawing upon quantitative results & case studies
           Programmatic Implications
Reliance on volunteers:

 Standardized volunteer training on OVC care is

 Volunteers possess limited skills to address
  psychological and legal issues

 Caseloads may be to high to expect anticipated
  coverage and outcomes
           Programmatic Implications

Service Provision:

 Barriers to accessing services, beyond cost, need to be

 Additional interventions required to address unmet

 Combination of interventions can have the greatest
             Programmatic Implications

Child focused interventions:

 Adolescent needs are largely unaddressed

 Ensure a comprehensive and age appropriate curriculum
  along with routine technical guidance

 Inclusion of community children in recreational

 Engage guardians in interventions addressing OVC needs
              Program Implications

Guardian focused interventions:

 Supporting guardians can translate into benefits
  for children under their care

 Home visiting needs to move beyond an
  emphasis on children to include guardians

 Beyond training, supplemental resources &
  support may be needed to ensure effectiveness of
             Program Implications

Community interventions

 Efforts to reduce community stigma holds
  promise if intensified

 Unintended consequences should be anticipated
  with initiatives in place to reduce them
         Programmatic Implications

Program Monitoring

 Regular assessments of program coverage and
  client participation are needed

 Tracking referral uptake

 Ongoing monitoring systems to register and
  track beneficiaries are needed

Other Implications?

             Thank You

We ultimately hope that this study benefits
the adults & children in need across SSA

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