MID-TERM EVALUATION OF THE COMMUNICATION FOR ...

April 2020

EVALUATION REPORT

MID-TERM EVALUATION OF THE COMMUNICATION FOR HEALTH PROJECT IN ETHIOPIA

This publication was produced at the request of the United States Agency for International Development. It was prepared independently by Tewabe Yilak Assaye, Woldemariam Girma Gebreegiziabher, and Alehegn Moges Tessema for ICOS Consulting PLC.

April 2020

April 2020

EVALUATION REPORT


April 2020

EVALUATION REPORT


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Abstract

The United States Agency for International Development in Ethiopia developed Communication for Health, a 5-year (2015–2020), 22.2 million USD budget project, which was implemented by Johns Hopkins Center for Communication Programs in partnership with the Federal Ministry of Health and John Snow, Inc. In 2019, ICOS Consulting PLC conducted the mid-term evaluation of the project, which included a desk review of project documentation, a survey of 1,773 women aged 15–49, and 40 key informant interviews. Overall, about 63% of the midline respondents reported being exposed to the project intervention, among whom 25% were exposed to three or more project activities. Results show some significant improvements between baseline and midline across the six health topics, specifically for early initiation of antenatal care; knowledge of short-acting, modern methods of family planning; rates of institutional delivery; receiving timely postnatal care; HIV testing during pregnancy and knowledge about prevention of mother-to-child transmission; knowledge on the causes, signs, and symptoms of malaria; self-efficacy with regard to malaria prevention; use of bed nets reported by women aged 15–49; presence of proper handwashing facilities; comprehensive knowledge about handwashing at key times; and knowledge about tuberculosis transmission. Respondents at midline reported significantly more equitable gender norms associated with partner violence, sexual relationships, domestic chores, and daily life. Despite these improvements, some key indicators appeared to have declined over time, particularly current use of modern family planning and exclusive breastfeeding. There were also significant declines in malaria-related indicators and fewer midline respondents reporting availability of bed nets.

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Acronyms and Abbreviations

ANC Antenatal Care

AOR Adjusted Odds Ratio

CCP Johns Hopkins University Center for Communication Programs

CI Confidence Interval

EA Enumeration Area

EDHS Ethiopia Demographic Health Survey

FMOH Ethiopia Federal Ministry of Health

GEM Gender Equitable Men

HDA Health Development Army

HEW Health Extension Worker

HIV Human Immunodeficiency Virus

AIDS Acquired Immune Deficiency Syndrome

IUD Intrauterine Contraceptive Device

LLIN Long-Lasting Insecticidal Net

MIS Management Information System

N Number of Respondents

PHCU Primary Health Care Unit

PMTCT Prevention of Mother-to-Child Transmission

PNC Postnatal Care

RHB Regional Health Bureau

RMNCH Reproductive, Maternal, Neonatal, and Child Health

SBCC Social and Behavior Change Communication

SNNPR Southern Nations, Nationalities, and People’s Region

SOW Statement of Work

TB Tuberculosis

TWG Technical Working Group

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WASH Water, Sanitation, and Hygiene

Contents

Abstract ........................................................................................................................................................................................................................................................................................................................................................i

Executive Summary ..........................................................................................................................................................................................................................................................................................................vi

Introduction..........................................................................................................................................................................................................................................................................................................................................1

1.1. Background ..................................................................................................................................................................................................................................................................................................................................1

1.2. Objectives of the Mid-Term Evaluation ............................................................................................................................................................................................................................................2

Evaluation Design and Methodology ...........................................................................................................................................................................................................................................4

2.1. Methodology .................................................................................................................................................................................................................................................................................................................................5

2.2. Study Limitations ................................................................................................................................................................................................................................................................................................................8

Results 9

3.1. Demographic Characteristics of Respondents .....................................................................................................................................................................................................................10

3.2. Exposure to Social and Behavior Change Communication Intervention ..................................................................................................................................10

3.3. Effectiveness ...............................................................................................................................................................................................................................................................................................................................11

3.4. Effectiveness of the Communication for Health project (Qualitative assessment) ..............................................................................................31

3.5. Relevance ..........................................................................................................................................................................................................................................................................................................................................33

3.6. Sustainability .............................................................................................................................................................................................................................................................................................................................34

3.7. Strengths, Facilitating Factors, Weaknesses, and Challenges of the Communication for Health Project ......................38

3.8. Innovative Practices and Lessons Learned ...............................................................................................................................................................................................................................40

Recommendations ..................................................................................................................................................................................................................................................................................................................41

Appendix ......................................................................................................................................................................................................................................................................................................................................................44

List of Tables

Table 1: Sample size for baseline and midline surveys .........................................................................................................................................................................6

Table 2: Percentage of respondents’ exposure to social and behavior change communication (SBCC) message, Communication for Health midline survey (April 2019) .........................................11

Table 3: Percentage of antenatal care uptake, knowledge, self-efficacy, and outcome expectancy on antenatal care among women with children under 2 years old, Communication for Health baseline (September 2016) and midline (April 2019) surveys............................................12

Table 4: Logistic regression result on antenatal care uptake, Communication for Health midline survey (April 2019), computed from 481 midline women who had a child under 2 years of age .........................14

Table 5: Percentage family planning indicators among married women aged 15–49 years, Communication for Health baseline (September 2016) and midline (April 2019) surveys, disaggregated by exposure ........15

Table 6: Percentage of institutional delivery, postnatal care, and knowledge of danger signs of pregnancy among women with children under 2 years old, Communication for Health baseline (September 2016) and midline (April 2019) surveys .............................................................................................................................17

Table 7: Logistic regression results for institutional delivery, Communication for Health baseline (September 2016) and midline (April 2019) surveys .......................................................................................................18

Table 8: Percentage prevention of mother-to-child transmission, HIV counseling and testing, Communication for Health baseline (September 2016) and midline (April 2019) surveys............................................19

Table 9: Result from logistic regression on HIV/AIDS test during recent pregnancy, Communication for Health baseline (September 2016) and midline (April 2019) surveys............................................20

Table 10: Percentage level of early initiation of breastfeeding and exclusive breastfeeding among mothers of children under 23 months old, Communication for Health baseline (September 2016) and midline (April 2019) surveys ........................................................................................................................................................21

Table 11: Result from logistic regression on early initiation of breastfeeding, Communication for Health midline survey (April 2019) ...............................................................................................................................................................................................22

Table 12: Percentage of respondents, by malaria status .......................................................................................................................................................................22

Table 13: Percentage availability and use of bed nets in households in malaria-prone areas .............................................................23

Table 14: Knowledge on malaria among respondents living in malaria-prone areas .......................................................................................25

Table 15: Self-efficacy and outcome expectancy on malaria in malaria-prone areas ......................................................................................25

Table 16: Practice, knowledge, self-efficacy, and outcome expectancy on handwashing ...........................................................................26

Table 17: Results of logistic regression on availability of proper handwashing stations, Communication for Health midline survey, April 2019 (computed from 1,773 midline women)..............................28

Table 18: Tuberculosis (TB) knowledge, self-efficacy, and outcome expectancy among all women aged 15–49 years, Communication for Health baseline (September 2016) and midline (April 2019) surveys................................................................................................................................................................................................................29

Table 19: Gender Equitable Men (GEM) scale, adapted for women aged 15–49 years, Communication for Health project baseline (September 2016) and midline (April 2019) surveys ....................31

List of Figure

Figure 1: Percentage of fever and treatment seeking for children under age 5 in malaria-prone areas ..............................24

Executive Summary


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BACKGROUND

Ethiopia is a country in Sub-Saharan Africa with a population of 105 million (World Bank, 2017). Despite economic growth and advancement in health policy, much work remains to be done to address gender inequalities, maternal health, and child health in Ethiopia. Communication for Health is a 5-year (2015–2020) social and behavior change communication (SBCC) project in Ethiopia that is funded by the United States Agency for International Development and managed by Johns Hopkins Center for Communication Programs in partnership with the Federal Ministry of Health and John Snow Inc. It focuses on six interconnected health areas: reproductive, maternal, neonatal, and child health; nutrition; malaria; prevention of mother-to-child transmission of HIV; tuberculosis (TB); and water, sanitation, and hygiene. Communication for Health utilizes an evidence-based approach to address these six health areas in 160 districts in four regions: Oromia; Amhara; Southern Nations, Nationalities, and People’s Region; and Tigray. Communication for Health incorporates issues of gender equality while being culturally mindful. Communication for Health has accomplished a wide variety of goals, from setting up the structure to provide SBCC-centered services at local universities, organizations, and health clinics, to implementing numerous campaigns targeting the six health areas in local communities. The key SBCC pillars of Communication for Health include community-level interventions, such as (a) provision of the Family Health Guide to the target population to guide and promote health service use, (b) facilitation of community meetings to promote healthy behaviors, and (c) four media activities consisting of a radio program, maternal and child health video, mobile application, and distribution of print materials to promote healthy behavior. Other SBCC pillars include different level capacity-

strengthening interventions in SBCC and data use practices.

PURPOSE OF THE MIDLINE EVALUATION

The Communication for Health intervention is currently in its fourth year, thus requiring a mid-term evaluation of the project. The evaluation aimed at reviewing the relevance and effectiveness of Communication for Health to inform programmatic goals for the project and to redesign strategies for the remainder of the project. This report summarizes the results from the mid-term evaluation of the intervention conducted by ICOS Consulting PLC from March to July 2019.

EVALUATION QUESTIONS

The key research questions that the mid-term evaluation was designed to answer were as follows:

1. To what extent does the project’s hypothesis describe the necessary and sufficient conditions to progress toward its ultimate goal?

2. How relevant and practical are the design and implementation approaches of Communication for Health in relation to the Government of Ethiopia’s Health Sector Transformation Plan priorities?

3. What are the early indications of the project’s effectiveness?

4. What approaches is the project using to address gender issues in Communication for Health, and what evidence shows how the project accounts for gender considerations during implementation?

5. What are the key project implementation challenges and lessons learned?

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EVALUATION METHODOLOGY

The evaluation used a mixed (quantitative and qualitative) method to examine changes in key outcome indicators between the baseline and midline. It was also designed to assess the possible effect of project exposure on various outcome indicators. The quantitative study included women aged 15 to 49 years who were the primary beneficiaries of the Communication for Health project. The quantitative study used systematic, multistage random sampling. The baseline sample included 2,770 women from six woredas per region, and the midline sample included 1,773 women from four woredas per region. The qualitative component included 40 key informant interviews with representatives from the implementing partners, as well as government staff at national, regional, and local levels. The study received ethical approval from the Ethiopian Public Health Institute ethical review committee, Addis Ababa, Ethiopia, and from the ethical review board of the Bloomberg School of Public Health at Johns Hopkins University, Baltimore, MD, USA.

FINDINGS

Comparisons of the baseline and midline data indicate that the samples are comparable across a host of key sociodemographic and socioeconomic variables. Overall, 63% of midline respondents reported being exposed to the Communication for Health intervention activities. Among these, 25% reported having been exposed to three or more of the five different activities.

Results show some significant improvements between baseline and midline across the six health topics, specifically early initiation of antenatal care; knowledge of short-acting modern methods of family planning; rates of institutional delivery; receiving timely postnatal care; HIV testing during pregnancy; knowledge about prevention of mother-to-child HIV transmission; knowledge about the causes,

signs, and symptoms of malaria; self-efficacy on malaria prevention; use of bed nets; presence of proper handwashing facilities; comprehensive knowledge about handwashing at key times; and knowledge about TB transmission. A key underlying principle of Communication for Health is its focus on gender sensitivity. Baseline data that fed into the design of Communication for Health indicated that gender-equitable norms were the key determinants for 10 of 16 key behaviors promoted by Communication for Health. Based on this information, the project focused on a gender-centric approach in the messages and within all capacity-building efforts. This focus on gender appears to have been successful, as evident in the significant improvements across three of the four subscales of the Gender Equitable Men scale, which was adapted for women. Respondents at midline reported significantly more equitable gender norms associated with partner violence, sexual relationships, domestic chores, and daily life. The subscales relating to reproductive health and disease prevention norms also improved over time, though these increases were not significant.

Despite these improvements, some key indicators appear to have declined over time. Of specific note were lower current use of modern family planning (baseline 48%, midline 43%) and exclusive breastfeeding (baseline 64%, midline 46%). Surprisingly, significant declines occurred in malaria-related indicators, with fewer midline respondents reporting availability of bed nets, actually showing bed nets to data collectors, and reporting that all children under 5 slept under a bed net (baseline 67%, midline 59%). On TB indicators, there were significant increases in knowledge of TB transmission and symptoms, but the overall awareness of TB as an illness was lower among midline respondents (baseline 78%, midline 67%).

Additionally, marginal differences in self-efficacy and outcome expectations were found for almost all key behaviors. These marginal


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differences may result from ceiling effects, as both efficacy and ability to achieve expected outcomes were very high at baseline across the health topics. The only significant efficacy finding related to higher self-efficacy at midline was for women’s perceived ability to seek treatment for a child with fever. However, women displayed significantly lower self-efficacy with regard to “immediate” screening for suspected TB (from 76.7% to 70.8%) and lower expectations that early screening of TB could lead to full recovery (75.3% to 61.8%).

When disaggregated by exposure to the Communication for Health project, the midline results indicated that, despite not finding significant differences between exposed and nonexposed respondents on levels of self-efficacy, and outcome expectancies, almost all behaviors (antenatal care, current use of family planning, institutional delivery, attending postnatal care, HIV testing during pregnancy, early initiation of breastfeeding, and bed net ownership) were reported in significantly higher proportions among exposed respondents compared to the women who were not exposed to the project.

Results from the multivariate logistic regression analysis examining differences between exposed and nonexposed respondents at midline (after controlling for key background factors including age, education, prior knowledge, level of vulnerability, and scores pertaining to gender equitable norms) pointed to significantly higher odds of different behaviors among those exposed, with higher levels of education and lower levels of vulnerability emerging as factors influencing positive behaviors. Exposure to project interventions significantly increased the likelihood of a woman attending four or more antenatal care visits, testing for HIV during pregnancy, delivering at a health facility, attending postnatal care services and having a handwashing station available in their households.

Data from the key informant interviews showed widespread acknowledgment of the relevance of Communication for Health, indicating the approaches utilized by the project were technology driven and evidence-based and that the design process was participatory. Some key informants questioned the relevance of some of the technology-driven materials, such as the mobile app, because the primary beneficiaries are rural women. Views on the level of participation by local stakeholders were mixed, with most key informants reporting that local-level engagement was the key to the successes of Communication for Health. A few urged for even higher levels of engagement. Similarly, views on the potential for sustainability were mixed, with questions raised about the technical and financial resources available within the local infrastructure to sustain the intervention over time.

CONCLUSIONS

The results indicate that Communication for Health was successful in initiating changes in multiple interrelated health behaviors. These findings support the importance of integrated SBCC programming that addresses a variety of issues associated with the health of women and children, rather than working in silos to address specific health promotion and disease prevention topics. Additionally, Communication for Health supported institutionalization of capacity building and system strengthening at all levels by creating mechanisms that provide sustained access to opportunities and by documenting and disseminating project activities and lessons, among other efforts. The trends indicated room for improvement, vis-à-vis engendering local ownership and wider and more innovative dissemination of messages. Overall, the Communication for Health project is moving in the right direction.

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Introduction


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1.1. Background

Ethiopia is a country in Sub-Saharan Africa with

a population of 105 million (World Bank, 2017).

Despite economic growth and advancement in

health policy, much work remains to be done

to address gender inequalities, maternal and

child health in Ethiopia. In the realm of maternal

health, only 32% of women go for antenatal

care visits, 28% of women undergo institutional

delivery, and 36% use modern contraceptives

(Central Statistical Agency and ICF, 2016).

Disparities exist between urban and rural

populations, with rural women utilizing maternal

health care services less than urban women

(Central Statistical Agency and ICF, 2016). For

women in Ethiopia, many health practices are

influenced by gender and cultural norms. Women

generally lack empowerment for independent

decision making in their families, such as

using family planning or whether to undergo

institutional delivery (Johns Hopkins Center for

Communication Programs [CCP], 2017). On child

health, an estimated 40% of children in Ethiopia

suffer from nutritional deficiencies during the

first critical 1,000 days of life, putting them at

risk of stunting (UNICEF, 2014). Almost 50% of

the deaths of children under 5 in the country

are caused by malnutrition (UNICEF, 2019).

Prevention of infectious diseases needs to be

addressed in Ethiopia as well. Ethiopia is one

of the 18 countries that contribute to 80% of

malaria cases and deaths globally, and a pattern

of seasonal local epidemics is present in areas

under 2,000 m in altitude (Ethiopian Public

Health Institute and Ethiopia Federal Ministry of

Health, 2016; World Health Organization, 2018).

According to the 2015 Ethiopia National Malaria

Indicator Survey, 64% of households in malaria-

prone areas owned at least one long-lasting

insecticidal net (LLIN), 32% had one LLIN per

two people, and 44% of pregnant women and

45% of children under 5 years of age slept under

an LLIN the night before the survey (Ethiopian

Public Health Institute and Ethiopia Federal

Ministry of Health, 2015). Malaria is one of the

top 10 causes of death among children less

than 5 years of age (World Health Organization,

2019).

Ethiopia also has the 10th highest tuberculosis

(TB) burden in the world, including drug-

susceptible TB, multidrug-resistant TB, and TB-

HIV co-infection (US Agency for International

Development, 2018). Countrywide surveys

between 2003 and 2006 showed that the

prevalence of multidrug-resistant TB was 1.6%

in new cases and 11.8% in previously treated

patients and that 25% of TB cases were

positive for co-infection with HIV (World Health

Organization Africa, 2018). While Ethiopia

showed a rapid decline in new HIV infections

among children, prevention of mother-to-child

transmission (PMTCT) continues to be an area

of concern, as the HIV epidemic is becoming

more generalized and the rate of comprehensive

knowledge, which is 31% among men and 18.5%

among women, is low (Central Statistical Agency

and ICF, 2012). Fear of stigma and abandonment

by husbands is high among women, and only

55% of HIV-positive pregnant women receive

PMTCT services (Central Statistical Agency and

ICF, 2012).

The water, sanitation, and hygiene situation

in Ethiopia is also very poor, with only 28%

of the population having access to improved

sanitation facilities, 29% of the population

practicing open defecation, and 57% of the

population having access to an improved water

supply (UNICEF and World Health Organization,

2015). While the prevalence of diarrhea

decreased for children under 5 years old from

2000 to 2011, handwashing is still not a norm,

with only about 12% of urban households

and 2% of rural households having access to

handwashing facilities (Addis Ababa University

School of Public Health and the Bill & Melinda

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Gates Institute for Population and Reproductive

Health at the Johns Hopkins Bloomberg School

of Public Health, 2014).

All of these health disparities require improving

the health status of the Ethiopian population

by providing accessible and high-quality

health services and by changing social norms,

individual behavior, and community practices

(CCP, 2017). An integrated social and behavior

change communication (SBCC) intervention to

inform, influence, and empower individuals and

communities to adopt evidence-based practices

to improve health was considered to be most

useful (CCP, 2017). The government of Ethiopia

places a high priority on SBCC interventions and

has already created a growing Health Extension

Program, which eventually led to the creation

of Communication for Health so that the United

States Agency for International Development

(USAID) and CCP can assist the Ethiopian

government in achieving its health goals (CCP,

2015).

It was against this background that USAID/

Ethiopia developed Communication for Health.

The Communication for Health project is a

5-year (2015–2020) SBCC project in Ethiopia

that is funded by the USAID and managed

by CCP in partnership with John Snow Inc.

(Communication for Health Project, 2016). It

focuses on six interconnected health areas:

reproductive, maternal, neonatal, and child

health; nutrition; malaria; PMTCT; TB; and

water, sanitation, and hygiene. The project

is being implemented in 160 districts in four

regions: Oromia; Amhara; Southern Nations,

Nationalities, and People’s Region; and Tigray.

Communication for Health has been implemented

for three full years now and is in its fourth year,

which necessitated a mid-term evaluation of the

project. CCP commissioned ICOS Consulting PLC

to undertake this evaluation of Communication

for Health from March to July 2019. This report

presents the findings.

1.2. Objectives of the Mid-Term Evaluation

The overall objective of this mid-term

evaluation was to assess the project’s progress

towards its goal and objectives in line with the

baseline measures of health indicators related

to health care system utilization, care-seeking,

knowledge, and other behavioral outcomes in

the six previously mentioned health areas. The

evaluation had the following specific objectives:

• To assess the extent to which the project’s

hypothesis describes the necessary and

sufficient conditions to progress toward

its ultimate goal. This objective refers to

the logical linkage between the different

results; whether sub results are necessary

for and sufficient to achieve higher results;

whether appropriate performance measures

(indicators) were identified and tracked;

and whether risks, assumptions, or external

factors were identified, monitored, and

adjusted as needed

• To assess the relevance of the design

and implementation approaches of the

Communication for Health project in relation

to the Government of Ethiopia’s Health

Sector Transformation Plan priorities, its

national communication strategy, and the

sustainability of project interventions

• To assess early indications of the project’s

effectiveness (i.e., tangible results achieved

against targets)

• To explore the project’s approaches to address

gender issues in Communication for Health

and whether the project accounts for gender

considerations during implementation

• To identify the key implementation

challenges and lessons learned


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1.2.1. Evaluation questions

The mid-term evaluation was designed to answer

the following five key evaluation questions:

• To what extent does the project’s hypothesis

describe the necessary and sufficient

conditions to progress toward its ultimate

goal?

• How relevant and practical are the design

and implementation approaches of the

Communication for Health project in relation

to the Government of Ethiopia’s Health

Sector Transformation Plan priorities?

• What are the early indications of the project’s

effectiveness?

• What approaches is the project using to

address gender issues in Communication for

Health, and what evidence shows whether the

project accounts for gender considerations

during implementation?

• What are the key project implementation

challenges and lessons learned?

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Evaluation Design and Methodology


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2.1. Methodology

The study used a mixed (quantitative and qualitative) method to examine changes in key outcome indicators between the baseline and midline. The quantitative survey was designed to assess the possible effect of project exposure on its various outcome indicators to answer the evaluation questions.

The qualitative tools were designed to provide insight into the project’s relevance, effectiveness, and sustainability from the perspectives of its stakeholders (local implementing partners, health facilities at the community level, woreda health bureaus, regional health bureaus, and the Federal Ministry of Health) and implementers (regional project managers and national project leaders), among others.

2.1.1. Study design

Pre- and post-intervention designs were used for the quantitative component of the evaluation. Neither the baseline nor the midline survey included a control group in non–program intervention areas. Thus, the study employed internal controls specifically for those individuals who were not exposed to any project activities, despite living in the same community with those exposed to specific activities. The study compared key project indicators, including family planning, antenatal care use, institutional delivery, postnatal care, early initiation of breastfeeding, bed net use, treatment seeking for fever, tuberculosis knowledge, gender issues, and others, at baseline and midline. The midline results then were further disaggregated between those exposed and not exposed to Communication for Health activities.

2.1.2. Study population and sampling procedure for household survey

The study population for the evaluation was women aged 15 to 49 years who were the primary beneficiaries of the project. The midline survey adopted the same sampling approach as the baseline. The study used multistage random sampling to identify the study population. The selection procedure was as follows:

1. Ten percent of the project’s target woredas (24 of 240 at baseline; 16 of 160 at midline) were selected, with an equal number of woredas from each of the four regions (Oromia; Amhara; Southern Nations, Nationalities, and People’s Region; and Tigray). At baseline, six woredas from each region were selected using probability proportional to size of population in the woredas. For comparability, at midline, four woredas from the six woredas where the baseline survey was conducted were randomly selected from each region.

2. An enumeration area (EA) list for the selected woredas was collected from the Central Statistical Agency. Three EAs were selected from each of the selected woredas using random sampling (72 at baseline and 48 at midline) and included for the study.

3. Complete household listings from all 72 EAs at baseline and 48 EAs at midline were conducted to establish a fresh sampling frame of households in each EA.

4. From these complete household listings, only households with women aged 15–49 were maintained, and 35 households were selected from each EA using systematic random sampling techniques. All eligible women in sampled households who were present during the survey were interviewed.

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2.1.3. Sample size

The sample size for the study population at midline was set at 35 households per EA,

the same as at baseline. Table 1 presents the sample size allocation by region.

Table 1: Sample size for baseline and midline surveys

Region

No. of Enumeration Areas Covered at Baseline No. of Households Selected

No. of Women Interviewed

Baseline Midline Baseline Midline Baseline Midline

Amhara 18 12 630 420 674 416

Oromia 18 12 630 420 688 448

SNNPR 18 12 630 420 760 448

Tigray 18 12 630 420 648 461

Total 72 48 2,520 1,680 2,770 1,773

Notes: SNNPR: Southern Nations, Nationalities, and People’s Region; 35 households from each enumeration area were selected at baseline and midline.

2.1.4. Data-gathering tools

Data were largely gathered using a quantitative questionnaire. However, the survey data were supported by collection of qualitative data from key informants at different administrative levels.

2.1.4.1 Questionnaire

To maintain comparability, the midline quantitative questionnaire was developed from the baseline questionnaire to include questions about program exposure. The midline questionnaire aimed to collect information on common themes, including sociodemographic; family planning; reproductive health; maternal and child health; child feeding; malaria; water sanitation and hygiene; tuberculosis; prevention of maternal-to-child HIV transmission; and gender issues.

The questionnaires were largely precoded with fixed-response categories and administered in the Amharic, Oromiffa, and Tigrigna languages. As previously noted, the midline questionnaire added a section on exposure to Communication for Health by

asking individuals about their participation in project activities, specifically their exposure to community-level interventions, such as exposure to the Family Health Guide; community meetings: health bazaars, roadshows, and media activities consisting of a radio program (e.g., Erkab in Amharic, Terkanfi in Afan Oromo, Erhab in Tigrigna, Fashoo in Sidama Afu, and Ilka in Wolitigna), maternal and child health video, mobile application (Hulu Beteina), and distribution of print materials to promote healthy behavior.

2.1.4.2 Interviews and qualitative

methods

Qualitative methods included key informant interviews with local implementing partners, primary health care units, the woreda health office, the regional health bureaus, and the program implementation office in each region. Further key informant interviews were conducted with focal persons from the Federal Ministry of Health, the John Snow Inc., and the Johns Hopkins Center for Communication Programs country office. Overall, 40 key informant interviews were


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conducted. Informants were recruited in close consultation with the head office of the Johns Hopkins Center for Communication Programs research and monitoring and evaluation team.

2.1.5. Data management and analysis

2.1.5.1. Quantitative data

Quantitative data were collected using mobile phones with KOBO prorating language. The midline data were merged with (appended to) the baseline data set, and steps such as data verification and cleaning preceded data analysis. Data analysis for the quantitative data mainly focused on the key outcome indicators between the baseline and midline using descriptive statistics and multivariate methods. A comparison of key outcome indicators at baseline and midline was conducted to assess differences over time. Further, midline data were analyzed to identify any significant differences between exposed and nonexposed respondents. The exposure variable was derived by creating an additive measure asking respondents if they had received or used the Family Health Guide, participated in any community meeting on the six health areas covered by Communication for Health, been exposed to any media components consisting of a radio program, used the mobile application, or received or used printed project materials promoting healthy behaviors. The relationship of exposure to the project intervention (predictor) was examined against outcome variables using univariate and multivariate methods. Bivariate associations and correlations were tested for statistical significance. A multivariate logistic regression analysis was used to identify behaviors contributing to the outcome variables, after controlling for confounding factors. Statistical significance was considered at p-values <.05. The data analysis was performed using SPSS v. 20.

2.1.5.2. Qualitative data

All key informant interviews were facilitated in the Amharic language, recorded in hard copy (paper-based), and then translated into English. The interview results were coded into different issues based on the interview guide and subsequently recorded in Microsoft Excel software. Content analyses were performed in Excel, and the results were summarized. Triangulation of responses was done across the various respondents.

2.1.6. Profile of data collectors and supervisors

The data collectors had at least a bachelor’s degree in public health, nursing, or other related social science fields. Additionally, they had previous experience in similar data collection. Proficiency of data collectors in the local languages of the sample woredas was a selection criterion. Coordinators and supervisors had at least a master’s degree in health-related and other social science fields, language fluency, and experience in coordinating and supervising similar studies.

2.1.7. Training of data collectors and survey teams

Quantitative data collection training was held from March 13 to 15, 2019, in Addis Ababa. A separate training was organized for data collectors who facilitated the key informant interviews. The quantitative training was attended by 37 quantitative interviewers, 8 quantitative supervisors, and 12 qualitative interviewers, researchers, and coordinators. The training included different techniques, including presentation of key terms, standard operating procedures, item-by-item review of questionnaires, mock (pair) interviews, question-and-answer sessions, and feedback sessions. Four experienced trainers facilitated the trainings. The Johns Hopkins Center for Communication Programs team also played

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an important role in monitoring, as well as in providing technical inputs in the different sessions of the quantitative and qualitative training.

2.1.8. Pretesting

The pretest was conducted in one of the rural kebeles in the Barak district of the Oromia regional state, Finfine Special Zone, which is about 40 km from Addis Ababa. The pretest was conducted on April 2, 2019, after ethical clearance for the survey was secured from the institutional review boards. This pretesting was conducted in a kebele that was not sampled for the midline. Each team member interviewed at least one respondent, using mobile phones. Supervisors recorded and noted gaps in procedures and got a sense of how the tool is piloted in the field. Coordinators and the CCP research team supervised interviews and logistics and provided guidance and feedback at the field site. The day after pretesting, the team met at the ICOS office for a debriefing on issues related to recruiting and selecting households for the survey, obtaining informed consent, and completing the survey instrument. The research team shared experiences and discussed the challenges they had faced during the pretest, allowing the CCP research team to provide guidance on how to handle these challenges.

2.1.9. Ethical aspects of the study

The study received ethical approval from the Ethiopian Public Health Institute ethical review committee, Addis Ababa, Ethiopia, and the ethical review board of the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.

2.2. Study Limitations

The key limitation of the midline study comes from its design. As there were no control groups, the findings presented in this report cannot be attributed directly and specifically to the project, because the baseline–midline comparison of outcome indicators could have been influenced by different confounders, although main confounding factors were controlled for during analysis. Some figures reported in the baseline survey report differ from the ones computed as part of this midline study because of the change in the weighting variable resulting from changes in the number of study woredas at baseline and midline. The evaluation team presented baseline values based on the values computed from the merged baseline dataset rather than on figures reported in the baseline survey report.


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EVALUATION REPORT

10

Results


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This section presents the findings of the midline study. The findings are presented under each of the key evaluation criteria of effectiveness, relevance, efficiency, and sustainability. The section starts with a brief description of the socioeconomic characteristics of survey respondents.

3.1. Demographic Characteristics of Respondents

As shown in the table presented under Annex 3, comparisons of the baseline and midline data indicate that the samples were comparable across a host of key sociodemographic and socioeconomic variables. The target population for this study included women of reproductive age (15–49 years). Most (64%) women who participated in the survey were younger than 35, and the rest were 35–49. Respondents’ age distribution between the baseline and midline was almost identical. Forty-five percent of women had a child under 5 years old (25% with a child under 2 years and 20% with a child between 3 and 5 years). Fewer than 10% of respondents were pregnant at the time of survey, which was also the case at baseline. Most (62%) had no formal education (baseline 57.9% and midline 62.3%). The remaining 38% had at least some primary education (baseline 42.1% and midline 37.7%). Most (79%) were married or cohabitating, whereas 20% were either divorced, widowed, or single. Over 46% of respondents fell in the low-income category (less than Birr 500 or less than 20 USD per month), whereas 28% and 26% belonged to middle- and high-income categories, respectively. A similar pattern was found in standards of living of respondents, with close to 46% reporting a low standard of living.

1 Exposure was computed by considering those that have heard or used the Family Health Guide, had exposure to radio program, participated in community meetings, or was exposed to the mobile application or video or print materials.

To better assess the respondents’ socioeconomic status, the study also explored their vulnerability levels based on four areas: food security, shelter, education, and access to health services. The women were asked to report their experiences in these areas in the past 12 months, and a vulnerability index was created. The proportion of respondents in the “highly vulnerable” category declined from 22% at baseline to 19% at midline, and the difference was statistically significant. There were significant differences by region, as was the case at baseline. A greater proportion of respondents (29%) from Southern Nations, Nationalities, and People’s Region (SNNPR) reported higher vulnerability than those in the three other regions. A sharp decline in highly vulnerable women was observed in Tigray, from 25% at baseline to less than 7% at midline (see Annex 3).

3.2. Exposure to Social and Behavior Change Communication Intervention

The main communication activities of the Communication for Health project are (1) provision of the Family Health Guide to the primary population to guide and promote health service use, (2) facilitation of community meetings to promote healthy behaviors, and (3) dissemination of different types of media components consisting of a radio program, maternal and child health video, a mobile application, and print materials that promote healthy behavior.

As shown in Table 2, 63% of respondents reported being exposed to one or more project activities.1 Among exposed respondents, 39.6% reported being exposed to three or

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more project activities. Among all study participants, 25% reported having been exposed to three or more Communication for Health activities, 38.4% to one or two, and 36.6% were not exposed to any Communication for Health activities. For the

2 Additional details on the computation of exposure is presented in Annex 2.

purposes of this report, a study participant is defined as exposed if she had received, participated in, or engaged with at least one project activity, and respondents who were not aware of any project activities were defined as nonexposed.2

Table 2: Percentage of respondents’ exposure to social and behavior change communication (SBCC) message, Communication for Health midline survey (April 2019)

CharacteristicsSample (N=1,773)

No. of SBCC program messages received

0 36.6

1–2 38.4

≥3 25.0

Exposure to the program (operational definition)

Nonexposed: Respondents who were not exposed to any SBCC program intervention 36.6

Exposed: Respondents who received at least one SBCC program intervention 63.4

3.3. Effectiveness

A critical evaluation question for Communication for Health relates to early indications of its effectiveness. Effectiveness was measured by comparing baseline and midline results. The evaluation team examined change over time in the target set for the Communication for Health project performance indicators. Though not found in the project document or agreements signed by the United States Agency for International Development and Johns Hopkins Center for Communication Programs (CCP), an aid tracker Excel file provided by CCP shows that the project aimed to increase overall appropriate health behaviors in targeted districts on malaria; reproductive, maternal,

neonatal, and child health; family planning; tuberculosis; water, sanitation, and hygiene; prevention of mother-to-child transmission (PMTCT), and nutrition by 15% from the baseline level by 2019–2020. Being a midline, the targets used to measure progress and achievement rates are half of the 5-year targets (7.5%) on each indicator (though the midline survey was conducted towards the end of the third year of the project). The findings are presented below under each intervention area. Annex 1 presents a summary project report card.


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3.1.1. Mothers’ and children’s health

3.3.1.1. Antenatal care

Women in the overall sample who had a child less than 2 years of age (baseline N=745, midline N=481) were asked questions

about their antenatal care (ANC). Table 3 summarizes the results on ANC knowledge and uptake.

Table 3: Percentage of antenatal care uptake, knowledge, self-efficacy, and outcome expectancy on antenatal care among women with children under 2 years old, Communication for Health baseline (September 2016) and midline (April 2019) surveys

Indicator

Baseline Midline Exposed Nonexposed

N=745 N=481 N=312 N=169

No. of antenatal care visits None 25.3 28.3 19.7*** 40.9

1–3 32.2 30.2 32.3*** 27.2

≥ 4 42.5 41.5 48.0*** 31.9

Early initiation for antenatal care ≤ 12 weeks 29.7 34.2*** 38.0*** 28.5

Knowledge on the right number of antenatal care visits that a pregnant woman should have (Knowledge) ≥ 4 71.4 68.4 72.8** 61.9

Knowledge on the importance for pregnant women to have at least one antenatal care visit with a skilled provider (Knowledge)

Moderate/high 97.8 94.4* 95.9 92.3

Attending antenatal care at least four times during pregnancy beginning in the first trimester is possible (Self-efficacy)

Moderate/high 93.3 92.3 92.2 92.5

Pregnant women who have at least four antenatal care visits during pregnancy will have better birth outcomes (Outcome expectancy)

Moderate/high 97.6 95.1 97.4* 91.8

*p<0.05, **p<0.01, and ***p<0.001.

As shown in Table 3, about a quarter of the women at both baseline and midline reported that they had not received any ANC. At the overall level, the number of ANC visits a woman has attended did not vary between baseline and midline. However, women who were exposed to Communication for Health were more likely to have one or more ANC visits than those who were not exposed. In contrast, nonexposed women were more

likely not to receive any ANC than those who were exposed.

Knowledge about and actual practice of four or more ANC visits was significantly higher among exposed respondents than nonexposed respondents. For example, 73% of exposed respondents, compared with 62% of nonexposed respondents, correctly reported that the number of ANC visits a pregnant

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woman should have is four or more. Similarly, almost half of exposed women reported four and more ANC visits, compared with one-third of those who were nonexposed.

The proportion of respondents reporting early initiation of ANC increased significantly between baseline and midline (baseline 30%, midline 34%). At midline, 38% of exposed respondents and 29% of nonexposed respondents reported early initiation of ANC. These numbers show a significant improvement from the figure reported in the 2016 Ethiopia Demographic and Health Survey (EDHS)3 in which only 20% of women (17% for rural women) had their first ANC during the first trimester. There were significant regional variations in reporting of early initiation of ANC at midline. Early ANC initiation improved significantly in SNNPR and Amhara, whereas an insignificant decline was seen in Tigray and Oromia. Annex 4 presents the regionally disaggregated results.

ANC knowledge of women at midline showed no significant change from baseline levels. At midline, over two-thirds of women with children under 2 years old knew the right number of ANC visits. This percentage did not vary significantly between baseline and midline. Almost all respondents knew that pregnant women should have at least one ANC visit with a skilled provider, although this percentage declined significantly from 98% at baseline to 94% at midline (see Table 3).

The proportion of women who were confident (self-efficacy) about attending ANC at least four times during pregnancy beginning in the first trimester did not show any significant change from baseline, though there were regional variations. A statistically significant decline on self-efficacy, from 96.5% to 78.1%, was observed in Tigray. The expectation that pregnant women who had at least four ANC visits during pregnancy would have better birth outcomes did not change significantly between the baseline and midline. There were regional variations, with significant declines in Amhara but no other region regarding the relationship between ANC and positive birth outcomes (see Annex 4).

The results from the multivariate logistic regression show that exposed women were more likely to have four or more ANC visits than those who were not exposed to Communication for Health activities (adjusted odds ratio [AOR]=1.795, 95% confidence interval [CI]=1.149–2.804). As expected, knowledge on the correct number of ANC visits and educational qualification were significantly associated with women who had four or more ANC visits. (AOR=7.845 and 2.274, for knowledge on ANC and educational qualification, respectively). Table 4 shows the results.


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Table 4: Logistic regression result on antenatal care uptake, Communication for Health midline survey (April 2019), computed from 481 midline women who had a child under 2 years of age

Indicator B Sig. AOR

95% CI for EXP(B)

Lower Upper

Age (15–24 is reference) 25–34 0.324 0.244 1.383 0.801 2.387

35–49 0.489 0.136 1.630 0.857 3.101

Education (Uneducated is reference) Educated 0.822 0.001 2.274 1.428 3.622

Knows the number of antenatal care visits a pregnant woman should have (<4 is reference) ≥ 4 2.060 0.000 7.845 3.791 16.235

Gender Equitable Men scale, partner violence index (Low is reference)

Moderate -0.403 0.089 0.669 0.420 1.063

High -0.185 0.696 0.831 0.328 2.104

Gender Equitable Men scale, sexual relationship index (Low is reference)

Moderate -0.483 0.111 0.617 0.340 1.118

High 0.149 0.680 1.160 0.573 2.349

Interpersonal communication on antenatal care Yes -0.448 0.089 0.639 0.382 1.070

Direct exposure, dichotomous (Nonexposed is reference) Exposed 0.585 0.010 1.795 1.149 2.804

Note: AOR=adjusted odds ratio; CI=confidence interval; EXP(B)= Exponentiation of the B coefficient.

The project targeted an overall 15% increase in adequate ANC during the Communication for Health project. At midline, the project aimed for a 7.5% increase in ANC behaviors. The results show that the project, on average, achieved more than 91% of its midline targets (see Annex 1).

3.3.1.2. Family planning

The survey questions around modern family planning methods focused on knowledge, reported confidence around using, ever use, current use, and beliefs about the benefits of using modern contraceptive methods. The results from these questions are presented in Table 5.

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Table 5: Percentage family planning indicators among married women aged 15–49 years, Communication for Health baseline (September 2016) and midline (April 2019) surveys, disaggregated by exposure

Family Planning Practice and Knowledge Baseline Midline Exposed Nonexposed

Ever use of modern family planning N=2,059 N=1,368 N=1,051 N=317

67.0 65.3 68.5*** 55.8

Current use of modern family planning N=1,830 N=1,223 N=935 N=288

47.5 42.6* 45.9*** 33.2

Knowledge on family planning N=2,770 N=1,773 N=1,343 N=430

Any family planning method 93.1 91.0*** 93.1*** 84.7

Type of family planning method known

Any modern method 75.7 73.5* 73.9*** 72.3

Any traditional method 17.4 17.5 19.1 12.3

Modern by period Any modern short-acting method 15.1 19.3*** 18.2*** 22.6

Any modern long-acting method 60.6 54.3 55.7 49.8

Family planning knowledge

1–3 methods 32.2 44.2 42.7 49.1

≥4 methods 56.9 46.8 50.4 35.6

Women who believe they are able to use modern contraceptive methods (Self-efficacy) Mod/High 83.9 87.1** 89.3*** 80.2

Women who believe their use of modern contraceptive methods improved quality of family life (Outcome expectancy) Mod/High 88.2 87.2 89.8*** 78.8

*p<0.05, **p<0.01, and ***p<0.001.

The results presented in Table 5 show that knowledge about modern contraceptive methods was very high, with over 9 of 10 women knew about modern methods. However, when the data were examined by specific methods, unexpectedly, knowledge of any modern or traditional method was significantly higher at baseline, compared to midline. Alternatively, knowledge of any short-acting method was higher at midline than at baseline. When analyzed by exposure, the midline data showed that exposed respondents were significantly more likely than their baseline counterparts to know about any method, as well as any modern method. Surprisingly, knowledge about any short-acting modern methods was significantly lower among exposed respondents than nonexposed ones.

Neither the baseline nor the midline findings were consistent with national figures. The 2016 EDHS, for example, reported that knowledge of contraceptive methods is universal in Ethiopia (99% of women in rural areas), compared to 93% and 91% at baseline and midline, respectively. Similarly, whereas about three-quarters of baseline and midline respondents knew any modern method, the 2016 EDHS reported that 98% of sexually active women knew any modern method. The same pattern was observed for knowledge of traditional family planning methods. The 2016 EDHS reported that over 34% of women knew any traditional method, compared to 17.5% at baseline and midline. The evaluation team cannot provide any credible justification to explain these differences.


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A significant decline occurred over time in current modern family planning use, with 48% of women at baseline and 43% at midline reporting current use. This decline could be partly attributed to a decrease in the proportion of women that reported knowing about these methods. The proportion of women who knew about four or more contraceptive methods declined from 57% at baseline to 47% at midline. A significantly higher proportion of women felt confident that they would be able to use modern contraceptive methods (self-efficacy) at midline (87.1%), compared to the baseline (83.9%). However, no significant change was observed in expectations that using family planning would improve family life (see Table 5).

At midline, regional variations were observed in reported current use of modern contraceptives, which also was the case at baseline. At baseline, higher current use of modern family planning methods was reported in Amhara (59%) than in the other three regions. Tigray and SNNPR were in the 41%–55% range, and Oromia had the lowest use of modern contraceptives at 31%. Current use of modern family planning declined sharply in Amhara, from 59% at baseline to 44% at midline. A similar pattern was observed in SNNPR, where use of modern methods declined from 55% at baseline to 49% at midline. These baseline–midline differences were statistically significant. The evaluation

team was not able to explain possible reasons for these declines in the two regions. In contrast, current use of contraceptives increased in Oromia and Tigray between baseline and midline (see Annex 10).

When the project’s performance was evaluated against targets set for key family planning performance indicators, the results showed that the project’s achievement averaged about 88% of the midline target (see Annex 1).

3.3.1.3. Institutional delivery and

postnatal care

Maternal and neonatal mortality can be reduced by increasing institutional deliveries. Statistical data produced by the Ministry of Health and Central Statistical Agency showed that institutional delivery has been growing in Ethiopia over the past two decades. According to the 2016 EDHS report, 26% of live births in the 5 years before the survey took place in a health facility. In rural areas, institutional delivery reached 20% in 2016. In the 5 years before the 2016 EDHS, 28% of births were delivered by a skilled provider. The status of institutional delivery and postnatal care (PNC) among target beneficiaries in the intervention areas was assessed as part of the baseline and midline. Table 6 summarizes the results.

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Table 6: Percentage of institutional delivery, postnatal care, and knowledge of danger signs of pregnancy among women with children under 2 years old, Communication for Health baseline (September 2016) and midline (April 2019) surveys

Indicator


N=745 N=481 N=169 N=312

Institutional delivery 43.3 48.1*** 54.4*** 38.9

Health/vaccination card with date recorded 56.7 61.3 65.3*** 55.6

Time of first check after delivery for postnatal care

Within 2 days NA 35.3*** 39.9*** 28.5

Within 7 days 27.9 41.2*** 47.9*** 31.4

Knowledge on pregnancy danger signsa

Low 39.2 44.5 41.5* 48.9

Medium 45.0 39.0 42.4* 34.0

High 15.8 16.5 16.1 17.0

Deliveries attended by skilled health personnel 58.5 59.8 71.8*** 56.2

Notes: *p<0.05; ***p<0.001; NA: Postnatal care within 2 days was not measured at baseline. aKnowledge of pregnancy and delivery danger signs was categorized as low (knowing 0–1 danger signs), medium (knowing 2–3), or high (knowing ≥4).

The results in Table 6 show that institutional delivery increased significantly (43% at baseline to 48% at midline). As expected, women who were exposed to one or more Communication for Health activities were significantly more likely to deliver at a health facility than those who were not exposed. Both the baseline and midline figures on institutional delivery in project regions are much higher than the national figure of 26% (EDHS, 2016).

Regional variations were observed in institutional delivery. Institutional delivery increased in Tigray, SNNPR, and Amhara but declined in Oromia. Institutional delivery in Oromia was the lowest (20%), and Tigray had the highest (79%), followed by SNNPR (72%). The proportion of deliveries attended by skilled health personnel increased slightly at midline, suggesting that deliveries outside health facilities were more likely to be assisted by skilled health personnel at both baseline and midline (see Annex 6).

PNC within 7 days was measured at baseline and midline. The midline measurement also

included PNC in the first 2 days of delivery. The findings indicate a significant increase in first postnatal checks within 7 days from baseline (27.9%) to midline (41.2%). This increase is reasonable, as institutional delivery also increased since baseline and is assumed to increase the likelihood of adequate PNC. Stakeholders consulted for the midline also confirmed that there have been positive changes in institutional delivery and PNC. “There are visible changes in some program performances, such as institutional delivery and PNC after introducing maternity home videos (MHVs) in selected health facilities,” a woreda health office head said. The results may also show that the significant changes in institutional delivery and PNC since baseline might have been affected by factors other than ANC (see Table 6). For example, as shown in Table 7, early initiation of ANC rather than number of ANC visits is positively correlated with institutional delivery.

In aggregate among respondents at baseline and midline, no significant variation was observed on knowledge of pregnancy


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danger signs.4 With regard to the regional disaggregated results, knowledge on pregnancy danger signs significantly improved in Tigray from 7.3% to 25.0, but significant changes were not observed in other regions (see Annex 6).

Multivariate analysis was conducted to examine the likelihood of behavioral outcomes after controlling for demographic factors (e.g., age, education), social factors (e.g., vulnerability, gender attitudes), interpersonal communication on delivery, and previous knowledge and behaviors related to the outcome of interest. The results on the

4 Women’s knowledge of pregnancy danger signs was calculated from the number of signs they mentioned from the list of pregnancy danger signs; those who knew at least three pregnancy danger signs were considered to have a minimum level of knowledge.

institutional delivery outcome, as presented in Table 7, show that exposed women had a higher probability of delivering in health facilities than those who were not exposed to Communication for Health intervention messages (AOR=1.746, 95% CI=1.096–2.781). Other factors that predicted institutional delivery included education (AOR=2.07) and early initiation of ANC (AOR=3.3). Being in the highly vulnerable group and displaying moderately negative attitudes on the gender inequality index on partner violence emerged as risk factors for institutional delivery.

Table 7: Logistic regression results for institutional delivery, Communication for Health baseline (September 2016) and midline (April 2019) surveys


95% CI for EXP(B)

Lower Upper

Age (15–24 is reference) 25–34 0.076 0.802 1.078 0.597 1.947

35–49 0.641 0.071 1.899 0.946 3.814

Education (Uneducated is reference)

At least primary 1.012 0.000 2.750 1.678 4.507

Knowledge on pregnancy danger signs (No is reference) Yes -0.044 0.858 0.957 0.589 1.553

Vulnerability index by three categories (Not vulnerable is reference)

Vulnerable -0.180 0.486 0.836 0.504 1.385

Highly vulnerable -0.936 0.007 0.392 0.200 0.770

Early initiation for antenatal care (No is reference) Yes 1.195 0.000 3.303 2.014 5.417


Moderate -0.874 0.000 0.417 0.257 0.678

High -0.876 0.089 0.416 0.151 1.144


Moderate -0.909 0.009 0.403 0.203 0.799

High 0.013 0.975 1.013 0.452 2.270

Interpersonal communication on delivery with anyone (No is reference) Yes 0.241 0.394 1.273 0.731 2.217



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In evaluating the Communication for Health project’s performance against the 7.5% change at the midline target, Annex 1 shows that the project’s achievement exceeded 95% for the midline targets.

3.3.1.4. Prevention of mother-to-child HIV transmission, HIV counseling, and testing

A series of questions were included in the survey about HIV testing during pregnancy, HIV transmission, self-efficacy about taking antiretrovirals, and expectations that antiretrovirals can reduce the risk of HIV transmission to children. Table 8 shows the results.

Table 8: Percentage prevention of mother-to-child transmission, HIV counseling and testing, Communication for Health baseline (September 2016) and midline (April 2019) surveys

Indicator


N=745 N=481 N=169 N=312

HIV test at recent pregnancy 50.4 57.5** 67.3*** 43.0

A pregnant woman with HIV can transmit it to her baby. 74.8 80.2*** 82.7** 76.5

A pregnant woman with HIV can prevent transmitting it to her baby if she takes antiretrovirals. 73.2 76.9* 82.8*** 68.2

I am able to be tested for HIV and take antiretrovirals if needed. 88.3 85.5 91.0*** 77.5

Testing for HIV and adhering to antiretrovirals can reduce the risk of HIV transmission to my babies. 79.1 78.5 84.1*** 70.3

*p<0.05, **p<0.01, and ***p<0.001.

As depicted in Table 8, the percentage of women who were tested for HIV/AIDS at their recent pregnancy increased significantly from 50% at baseline to 58% at midline. Midline comparisons also show that women exposed to Communication for Health were more likely to have been tested for HIV/AIDS at their recent pregnancy (67%) than those who were not exposed (43%).

Women’s knowledge on mother-to-child transmission of HIV/AIDS and its prevention improved significantly from the baseline. Yet, there were no significant differences between baseline and midline respondents on self-efficacy (confidence to seek testing for HIV and take antiretroviral therapy or

knowing that testing and antiretroviral therapy adherence reduces the risk of HIV transmission to infants). However, midline respondents exposed to Communication for Health reported significantly higher levels of knowledge, self-efficacy, and outcome expectancies than their nonexposed counterparts (see Table 8).

Multivariate analysis was conducted to examine the likelihood of behavioral outcomes after controlling for demographic factors (e.g., age, education), social factors (e.g., vulnerability, gender attitudes), interpersonal communication on PMTCT, HIV counseling, and testing. Table 9 shows the results.


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Table 9: Result from logistic regression on HIV/AIDS test during recent pregnancy, Communication for Health baseline (September 2016) and midline (April 2019) surveys


95% CI for EXP(B)

Lower Upper

Age (15–24 years is reference)

25–34 -0.004 0.990 0.996 0.549 1.806

35–49 0.156 0.656 1.169 0.588 2.324


At least primary 0.608 0.017 1.836 1.114 3.026

Knowledge (Low is reference)

Medium 0.630 0.018 1.877 1.117 3.156

High 0.720 0.031 2.055 1.067 3.960

Vulnerability index (Not vulnerable is reference)

Vulnerable -0.539 0.030 0.583 0.358 0.950



Moderate -0.638 0.008 0.528 0.329 0.848

High -1.136 0.025 0.321 0.119 0.867


Moderate -0.521 0.119 0.594 0.308 1.144

High 0.427 0.309 1.532 0.673 3.486

Interpersonal communication on prevention of mother-to-child HIV transmission with anyone (No is reference) Yes -0.022 0.946 0.979 0.526 1.822



Some background characteristics were correlated with having or not having HIV/AIDS testing during pregnancy. As shown in Table 9, women who were exposed to Communication for Health messages were twice as likely (AOR=2.199, 95% CI=1.409–3.433) as their nonexposed counterparts to have had an HIV/AIDS test during their recent pregnancy. Higher levels of education and knowledge about the value of HIV testing were protective factors for women to get tested during pregnancy. Higher levels of vulnerability contributed to lower odds of being tested for HIV during pregnancy. Hence, vulnerability was a risk factor. Gender attitudes on the partner violence subscale had a significantly negative

effect on women having had an HIV/AIDS test during their recent pregnancy, indicating that women who had negative attitudes towards partner violence reported lower levels of HIV testing at their recent pregnancy.

3.3.2. Child feeding

Breastfeeding benefits are multiplied with early initiation of breastfeeding and exclusive breastfeeding for 6 months. Both the baseline and midline surveys gathered data on child-feeding practices of women with children under 2 years old. Table 10 presents the results.

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Table 10: Percentage level of early initiation of breastfeeding and exclusive breastfeeding among mothers of children under 23 months old, Communication for Health baseline (September 2016) and midline (April 2019) surveys

Indicator Baseline Midline Exposed Nonexposed

Early initiation of breastfeeding

N=745 N=481 N=169 N=312

67.5 68.5 72.8* 62

Exclusive breastfeeding

N=195 N=130 N=78 N=52

64 46.3* 46.7 45.8

N=745 N=481 N=169 N=312

Children should have at least four food groups (Knowledge) 99 98.3 97.7 99.2

Exclusive breastfeeding in first 6 months improves child health status (Outcome expectancy) 98.2 97.4 97.5 97.3

Notes: *p<0.05. Exclusive breastfeeding at midline was measured differently from baseline, hence comparison between baseline and midline may not be reliable.

Rates of early initiation of breastfeeding, as shown in Table 10, increased slightly from 67.5% at baseline to 68.5% at midline, though the difference was not statistically significant. Early initiation of breastfeeding was significantly higher (73%) among those exposed to Communication for Health intervention messages than those who were not exposed (62%). However, the results also show a sharp decline from 64% at baseline to 46% at midline in the proportion of women with children under 2 years old who practiced exclusive breastfeeding. At midline, there were no statistically significant differences between exposed and nonexposed women regarding early initiation of breastfeeding. No improvements were noted in knowledge and outcome expectancies on child feeding between baseline and midline, which may be due to ceiling effects resulting from the fact that almost all respondents had the required knowledge and outcome expectancies

associated with the importance of exclusive breastfeeding. Regional comparisons indicate significant increases in early initiation of breastfeeding among women with a child under 5 in Oromia and Tigray. However, exclusive breastfeeding of children under 6 months of age declined significantly between baseline and midline in all four regions. See Annex 12 for regionally disaggregated results.

The result of the multivariate analysis presented in Table 11 shows that early initiation of breastfeeding was not statistically significantly different between women who were exposed to health messages and those who were not. Hence, the significant variation among exposed and nonexposed groups that is reported in the bivariate analysis might be due to other confounding factors.


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Table 11: Result from logistic regression on early initiation of breastfeeding, Communication for Health midline survey (April 2019)


95% CI for EXP(B)

Lower Upper

Age in years (15–24 is reference)

25–34 0.228 0.447 1.256 0.697 2.263

35–49 0.029 0.932 1.030 0.524 2.025


At least primary 0.033 0.900 1.034 0.617 1.732

Knowledge (Low is reference) High -0.855 0.485 0.425 0.038 4.699

Outcome expectancy (Low is reference) High 0.790 0.323 2.204 0.460 10.549


Vulnerable 0.042 0.877 1.043 0.614 1.771



Moderate -0.448 0.074 0.639 0.391 1.044

High -1.493 0.001 0.225 0.090 0.564


Moderate -0.762 0.055 0.467 0.214 1.015

High -1.048 0.017 0.351 0.149 0.826



When evaluating the project’s performance against half of the 5-year targets set for key child-feeding performance indicators, project achievement exceeded 94% of the midline targets (Annex 1).

3.3.3. Malaria

The analysis presented in this section is based on a smaller sample of respondents who live in malaria-prone areas. These woredas were categorized based on the information from the Ministry of Health on malaria prevalence. The results, as presented in Table 12, showed that 62.5% of midline survey respondents lived in areas that are moderately or highly prone to malaria. The proportion of respondents at baseline was 58.5%.

Table 12: Percentage of respondents, by malaria status

Baseline N=2,770 Midline N=1,773 Total N=4,543

% % %

Malaria Free/Low 41.5 37.5 40.0

Moderate/High 58.5 62.5 60.0

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Close to half of the midline respondents (48%) living in malaria-prone areas reported owning at least one bed net, which was a statistically significant decline from the baseline report of 66%. The average bed nets per household grew from 1.3 at baseline to 2.1 at midline, and this change was statistically significant. Women who were exposed to Communication for Health were significantly more likely to belong to a household that had at least one bed net, compared to their nonexposed counterparts. Bed net use by women aged 15–49 revealed an insignificant increase from

62% at baseline to 63% at midline. However, bed net use among exposed women (66%) was statistically significantly higher than bed net use among the nonexposed (56%). Similarly, bed net use among all adults aged 35–49 was significantly higher among exposed respondents than nonexposed ones. Unfortunately, bed net use by children under 5 years of age registered significant declines from baseline (67%) to midline (59%). This decline in bed net use could be associated with the sharp decline in household availability of bed nets. Table 13 shows the results.

Table 13: Percentage availability and use of bed nets in households in malaria-prone areas

Indicator


N=1,620 N=1,107 N=765 N=342

Households with at least one bed net in malaria-prone areasa

N=1,057 N=538 N=402 N=136

65.8% 48.6%*** 50.3%*** 41.7%

No. of bed nets in households in malaria prone areas 2,172 1,241 919 322

Average no. of bed nets or long-lasting insecticidal nets per household in malaria-prone areas 1.3 2.1 2.1 2.2

Average family size of households with at least one bed net per household in malaria-prone areas

N=1,057 N=538 N=402 N=136

4.89 4.89 4.87 4.95

Households with at least one bed net per two persons in malaria areas 24.2% 36.0%*** 34.8% 38.9%

Households with at least one net (any type) per two persons who stayed in the household last night

N=1,107 N=765 N=342

29.6%b 32.2% 32.7%* 28.9%

Women aged 15–49 who slept under a bed netc N=1,480 N=639 N=461 N=178

62.3% 63.2% 66.3%** 55.9%

Pregnant women residing in malaria-prone areas who used bed netd

N=117 N=54 N=42 N=12

54.9% 74.5% 75.3% 73.2%

All children under 5 sleep under a bed nete N=700 N=301 N=230 N=71

67.3% 59.3%*** 61.6% 53.4%

Adults aged 35–49 who slept under long-lasting insecticidal nets the previous nightf 43%b 58.5% 61.2%** 50.9%

Population that slept under long-lasting insecticidal nets the previous night (all household members)f 38.4%b 55.4% 58.0%** 47.3%

Note: a. Calculated from households and respondents that live in malaria-prone areas. b. Malaria indicator survey (MIS), 2015. c. Calculated from women aged 15–49 who have a bed net, regardless of location. d. Calculated from pregnant women who have a bed net, regardless of location. e. Calculated from women with children under 5 who have bed nets, regardless of location. f. Calculated from malaria-prone areas, regardless of bed net possession.

*p<0.05, **p<0.01, and ***p<0.001.


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A total of 3,394 children under 5 years old (2,093 at baseline and 1,301 at midline) lived in malaria-prone areas in the sampled households. As depicted in Figure 1, close to 14% of the baseline and 11.9% of the midline respondents reported a fever in these children in the 2 weeks before the survey. At both

baseline and midline, treatment was sought for approximately 70% of these children. Treatment-seeking behavior of exposed respondents was (49.8%) significantly higher than it was (33.5%) for those that were not exposed to Communication for Health.

Figure 1: Percentage of fever and treatment seeking for children under age 5 in malaria-prone areas

UnexposedExposedMidtermBaseline

Percentage of incidence and treatment seeking for children under 5(NB = 2,093 and ML = 3,394)

0

20

40

60

80

100

Percentage of children had fever in two weeks

(of those who live in malaria prone Woredas)

Percentage of children sought treatment for fever

(out of those who had fever in the two weeks)

Percentage of children sought timely treatment within 24 hours of fever incidence

(of those who live in malaria prone Woredas)

13.811.9 11.7 12.2

70.5

77.7

57

66.9

44.1

49.8

33.5

45.2

Women’s knowledge on the cause, symptoms, and prevention of malaria was measured using the survey data collected from women who lived in malaria-prone areas. A total of 2,727 women responded to these questions at baseline (N=1,620) and midline (N=1,107). The responses indicated that knowledge was significantly higher at midline than at baseline. Close to 3 out of 10 respondents were able to identify the cause of malaria at baseline and midline. These results indicate that knowledge levels are quite low. Knowledge about three or more signs or symptoms of malaria was significantly higher among respondents at midline (39%) than at baseline (33%). At

midline, exposed respondents displayed significantly higher levels of knowledge on the causes of malaria and naming three or more signs or symptoms of malaria, compared to nonexposed respondents. There were no significant differences between baseline and midline responses for knowing that sleeping under an insecticide-treated mosquito net protects against malaria: 24% of exposed midline respondents compared with only 13% of nonexposed respondents reported knowing about sleeping under an insecticide-treated mosquito net. Table 14 shows the results.

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Table 14: Knowledge on malaria among respondents living in malaria-prone areas

Indicator

Baseline (%) Midline (%) Exposed (%) Nonexposed (%)

N=1,620 N=1,107 N=765 N=342

Knowledge on cause of malaria 29.0 31.1*** 33.6** 25.1

Knowledge on three or more signs or symptoms 32.8 38.9*** 42.2** 32.2

Knowledge about sleeping under insecticide-treated mosquito net to prevent malaria 18.0 20.5 24.3** 12.7

*p<.05, **p<.01, and ***p<.001.

Some of the intermediate outcomes around malaria expected from the project are improving the knowledge, self-efficacy, and expectation of beneficiaries that seeking treatment for fever in their children under age 5 within 24 hours of onset will improve their health. As shown in Table 15, the self-efficacy of women on the use of long-lasting

insecticidal nets and treatment seeking for children under 5 improved at midline, compared with baseline figures. At midline, there was no statistically significant change in knowledge and expectations from the baseline. However, exposed respondents were found to have significantly higher positive expectations than nonexposed respondents.

Table 15: Self-efficacy and outcome expectancy on malaria in malaria-prone areas

Indicator Baseline (%) Midline (%) Exposed (%) Nonexposed (%)

All Respondents Living in Malaria-Prone Areas N=1,620 N=1,107 N=765 N=342

Use of bed net can prevent malaria (Outcome expectancy) (Agree/Strongly agree) 95.1 94.3 95.5* 91.8

Having my children sleep under long-lasting insecticidal nets each night will prevent malaria (Outcome expectancy) (Agree/Strongly agree) 94.5 94.2 95.2* 92.2

I am able to have children under 5 sleep under a bed net each night (Self efficacy) (Agree/Strongly agree) 84.4 87.7*** 88.9* 85.2

I am able to sleep under a long-lasting insecticidal net each night (Self-efficacy) (Agree/Strongly agree) 85.0 89.2*** 91.1** 85.2

I should seek treatment within 24 hours of fever in children under (Knowledge) (Agree/Strongly agree) 93.0 92.5 92.8* 91.8

I can take my child to treatment within 24 hours of fever onset (Self efficacy) (Agree/Strongly agree) 89.9 92.0* 92.8* 90.3

Seeking treatment within 24 hours of fever for children under age 5 can improve their health (Outcome expectancy) (Agree/Strongly agree) 96.8 95.2 95.8** 93.8

Pregnant Women Living in Malaria-prone Areas N=143 N=88 N=68 N=20

Use of a bed net can prevent malaria 92.5 95.2 98.6 87.4

Having my children sleep under long-lasting insecticidal nets each night will prevent malaria (Agree/Strongly agree) 92.1 94.6 97.7 87.4


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I am able to have children under age 5 sleep under a long-lasting insecticidal net each night (Agree/Strongly agree) 75.4 86.1* 85.6 87.4

I am able to sleep under a long-lasting insecticidal net each night (Agree/Strongly agree) 77.2 88.2* 88.6 87.4

I should seek treatment for fever in children under age 5 within 24 hours (Agree/Strongly agree) 93.5 95.9 94.2 100.0

I can take my child to treatment within 24 hours of fever onset (Agree/Strongly agree) 92.6 93.8 91.2 100.0

Seeking treatment within 24 hours of fever onset will improve health outcomes in children under 5 (Agree/Strongly agree) 97.7 98.5 97.9 100.0

*p<0.05, **p<0.01, and ***p<0.001.

When the project’s performance is evaluated against half of the 5-year targets set for key malaria performance indicators, the project’s achievement averaged about 100% of the midline targets (see Annex 1).

3.3.4. Water, Hygiene, and Sanitation

Water, hygiene, and sanitation (WASH) in Ethiopia is very poor due to lack of awareness

about the benefits of clean water, lack of handwashing and latrine use, and limited access to improved sanitation and water supply facilities. Against this background, the Communication for Health project included WASH as one of the six areas of intervention. Table 16 summarizes the results of the survey data, gathered from target women at baseline and midline and by exposure at midline on some WASH indicators.

Table 16: Practice, knowledge, self-efficacy, and outcome expectancy on handwashing


N=2,770 N=1,773 N=1,124 N=649

Practices handwashing at all key times 62.2 65.1 66.4 63.6

Has proper handwashing facility with soap and water 13.2 19.3*** 19 13.2*

Comprehensive knowledge on handwashing at key times

Knows all 5 key times 14.3 26.7*** 27.2 27.8

Knows 3–4 key times 29 35.1*** 31.8*** 27.2

Knows <2 key times 56.7 38.2*** 41.0*** 45.0

I can practice proper handwashing (Self-efficacy) 94.2 92.1 93.6** 90.3

Proper handwashing prevents diseases such as diarrhea (Outcome expectancy) 98 97.8 98.4* 96.7

*p<0.05, **p<0.01, and ***p<0.001.

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The results presented in Table 16 show that handwashing under all key circumstances did not significantly improve from baseline, though there were some modest increases. No significant difference was observed in handwashing practices among exposed and nonexposed women at midline. The qualitative data suggest that handwashing practices improved at schools and contributed to a reduction in diseases. According to one key informant who is a primary health care unit officer, “If it wasn’t for the project, students wouldn’t be aware of important health practices, such as handwashing.” As a result of increased awareness, transmitted diseases have decreased, especially at schools. Some key informants recommended the need to capture changes happening in schools after realizing that the household survey might not fully reflect results achieved by the project.

Presence of a proper handwashing place with soap and water grew significantly over the past 3 years in project intervention areas. As shown in Table 16, over 19% survey respondents at midline reported the presence of a proper handwashing place, compared to 13% at baseline, and this difference was

statistically significant. The largest increase was observed in Amhara (from 3% to 11%), followed by SNNPR (from 36% to 41%). Presence of a proper handwashing place was lowest in Oromia, with only 3% of respondents having this basic resource (see Annex 17).

Comprehensive knowledge on handwashing at key times improved significantly at midline, compared to baseline. The percentage of women who know all five critical times of handwashing increased from 14% at baseline to 27% at mid-term. At midline, the percentage of women who knew three to four critical handwashing times was significantly higher among women exposed to Communication for Health (32%) than those who were not exposed (27%). Similarly, at midline, exposed women had statistically significantly higher levels of self-efficacy and outcome expectations than nonexposed women regarding the value of handwashing. Some regional differences were evident, with self-efficacy and outcome expectancies increasing everywhere but Amhara, where it declined (see Annex 17).


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Table 17: Results of logistic regression on availability of proper handwashing stations, Communication for Health midline survey, April 2019 (computed from 1,773 midline women)

Indicator B Sig. Exp(B)

95% CI for Exp(B)

Lower Upper

Age in years (15–24 is reference) 25–34 0.322 0.131 1.379 0.909 2.094

35–49 0.200 0.387 1.221 0.776 1.922


At least primary 0.315 0.079 1.370 0.964 1.946

Comprehensive knowledge on handwashing at key times (Knows <2 key times is reference)

Knows 3–4 key times 1.506 0.000 4.510 2.913 6.983

Knows all 5 key times 1.794 0.000 6.011 3.793 9.526

Self-efficacy on proper handwashing (Low and moderate is reference) High -0.463 0.117 0.629 0.353 1.122

Outcome expectancy on proper handwashing (Low and moderate is reference) High -0.320 0.212 0.726 0.439 1.201


Vulnerable 0.288 0.100 1.333 0.946 1.879


Gender Equitable Men scale (Low is reference)

Moderate 1.411 0.021 4.102 1.234 13.638

High 0.933 0.125 2.543 0.772 8.377



The results of the multivariate analysis presented in Table 17 show that women who were exposed to the Communication for Health intervention were more likely (AOR=1.425, 95% CI=1.021–1.989) than their nonexposed counterparts to have access at home to a proper handwashing station. Respondents at midline who knew three to four (AOR=4.510) or all five (AOR=6.011) key handwashing times were more likely to have a proper handwashing station at home than those who knew fewer critical times of handwashing. Higher levels of vulnerability contributed to lower odds of having proper handwashing stations. Women at a moderate level on the Gender Equitable Men (GEM) scale, adapted for women, were

significantly more likely to have proper handwashing stations than women at a lower level on the scale.

When the project’s performance is evaluated against half of the 5-year targets set for key WASH performance indicators, the results showed that the project’s achievement averaged about 119% of the midline targets (see Annex 1).

3.3.5. Tuberculosis

Respondents who had heard of tuberculosis (TB) declined significantly from 78% at baseline to 67% at midline. However, respondents exposed to Communication for

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Health were more likely to have heard of TB than those that were not exposed. The proportion of respondents who knew about airborne transmission of TB increased from 43% at baseline to 45% at midline. Similarly, 23% of midline survey respondents knew three or more TB symptoms, compared to

15% at baseline. Women who were exposed to Communication for Health were more likely than nonexposed women to know three or more TB symptoms and to know about airborne transmission of TB. Table 18 shows the results.

Table 18: Tuberculosis (TB) knowledge, self-efficacy, and outcome expectancy among all women aged 15–49 years, Communication for Health baseline (September 2016) and midline (April 2019) surveys

Characteristics Baseline (%) Midline (%) Exposed (%) Nonexposed (%)

Sample size N=2,712 N=1,768 N=1,121 N=547

Respondents who ever heard of tuberculosis or TB 78.2 67.0*** 74.8*** 55.0

Respondents who know coughing through air is means of TB transmission 43.1 45.0** 52.1*** 39.8

Respondents who know three or more TB symptoms 14.7 22.5*** 26.7*** 15.8

Sample size N=2,681 N=1,764 N=1,120 N=644

Agrees that she can go to be immediately screened on suspected TB (Self-efficacy) 76.2 66.1*** 73.4*** 54.3

Agrees that early screening of TB may lead to full recovery (Outcome expectation) 75.4 62.1*** 70.1*** 49.5

*p<0.05, **p<0.01, and ***p<0.001.

Analysis of results between baseline and midline shows a statistically significant decline in self-efficacy and outcome expectations for knowing that early screening for TB may lead to full recovery. As shown in Table 18, the proportion of respondents who agreed that they could be immediately screened on suspected TB declined (self-efficacy) from 76% at baseline to 66% at midline. Similarly, 62% of respondents in the midline survey expected that early screening of TB may lead to full recovery from TB, compared to 75% at baseline. At midline, women who were exposed to Communication for Health were more likely to have stronger self-efficacy and positive expectations than those who were not exposed.

When the project’s performance is evaluated against half of the 5-year targets set for key TB performance indicators, the results show that the project’s achievement averaged about 100% of the midline targets (see Annex 1).

3.3.6. Gender equality norms

The Government of Ethiopia has adopted several policy and institutional measures to promote gender equality and women’s empowerment. The Ethiopian Constitution, the 1993 Ethiopian National Policy on Women, the 2005 Family Law, and the Second Growth and Transformation Plan are among the legal and policy instruments that further gender


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equality and empowerment. The government requires all government institutions to address women’s issues in policies, laws, and development programs and projects. Gender issues influence all six health areas of the Communication for Health project.

A total of 21 questions were asked to ascertain gender equitable norms. These questions were adapted from a validated GEM scale.5 The questions were grouped into gender equality subcomponents for partner violence, sexual relationships, reproductive health, and disease prevention, as well as domestic chores and daily life. Gender equality on partner violence included questions about whether a husband can beat his wife, whether there are times when a woman deserves to be beaten, whether a woman should tolerate violence to keep family together, whether a man can hit his wife if she refuses to have sex with him, whether a man can beat his wife if she is unfaithful, whether a man using violence against his wife is a private matter that should not be shared with outsiders, and whether a man should defend his reputation with force. The sexual relationship subscale questions included questions about whether men need sex more than women, whether a man needs other women even if he is fine with his wife, whether women should talk about sex or just do it, whether it is disgusting if a man acts like a woman, whether a woman should initiate sex, and whether a woman loses respect if she has sex before marriage. Reproductive health and disease prevention questions included items asking if it is woman’s responsibility to avoid pregnancy, if a woman is only a real woman if she has a child, and if a real man produces a male child. Domestic chores and daily life questions included whether childcare and feeding is the responsibility of

5 Available at https://c-changeprogram.org/content/gender-scales-compendium/gem.html

a woman, whether caring for home and family is the responsibility of a woman, whether the husband should decide when to buy major household items, whether a man should have final word about decisions in his house, and whether a woman should obey her husband in all things.

All questions were structured using a Likert scale (agree, partially agree, and disagree). During analysis, the questions were combined to establish subscales corresponding to low, moderate, and high gender inequality. A composite measure of 21 questions on the GEM scale illustrated significant differences between baseline and midline respondents, with 17.0% at baseline and 35.5% at midline reporting low gender inequality. Further, at midline, exposed respondents were significantly more likely than nonexposed respondents to report lower levels of perceived gender inequity. Table 19 shows the results. These positive developments were observed on most subscales across the intervention regions, except for Amhara, where the change over time was smaller and nonsignificant (see Annex 21).

https://c-changeprogram.org/content/gender-scales-compendium/gem.html

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Table 19: Gender Equitable Men (GEM) scale, adapted for women aged 15–49 years, Communication for Health project baseline (September 2016) and midline (April 2019) surveys

Baseline (%) Midline (%) Exposed (%) Nonexposed (%)

Sample size N=2,243 N=1,557 N=1,004 N=553

GEM scale, adapted for women (derived from 21 variables), % low inequality*** 17.0 35.5*** 37.5*** 30.6

Sample size N=2,603 N=1721 N=1,097 N=624

GEM scale, adapted for women (partner violence), % low inequality*** 46.0 57.9*** 58.2** 56.0

Sample size N=2,303 N=1,584 N=1,019 N=565

GEM scale, adapted for women (sexual relationship), % low inequality*** 4.8 15.9*** 17.4* 11.7

Sample size N=2,770 N=1,773 N=1,124 N=649

GEM scale, adapted for women (reproductive health and disease prevention), % low inequality 67.4 67.3 68.1 66

GEM scale, adapted for women (domestic chores and daily life), % low inequality*** 20.7 33.7*** 35.7*** 28.2

*p<0.05, **p<0.01, and ***p<0.001.

3.4. Effectiveness of the Communication for Health project (Qualitative assessment)

Qualitative data from key informant interviews provide different stakeholder perspectives on the Communication for Health project. The stakeholders interviewed are from regional health bureaus (RHB), woreda health offices, local implementing partners (LIPs), and primary health care units (PHCUs). Multiple views were expressed by the key informants on the challenges and successes of the project. A major issue stated by key informants is that the project addressed priority health needs of families in terms of promoting ANC check-ups, health facility deliveries and post-natal care.

Successful in initiating changes in multiple interrelated health behaviors

Several key informants mentioned improvement in adoption of maternal health and other behaviors during the course of the Communication for Health intervention. ““…women are attending antenatal care services, using family planning services, delivering in health facilities and brining their children for immunization better than it was before this project,” a key informant from a primary health care unit (PHCU) said.

Maternal health videos, the radio program, and school health programs implemented at health facilities and schools respectively are identified by some of the project woredas as the most effective approaches in improving gender norms and changing behavior of beneficiaries.


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SBCC focus allows for intensity and integration

The Communication for Health project is an integrated SBCC project and its strategic planning from the beginning focused on how to maintain the intensity of the SBCC intervention and at the same time facilitate integration stated key informant from regional health bureau. The project’s integration strategy identified common influencing factors of behavior and the use of multiple channels from mass media to community engagement, further provided the platform for promoting multiple behaviors.

Innovative SBCC approaches

One of the challenges faced by the Communication for Health project was to develop an SBCC strategy that was attractive to the audience and at the same time addressed behavioral issues associated with the adoption of new healthy behaviors.

A woreda level functionary remarked that the program approaches “are new innovations compared with the traditionally known print materials. As they are entertaining, they are liked by the beneficiaries.” Project activities such as the Erkab radio programs, health bazaars, and maternal health videos were entertaining and liked by beneficiaries. The maternal health videos were particularly praised by all stakeholders. Similarly, the school health programs were viewed as innovative, with the potential to be disseminated in the larger community by using students to promote messages.

The project also contributed to improvements in health service delivery through compassionate and respectful caring, enhanced counseling skills of health workers, and increased capacity. These contributions have improved service quality and reduced

complaints about service delivery from the community. “Group communication through the radio listeners group [Erkab radio] helps implement creating respectful and compassionate health work force. As a result, community complaints on service quality have been addressed,” a key informant from PHCU said.

Capacity strengthening of the health system

The Communication for Health project also reportedly brought about some changes at the health system level. Capacity-building trainings and technical support helped to improve knowledge and attitudes of professionals in the health system. In this regard, the organization capacity assessment conducted by the project was mentioned as among the top achievements of the project. The assessment, as one key informant stated, was helpful in assessing available capacity of the regional health bureau in identifying existing resources for leveraging, and in highlighting the gaps that should be filled to achieve organizational goals. Another key informant noted that “the organization capacity assessment might not have been conducted with such professionalism and scientific approach with the available capacity of the RHB. Hence, the RHB might not have known its available capacity, gaps, and resources, which are necessary to fulfill its mandate to the extent it is expected in the absence of this project.”

Gender participation

The Communication for Health project has been engaging both females and males in the project activities that are deemed relevant to both groups. For the successful implementation of the gender issues as part of this project, gender integration and mainstreaming guidelines were prepared

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and put into practice by the health extension workers and woreda level SBCC experts in all the planned Communication for Health activities. The program team hired a gender specialist all through the project and she ensured that gender messaging was an integral part of program planning.

3.5. Relevance

Improving health service utilization and hence health status through the use of social behavior change communication and strengthening health system capacity are among the pillars of the Health Sector Transformation Plan of Ethiopia.6 The plan specifically identifies the need to enhance evidence-based health education and behavioral change communication as a strategic initiative to improve community participation and engagement. The Communication for Health project is well aligned with major health sector goals and the priorities of the country.

Aligned with health system priorities

In the regions and woredas where Communication for Health is being implemented, project activities were identified and designed in line with the national and local priorities. Relevance was ensured with the identification of targets and activities in each intervention area following organizational capacity assessments, formative and behavioral assessments, and root cause analyses that were conducted through a participatory process.

“All phases of the project, including the root cause analysis and planning, were based on problems at hand. In addition, regular reviews were done based on the routinely generated data and corrective actions taken,” a key

6 Federal Ministry of Health. (2015). Health Sector Transformation Plan 2015/16-2019/20 (2008-2012 EFY).

informant from Woreda Health Office said. According to many stakeholders interviewed during the midline, this approach helped align the project with Health Sector Transformation Plan priorities and the Woreda Transformation Plan while also being responsive to the health needs of primary beneficiaries. In the words of one key informant, “It [the Communication for Health project] is unquestionably relevant, and the activities are aligned with national and local priorities.”

Several study participants mentioned that the formative need assessment undertaken by the project, aligned with the HSTP priorities and the woreda transformation plan (WTP). Since the six health areas covered by the project were already being addressed at the woreda level, it resulted in synergy of health focus with the government program. The ability to contextualize woreda plans according to local needs highlighted the utility of the Communication for Health project according to a key informant from Woreda Health Office.

Generally, most Communication for Health activities were appropriate and relevant for bringing about desired changes in behaviors among target communities. Among the most relevant project activities were the radio listeners’ groups established at the community level, knowledge creation activities in schools, health messaging via mobile application, and radio spots transmitted through regional FM stations.

Improvement in the coordination capacity at different administrative levels was mentioned as another important outcome achieved by Communication for Health. This achievement was made possible through the establishment of the Technical Working Group (TWG), with the


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support of the project. The TWG has enabled synergy and coordinated engagement among stakeholders, and it helps manage existing and emerging challenges. The formation of TWG facilitated institutionalization of SBCC in government structures and systems. Increased coordination among stakeholders also contributed to resource utilization efficiency. As a result of the project, fragmented SBCC activities in government are now better coordinated.

To many stakeholders, the project helped officials and government staff realize that communication is an important means to increase health service utilization and improve health status of the population. The project has played important roles in ensuring that SBCC gets attention from government officials and staff, though there are variations among intervention areas. “Attitudinal change of experts and managers is the bigger outcome for me, as this [SBCC] was the least priority before, which is now got attention,” a Woreda Health Office staff said. Another Woreda Health Office staff said that, “As a result of the project implementation, SBCC activities are now considered among the key issues in every woreda. Before SBCC works were additional assignment for the health extension supervisors. But now, the SBCC officer is getting assigned to work on SBCC issues only. Moreover, SBCC is becoming as one part of the planning, monitoring, and evaluation activities in the woreda.

3.6. Sustainability

Sustainability of components of the Communication for Health project is discussed under the following areas, systems strengthening, coordination, local implementation, technical working groups (TWGs), and risks to sustainability.

System Strengthening

The system strengthening activities of the Communication for Health project from the inception of the project form the basis of sustainability and continuation. These initiatives include the capacity and organizational assessments which identified the gaps in the system. Based on these assessments, capacity strengthening efforts were undertaken.

Mention of sustainability varied by project activity and results. Capacity-building activities that were implemented by the project were considered relatively more sustainable than others. Additionally, the establishment of a TWG to oversee the planning and implementation of project activities in the project woredas was considered a step toward sustainability. The capacity-building trainings given to the focal persons at all levels were helpful in providing the necessary knowledge and skills to implement the planned SBCC activities and sustain some project activities.

“Linkages have been strengthened with the local media, Schools, Women and Children Affairs Offices, and the PHCUs for sustaining project activities. The government has shown high commitment to own and sustain gains, overseeing the implementation and monitoring of the activities of the project in this region.” Key informant from Regional Health Bureau “SBCC activities are now considered among the key issues in every Woreda… SBCC is becoming a part of the planning, monitoring, and evaluation activities in the Woreda.” Key informant from Woreda Health Office.

Coordination with different stakeholder levels

Many key informants agreed that sustainability issues were considered at different stages of the project cycle. Though views varied, stakeholders were involved from the

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design stage to implementation. In specific intervention areas, the government has shown high commitment and ownership of the project, which are vital to sustaining the activities and results. Coordination mechanisms established at different administrative levels for SBCC were considered vital to enhance chances of sustainability. A Regional Health Bureau official said the following:

“The respective stakeholders were engaged throughout the key processes, such as the designing, planning, implementation, and monitoring of the project. The health system is the owner and implementer of this project. The project has been working on creating sense of ownership by the health system and the respective stakeholders through the provision of a series of capacity building trainings, which also contributed to sustenance of project results. Linkages have been created with the local media, schools at local level, women and children affairs offices at different levels, and the PHCUs for sustaining these project activities. The government has shown very high commitment and ownership in sustaining the project and has been leading/overseeing the implementation and monitoring of the activities of this project in this region.”

Designed for local implementation

Responses of key informants showed varying levels of stakeholder engagement from the design to the implementation and monitoring phases. Stakeholders at the regional level indicated that their involvement was relatively high at different stages of the project cycle. There was some regional variation in the level of their involvement. In SNNPR, for example, engagement of government bodies in selecting woredas for Communication for Health intervention, as well as planning and review of the activities in the region, were considered inadequate by some key informants.

Stakeholders in Amhara, Oromia and Tigray regions indicated that their engagement in project activities was high, which they found instrumental in promoting a sense of ownership and commitment among some officials.

Stakeholders at the PHCU level tended to have more measured opinions about the sustainability of the project which they largely attributed to their low-level engagement in the project design.

Technical Working Groups as an institutionalization platform

Technical working groups established at regional and zonal levels were important mechanisms for coordinating project activities between the respective stakeholders. Most key informants agreed that the coordination mechanisms established and used by the project were appropriate to their context. The TWGs were established after the commencement of the Communication for Health project and found to be appropriate, composed of different stakeholders with direct or indirect influence on SBCC activities. These TWGs had regular meetings to discuss the progress of planned activities, challenges, and future plans. Resources were shared, and activities were integrated between the existing partners. “The Communication for Health project was effective in coordinating the implementation and monitoring of the project activities through the TWGs established, which did not exist before the commencement of this project,” a key informant said.

Improved coordination

Coordination mechanisms or linkages that have been created among the different stakeholders at each level were considered sustainable, as one key informant reported:


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“The government structure and system is updated by the project. Once the system is practiced and the benefit at community level is observed, the project would be sustainable. For example, this day there is no need for HDA [the Health Development Army] to make announcements for parent to vaccinate their child, as the parent understood the value and vaccinate their child on time.”

The fact that some project activities are designed so that they can be implemented with local capacity was also supported as a way to ensure sustainability of these activities. “The project is one and only that is being implemented in the region using a scientific communication and behavior change approach, which is feasible to implement with local capacity,” a Regional Health Bureau official said.

Design and distribution of SBCC print materials were considered to be sustainable, as the project has built capacity to do so at different levels. Indeed, many stakeholders found many of the project activities innovative and would like to continue implementing them even after the project ends, as long as they obtain the necessary support in the remaining implementation period. “They [project activities] could be implemented with our own capacity if proper implementation follow-up and final sustainability interventions were implemented to the end,” a Woreda Health Official said.

The maternal health videos that the project introduced were considered to be sustainable in intervention areas where they were distributed. It is important to note that according to some key informants, these videos were not provided to some intervention woredas.

Many other project activities may not be sustainable unless strong measures are taken during the remaining timeline of the

project. One of the less sustainable activities was the radio program. Many stakeholders agreed that it may not be sustainable, as the government lacks the financial capacity to buy airtime. Similarly, though they were considered successful, health bazaars, according to government officials, may not be implemented consistently due to resource and financial constraints.

SBCC materials developed during the project are considered sustainable as they can be continued to be used by the health system. According to some key informants, designing audiovisual materials for health communication requires funding that the government may not be able to afford, and hence development of new materials can be difficult. However, at the same time, stakeholders acknowledged that the project had developed the technical expertise and commitment needed to design such materials. Besides, the fact that the project is distributing some audiovisual materials, such as the maternal health videos, to PHCUs shows that these activities can be sustained with existing messages and materials.

Another activity of the project that may not be sustainable was the mobile application, mainly because “many people do not have appropriate phone [smart or JAVA-installed feature phones], and even those who had the phones were not able to use technology properly. Thus, I doubt its sustainability,” a key informant said. Some stakeholders questioned the relevance of the mobile application. These applications require smart phones or a phone with the JAVA platform, and primary beneficiaries do not often own such phones. The stakeholders recommend a simpler digital strategy that is not dependent on smart phones.

EVALUATION REPORT

38

The findings suggest an uneven implementation of project activities in intervention areas that were partly attributed limited funding. This was also confirmed by some project staff: “…the project priorities were not equally addressed due to various factors. For example, there was no funding for the nutrition project, and hence some of the targets set were not addressed as per the plan.”

One woreda official said that “In some woredas, the maternal health videos were not distributed or implemented, while in others malaria campaigns did not take place…” Differences were also observed in intensity of implementation of some project activities, such as distribution of SBCC materials. Some woredas and PHCUs complained that the project failed to provide them with adequate SBCC materials.

Risks to sustainability

Several challenges and risks to the sustainability of project activities were identified. Although the capacity-building work undertaken at different levels was seen as largely sustainable, high turnover of government staff and officials was identified as a challenge. “If I leave the woreda health office, there will be no one to implement the project,” a woreda officer said.

Many stakeholders agreed that government officials lack adequate ownership of and commitment to SBCC interventions. Ownership and commitment were particularly low at the PHCU level. Some key informants indicated that this situation was partly attributable to their inadequate understanding of the importance of SBCC, which might be due to their limited participation in monitoring and review meetings. Indeed, inadequate follow-up was consistently identified as a risk to sustainability, and it was said to be getting

worse, as local implementing partners are now excluded from project implementation. In the absence of implementing partners, most stakeholders indicated that the project would be unable to implement activities and provide necessary follow-up support.

Many stakeholders identified the lack of permanent structures for SBCC activities as a key challenge to sustainability of project results and activities. In most project areas, there was no dedicated staff or unit for health communication activities, particularly at the zonal and woreda levels. This may also be true at the regional health bureau level. These activities must be managed by the public relations unit at the RHB level in regions such as SNNPR. The experts at this level are not SBCC professionals. They are journalists or public relation experts who may not have adequate SBCC training. According to key informants, despite initiatives to establish a separate unit (i.e., health communication unit) at the regional level, it may take time to become functional.

SBCC activities do not have a dedicated budget. The government gives inadequate attention to SBCC activities. Communication activities are not often among key priorities, and government officials tend to assign competent personnel to other programs. The government also has a shortage of funding to allocate to SBCC activities. One of the key informants was quoted as saying “... there is no permanent staff assigned in majority of the cases, as it is not in their priority to allocate budget, which will definitely affect sustainability.’ Some key informants attributed these challenges to government officials’ inadequate understanding of the impact of SBCC. This could be possible because direct results from communication interventions are not


39

as tangible or observable as those from other programmatic efforts. All of these factors are risks for sustainability once the Communication for Health project is completed.

3.7. Strengths, Facilitating Factors, Weaknesses, and Challenges of the Communication for Health Project

Both internal and external factors have affected the implementation and effectiveness of the Communication for Health project. These factors include strengths and facilitating factors, as well as weaknesses and challenges.

3.7.1. Strengths and facilitating factors

Stakeholders identified the following strengths and enabling factors that facilitated implementation of the Communication for Health project:

• Need-based intervention design and implementation: the participatory and need-based approach of the project was a key strength that was cited by stakeholders across the board. The interventions were designed based on the initial gap assessment and with active involvement of stakeholders in the process. This has helped the project to address the priority needs of target beneficiaries and align them with Health Sector Transformation Plan priorities. The project was implemented in deserving areas, according to stakeholders.

• Responsiveness: the project was said to be responsive to changing circumstances and emerging issues. For instance, it was involved in developing key messages during acute watery diarrhea and scabies outbreaks.

• Focused nature of the project: being a focused intervention was seen as a strength of the project. As such, the project was able to better demonstrate its importance and bring about noticeable changes in the intervention areas. In this regard, a government official said the following: “Actually, other partners were also supporting the region in this regard though it was not a standalone like this project. By virtue of the project’s nature (focused only on SBCC), it brought major changes in the region. That means, I guess the contribution is immense, and we would not be able to achieve these with other programs as such.”

• Enabling policy environment: though this could be improved, there was some evidence of an enabling policy environment for SBCC interventions, which was considered favorable for project implementation.

3.7.2. Weaknesses and challenges

Several weaknesses and challenges were identified as constraints to project implementation and its effectiveness, such as inadequate ownership and commitment of government officials, inadequate budget and resources, lack of dedicated staff and enabling structure, government staff turnover, insecurities and displacements, weak follow-up, illiteracy, and inadequate facilities at service providers. These are briefly described below.

• Inadequate ownership and commitment of government officials: although positive changes have happened, there was a perceived lack of ownership and commitment from government officials. This was partly attributed to inadequate understanding of SBCC and its importance in improving the health status of the population. Some stakeholders also

EVALUATION REPORT

40

associated the government’s inadequate commitment to and ownership of the project and SBCC activities with the fact that the results of SBCC are not as visible and tangible as other intervention areas.

• Inadequate budget and resources: shortage of budget for some specific interventions, such as nutrition, and delays in the release of the annual budget were among the factors that hindered project implementation.

• Lack of dedicated staff and enabling structure: a lack of permanent structure for SBCC was another constraint of the project that could challenge the sustainability of some of its results. The health system in intervention areas lacks SBCC experts at different levels of the administration tier (region, zone, woreda, and PHCU). The project has focal persons, and the TWG established by the project did support and oversee the implementation of the Communication for Health project. In one of the regions, the lack of staff or a focal person dedicated to the SBCC activities, particularly at the zonal level, was identified as the reason behind weak implementation of project activities. A key informant from an RHB explained the problem and offered a recommendation:

… there is no dedicated staff at zonal and woreda levels who will be responsible for managing the Communication for Health project. Therefore, this requires a need to strengthen the existing TWG and assign focal persons at all levels to continue implementing and monitoring the Communication for Health project unless restructuring and filling the structure is possible.

• Government staff turnover: high turnover of government officials and personnel was another challenge to the project

implementation and a threat to its sustainability. In many areas, trained technical staff and officials left their positions, which hampered implementation of planned activities. According to key informants, in the last 3 years of the project period, there was high turnover of staff working in the health system at the regional, woreda, and primary health care unit levels. This turnover affected the project by requiring more trainings and additional time for newly hired staff to familiarize themselves with the project.

• Insecurities and displacements: in some Communication for Health project areas, activities could not be implemented as planned due to various conflicts, insecurities, and displacement of people. In the words of one key informant:

The security situation is now different from the one that existed before three years. Since last year, there were so many ethnic-based conflicts that happened in the regions. As a result of such insecurities, some of the woredas were not accessible, and there were times that the woredas were not having heads of health offices and other staffs too. Therefore, there had been time that the project was not even having a communication with the woredas, and Communication for Health activities were stopped, which might have contributed to the low performance in the planned project.

• Weak follow-up: the project was rated poorly on follow-up of its interventions. It was not possible to closely monitor and evaluate the activities. For example, according to a government official from a regional health bureau, “It did not adequately monitor radio programs.”

As a result of weak follow-up and shortage of materials, some project activities were


41

not implemented as planned. Review meetings also were not conducted uniformly in target woredas. One key informant summarized the problem as follows:

There are some shortages of materials. For example, memory card (for the video) was not enough. The radio program was not implemented at all. Brochures and other printouts were distributed only once. It would have been better if the materials were durable and updated at least yearly. Review meetings are sometimes skipped but I don’t know why, and this should be improved.

• Illiteracy: a low literacy level among target women was a constraint to implementation, specifically for some activities, such as the mobile application. The project tried to mitigate the challenge by advising women to get reading assistance from their children. However, the efficacy of developing mobile applications to serve illiterate women remains untested.

• Inadequate facilities at service providers: lack of availability of some basic equipment in some health facilities hampered implementation. For example, maternal home videos were not implemented in some PHCUs because televisions were not available. According to one PHCU staff member, “The maternity waiting home video has only been used in two PHCUs out of the five in our woreda. This is because the other three PHCUs doesn’t have television. I think TVs need to be given together with the video next time.”

3.8. Innovative Practices and Lessons Learned

The project started from the baseline root cause analysis and organization capacity assessment that accounts for the prevailing challenges in the local context, followed by joint implementation and monitoring of the activities that contributed to the overall capacity improvement of staff. Leaders and experts were involved in the process (particularly during the kickoff time). This process aided in the design of activities based on global best practices, while also gaining the support of government officials. Stakeholders considered this approach of the project as a key lesson learned for future programming.

Project activities such as the maternity home video were found to be very innovative and impactful by government personnel and officials. Similarly, school health programs were also viewed as innovative activities to reach the larger community by using students as a vehicle to reach health messages. Communication for Health promoted strong coordination with the education sector, such that teachers and students conveyed key health messages. This approach was considered to be effective by many stakeholders.

An important lesson learned from the project implementation also relates to the need to engage with policy makers at the federal level to ensure that SBCC gets the necessary attention in government structure and plans. The current government structure does not give the necessary attention to SBCC activities, as they are currently mainly undertaken by focal persons rather than full-time staff. These circumstances, according to many key informants, cannot be addressed by working with regional and local governments alone. Policy makers at the federal level also need to be involved in this process.

EVALUATION REPORT

42

Recommendations


43

The results in this report showcase that the Communication for Health project is moving in the right direction and has made several important gains over the past 3 years. Even in the face of infrastructural weaknesses and political instability, which at times has hindered implementation, there is evidence of improvement. In terms of recommendations, there are specific steps that can be taken by project implementing bodies, government, and donors.

Project Implementers (Johns Hopkins Center for Communication Programs and John Snow, Inc.)

• The results indicate that the intervention was successful in initiating changes in multiple interrelated health behaviors. These findings support the importance of integrated social and behavior change communication (SBCC) programming that addresses a variety of issues associated with improvements in the health of women and children, rather than efforts that work in silos to address specific health promotion and disease prevention topics. There is need for continued support for institutionalization of capacity-building and system-strengthening work at all levels by creating mechanisms that provide sustained access to capacity-building opportunities. Additionally, documenting and disseminating project activities and lessons are important, although caution should be exercised when adding multiple messages into one program to avoid information overload. Hence, the focus should be on interrelated health issues that are integral to building successful SBCC programs. Once a program is well-established, it makes sense for it to take on additional health topics. However, starting

with a variety of discrete health topics in the absence of an enabling environment and funding constraints can run the risk of diluting messages.

• A gender-focused SBCC program built on evidence that equitable gender norms influence health behaviors has shown that the gender is a cross-cutting issue that influences several health behaviors. We recommend that gender-focused SBCC should form the basis for all future development programs in Ethiopia.

• The Communication for Health project has launched its Hulu Beteina App for rural families. We recommend that this digital approach is systematically implemented by ensuring that it is used by primary beneficiaries. The last year of the project should focus on evaluating the efficacy of mobile interventions by using the Hulu Beteina App as a case study.

• Strengthen infrastructure and coordination mechanisms to improve the potential for success of SBCC efforts. More specifically, strengthen the established technical working groups for better coordination and implementation of the activities. In addition, consider using other community-based platforms, such as a one-to-five women development army, houses of religion, schools, and other existing platforms to sustain project activities, particularly in areas where these structures are effective and less politicized.

• Strengthen linkages between the structures at grass-root levels, such as the Health Development Army, schools, and woreda health offices.

• Strengthen the existing system’s capacity to closely follow and monitor implementation of activities at all levels.

EVALUATION REPORT

44

• Enhance engagement of government bodies, including regional health bureau staff and other stakeholders in joint project planning, implementation, and monitoring, so as to facilitate learning and ownership. It is also vital to strengthen joint project follow-up and review with active participation of stakeholders at all levels, including woreda cabinets.

• Engage in advocacy activities targeting officials at the regional and federal levels to ensure that SBCC gets the necessary attention in the health structure and systems and that it receives adequate ownership and commitment from senior officials at the local, regional, and national levels.

• Ensure that project support mechanisms are accessible to intervention areas by expanding project staff presence and continuing to engage local implementing partners.

• Design exit strategies considering the findings of this study and through additional consultations. Implement them as early as possible to facilitate the successful handover of the SBCC activities to government bodies.

• Strengthen and build the capacity of the SBCC focal persons and experts, particularly at the primary health care unit and woreda levels through the provision of refresher trainings and technical support.

• Conduct operations research to explore why some desired outcomes (e.g., use of modern contraceptives) have declined in some regions, such as Amhara and Southern Nations, Nationalities, and People’s Region.

Government

• Staff turnover is a key challenge for the implementation and long-term sustainability of project activities and results. The government needs to exert greater effort to reduce turnover of officials and experts while also looking for ways to institutionalize capacity and coordination mechanisms that are created or strengthened with the support of the project.

• The government needs to demonstrate its commitment to SBCC by providing permanent positions in its structure at all levels, so as to ensure that SBCC has designated personnel that are vital to sustain those activities started with the support of the project.

Donor

• Ensure that the project is funded as planned originally, so as to allow uniform implementation of project interventions across intervention areas and retain local implementing partners, which are vital for sustainability of many project activities and results.


45

APPENDIX

ANNEXES: MID-TERM EVALUATION OF THE COMMUNICATION FOR HEALTH PROJECT IN ETHIOPIA

47

5.

APP

END

IX

Anne

x 1:

Proj

ect

Achi

evem

ent

Sum

mar

y

i.

Ach

ieve

men

ts A

gai

nst

Mid

line

Tar

get

s

Pro

ject

goal

: To

incr

ease

kn

owle

dg

e an

d h

ealt

h p

ract

ices

of

ind

ivid

ual

s an

d c

om

mu

nit

ies,

wh

ile s

up

po

rtin

g s

yste

ms

to im

pro

ve t

he

qu

alit

y,

capa

city

, an

d c

oo

rdin

atio

n o

f so

cial

an

d b

ehav

ior

chan

ge

com

mu

nic

atio

n

Obje

ctiv

es a

nd I

ndic

ator

sB

asel

ine

(%)

Mid

line

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(%

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ear

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get

(%

)P

rogre

ss t

o

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e (%

)Tar

get

A

chie

vem

ent

(%)

Rep

roduct

ive,

mat

ernal

, neo

nat

al, an

d c

hild h

ealt

h

Con

trac

epti

ve p

reva

lence

(cu

rren

t use

of

mod

ern f

amily p

lannin

g)

47.

55

1.15

4.6

42

.68

3.0

Wom

en a

tten

din

g a

nte

nat

al c

are

in f

irst

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eeks

of p

regnan

cy29

.731

.93

4.2

34

.210

7.0

Wom

en a

tten

din

g a

t le

ast

four

ante

nat

al c

are

visi

ts

42

.54

5.7

48

.94

1.59

1.0

Inst

ituti

onal

del

iver

y4

3.1

46

.34

9.6

48

.110

4.0

Del

iver

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atte

nded

by s

kille

d h

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nnel

58

.56

2.9

67.

35

9.8

95

.0

Wom

en a

ged

15–4

9 w

ho

bel

ieve

thei

r use

of

mod

ern c

ontr

acep

tive

m

ethod

s im

pro

ved t

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qual

ity o

f fa

mily lif

e8

8.2

94

.810

0.0

87.

29

2.0

Wom

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ged

15–4

9 w

ho

know

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ow=

39.2

36.3

33.3

44

.578

.0

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ate=

45

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feel

that

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can

att

end a

nte

nat

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are

at lea

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tim

es

duri

ng p

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cy9

3.3

100

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92

.39

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ho

bel

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EVALUATION REPORT

48

Obje

ctiv

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nd I

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(%)

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chie

vem

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(%)

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itio

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ly init

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on o

f bre

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6 m

onth

s6

7.5

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.59

4.0

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en w

ith c

hildre

n a

ged

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onth

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that

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ld

hav

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lea

st f

our

food

gro

ups

a day

9

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100

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.39

8.3

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en w

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to

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to

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75.4

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aria

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t w

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who

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174

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6.0

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67.

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s ag

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d w

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s nig

ht

38.4

b

41.

34

4.2

55

.413

4.0

Childre

n u

nder

5 y

ears

old

who

sought

trea

tmen

t w

ithin

pas

t 24 h

ours

fo

r fe

ver

45

.24

8.6

52

.04

4.1

91.0

Wom

en a

ged

15–4

9 w

ho

feel

they

can

tak

e th

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child t

o tr

eatm

ent

wit

hin

24 h

ours

of

feve

r on

set

89

.99

6.6

100

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2.0

95

.0

Pre

gnan

t w

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who

feel

they

are

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e th

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childre

n u

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.0

Wom

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ith c

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will

pre

vent

mal

aria

9

4.5

100

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4.2

Pre

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t w

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will

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92

.510

0.0

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wit

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(an

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per

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who

stay

ed

in t

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d las

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29.6

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49

Obje

ctiv

es a

nd I

ndic

ator

sB

asel

ine

(%)

Mid

line

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get

(%

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ear

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chie

vem

ent

(%)

Wat

er, sa

nit

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n, an

d h

ygie

ne

(WA

SH

)

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wit

h s

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nd w

ater

han

dw

ashin

g s

tati

on

13.2

14.2

15.2

19.3

136

.0

Res

pon

den

ts w

ith c

ompre

hen

sive

know

ledge

on h

andw

ashin

g (know

all

key

tim

es)

14.3

15.4

16.5

26.7

174

.0

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that

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ctic

e han

dw

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g w

ith s

oap a

t cr

itic

al t

imes

62

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6.9

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65

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7.0

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sehol

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that

fee

l th

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ice

pro

per

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dw

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94

.210

0.0

100

.09

2.1

92

.1

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sehol

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that

bel

ieve

pro

per

han

dw

ashin

g p

reve

nts

dis

ease

s su

ch a

s dia

rrhea

98

.010

0.0

100

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Not

e:

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IN=

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g-l

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ctic

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net

. Ave

rag

e n

um

ber

of

net

s an

d L

LIN

s p

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selin

e 1.

3, m

idlin

e 2

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Sour

ce:

a HM

IS. b M

IS (

2015

).

EVALUATION REPORT

50

ii.

Ach

ieve

men

ts A

gai

nst

Tar

get

s: E

xpos

ed V

ersu

s N

onex

pos

ed R

esponden

ts

Pro

ject

goal

: To

incr

ease

kn

owle

dg

e an

d h

ealt

h p

ract

ices

of

ind

ivid

ual

s an

d c

om

mu

nit

ies

wh

ile s

up

po

rtin

g s

yste

ms

to im

pro

ve t

he

qu

alit

y,

capa

city

, an

d c

oo

rdin

atio

n o

f so

cial

an

d b

ehav

ior

chan

ge

com

mu

nic

atio

n

Obje

ctiv

es a

nd I

ndic

ator

sB

asel

ine

(%)

Mid

line

Tar

get

(%

)M

idline

Expos

ed a

nd

Non

expos

ed (%)

Mid

line

Expos

ed (%)

Mid

line

Non

expos

ed (%)

Rep

roduct

ive,

mat

ernal

, neo

nat

al, an

d c

hild h

ealt

h

Con

trac

epti

ve p

reva

lence

(cu

rren

t use

of

mod

ern f

amily p

lannin

g

met

hod

)4

7.5

51.1

42

.64

5.9

33.2

Wom

en a

tten

din

g a

t le

ast

four

ante

nat

al c

are

visi

ts4

2.5

45

.74

1.54

8.0

32.0

Inst

ituti

onal

del

iver

y4

3.3

56

.64

8.1

54

.438

.9

Del

iver

ies

atte

nded

by s

kille

d h

ealt

h p

erso

nnel

58

.56

2.9

59

.87

1.85

6.2

Wom

en a

ged

15–4

9 w

ho

bel

ieve

thei

r use

of

mod

ern c

ontr

acep

tive

m

ethod

s im

pro

ved t

he

qual

ity o

f fa

mily lif

e8

8.2

94

.88

7.2

89

.878

.8

Wom

en a

ged

15–4

9 w

ho

know

dan

ger

sig

ns

duri

ng p

regnan

cyL

ow=

39.2

36.3

44

.54

1.54

8.9

Mo

der

ate=

45

.04

8.4

39.0

42

.43

4.0

Hig

h=

15.8

17.0

16.5

16.1

17.0

Wom

en w

ho

feel

that

they

can

att

end a

nte

nat

al c

are

at lea

st f

our

tim

es

duri

ng t

hei

r pre

gnan

cy9

3.3

100

.09

2.3

92

.29

2.5

Wom

en w

ho

bel

ieve

that

at

leas

t fo

ur

ante

nat

al c

are

visi

ts d

uri

ng

pre

gnan

cy w

ill le

ad t

o goo

d b

irth

outc

omes

97.

610

0.0

95

.19

7.4

91.8

HIV

tes

t at

rec

ent

pre

gnan

cy5

0.4

54

.25

7.5

67.

34

3.0

Nutr

itio

n

Wom

en w

ho

pra

ctic

ed e

arly

init

iati

on o

f bre

astf

eedin

g in f

irst

6 m

onth

s6

7.5

72.6

68

.572

.86

2.0

Wom

en w

ith c

hildre

n a

ged

6–2

3 m

onth

s w

ho

know

that

childre

n s

hou

ld

hav

e at

lea

st f

our

food

gro

ups

a day

9

9.0

100

.09

8.3

97.

79

9.2

Wom

en w

ith c

hildre

n a

ged

6–2

3 m

onth

s w

ho

bel

ieve

that

excl

usi

ve

bre

astf

eedin

g w

ill en

han

ce c

hild s

urv

ival

98

.210

0.0

97.

49

7.5

97.

3


51

Obje

ctiv

es a

nd I

ndic

ator

sB

asel

ine

(%)

Mid

line

Tar

get

(%

)M

idline

Expos

ed a

nd

Non

expos

ed (%)

Mid

line

Expos

ed (%)

Mid

line

Non

expos

ed (%)

Tuber

culo

sis

(TB

)

All f

orm

s of

pre

sum

pti

ve T

B r

efer

red b

y h

ealt

h e

xte

nsi

on w

orker

for

T

B d

iagnos

is

59

.0a

63.

4-

--

Pro

por

tion

of

the

pop

ula

tion

that

rec

ogniz

e key

sym

pto

ms

14.7

15.8

22.5

26.7

15.8

Pro

por

tion

of

the

pop

ula

tion

that

fee

l th

ey a

re a

ble

to

get

im

med

iate

sc

reen

ing o

n s

usp

ecti

ng T

B

76.2

81.9

66

.173

.45

4.3

Pro

por

tion

of

the

pop

ula

tion

that

bel

ieve

ear

ly s

cree

nin

g o

f TB

lea

ds

to

full r

ecov

ery

75.4

81.1

62

.170

.14

9.5

Mal

aria

Pre

gnan

t w

omen

who

slep

t under

LLIN

s th

e pre

viou

s nig

ht

54

.95

9.2

74.5

75.3

73.2

Childre

n u

nder

5 w

ho

slep

t under

LLIN

s th

e pre

viou

s nig

ht

67.

372

.45

9.3

68

.26

7.3

Adult

s ag

ed 3

5–4

9 w

ho

slep

t under

LLIN

s th

e pre

viou

s nig

ht

43.

0b

46

.25

8.5

61.2

50

.9

Pro

por

tion

of

the

pop

ula

tion

that

sle

pt

under

LLIN

s th

e pre

viou

s nig

ht

38.4

b4

1.3

55

.45

8.0

47.

3

Childre

n u

nder

5 w

ho

had

tre

atm

ent

wit

hin

24 h

ours

of

fever

45

.24

8.6

44

.14

9.8

33.5

Wom

en a

ged

15–4

9 w

ho

feel

they

can

tak

e th

eir

child t

o tr

eatm

ent

wit

hin

24 h

ours

of

feve

r8

9.9

96

.69

2.0

92

.89

0.3

Pre

gnan

t w

omen

who

feel

they

are

able

to

hav

e th

eir

childre

n u

nder

5

slee

p u

nder

an L

LIN

eac

h n

ight

75.4

81.1

86

.18

5.6

87.

4

Wom

en w

ith c

hildre

n u

nder

5 w

ho

bel

ieve

that

sle

epin

g u

nder

an L

LIN

ea

ch n

ight

will pre

vent

mal

aria

94

.510

0.0

94

.29

5.8

93.

8

Pre

gnan

t w

omen

aged

15–4

9 w

ho

bel

ieve

that

sle

epin

g u

nder

an L

LIN

ea

ch n

ight

will pre

vent

mal

aria

92

.510

0.0

95

.29

8.6

87.

4

Hou

sehol

ds

wit

h a

t le

ast

one

mos

quit

o net

65

.870

.74

7.5

50

.34

1.7

Hou

sehol

ds

wit

h a

t le

ast

one

net

(an

y t

ype)

per

tw

o per

sons

who

stay

ed

in t

he

hou

sehol

d las

t nig

ht

29.6

b31

.832

.232

.7*

28.9

EVALUATION REPORT

52

Obje

ctiv

es a

nd I

ndic

ator

sB

asel

ine

(%)

Mid

line

Tar

get

(%

)M

idline

Expos

ed a

nd

Non

expos

ed (%)

Mid

line

Expos

ed (%)

Mid

line

Non

expos

ed (%)

Wat

er, sa

nit

atio

n, an

d h

ygie

ne

(WA

SH

)

Hou

sehol

ds

wit

h h

andw

ashin

g s

tati

on w

ith s

oap a

nd w

ater

13.2

14.2

19.3

19.0

13.2

Res

pon

den

ts w

ith c

ompre

hen

sive

know

ledge

on h

andw

ashin

g (know

s al

l key

tim

es)

14.3

15.4

26.7

27.2

27.8

Hou

sehol

ds

that

pra

ctic

e han

dw

ashin

g w

ith s

oap a

t cr

itic

al t

imes

62

.26

6.9

65

.16

6.4

63.

6

Hou

sehol

ds

that

rep

ort

pro

per

han

dw

ashin

g

94

.210

0.0

92

.19

3.6

90

.3

Hou

sehol

ds

that

bel

ieve

pro

per

han

dw

ashin

g p

reve

nts

dis

ease

s su

ch a

s dia

rrhea

98

.010

0.0

97.

89

8.4

96

.7

Not

e:

LL

IN=

lon

g-l

asti

ng

inse

ctic

idal

net

. Ave

rag

e n

um

ber

of

net

s p

er h

ou

seh

old

at

base

line

1.3

; at

mid

line

2.1

Sour

ce: a H

MIS

. b MIS

(20

15).

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.


53

Annex 2: Media Exposure Computation

Family Health Guide %a

Not heard of 52.2

Heard of, do not have 27.2

Have, never use 5.9

Have, rarely use 5.1

Have, sometimes use 7.7

Have, often use 1.5

Have, always use 0.3

Family Health Guide exposure, dichotomous

No 52.2

Yes 47.8

Radio program, among those who have access to radio (N=302)

No 95.7

Yes 4.3

Community meetings

0 72.3

1 15.2

2 4.8

3 3.5

4 2.5

5 0.6

6 0.8

7 0.2

Community meetings, dichotomized

No 72.3

Yes 27.7

Mobile app

No 98.9

Yes 1.1

Print

No 93.4

Yes 6.6

Video

No 97.0

Yes 3.0

EVALUATION REPORT

54

Direct exposure, additive index

0 36.9

1 27.8

2 10.7

3 6.2

4 9.3

5 3.4

6 2.2

7 1.3

8 0.7

9 0.6

10 0.3

11 0.3

12 0.3

13 0.1

14 0.1

Direct exposure levels

None 36.9

1–2 38.5

≥3 24.7

Interpersonal communication

Spouse 37.8

Family 23.0

Neighbors 24.1

Total reporting of interpersonal communication along socio-ecologic model 45.3

Interpersonal communication

Family planning 33.2

Antenatal care 21.4

Delivery 19.6

Postnatal care 16.6

Child care 30.9

Malaria 20.6

Tuberculosis 13.4

Prevention of mother-to-child transmission 16.3

Total reporting of interpersonal communication across topics 46.9

Direct exposure and interpersonal communication

None 25.0

Interpersonal communication only 29.7

Direct exposure only 11.9

Both direct exposure and interpersonal communication 33.4

aPercentages are based on N=1,773, except where noted.


55

Anne

x 3:

De

mog

raph

ic C

hara

cter

isti

cs o

f Sur

vey

Resp

onde

nts

Dem

ogra

phic

Char

acte

rist

ic

Bas

elin

eM

idte

rm

Tota

l N

=2

,770

Am

har

a N

=674

Oro

mia

N

=6

88

SN

NP

R

N=76

0Tig

ray

N=6

48

Tota

l N

=1,

773

Am

har

a N

=4

16O

rom

ia

N=4

48

SN

NP

R

N=4

48

Tig

ray

N=4

61

Age

of p

arti

cipan

t

15–2

49

33a

(35

%)

202

a

(31%

)23

0a,

b

(33%

)29

6b

(40

%)

205

a

(32

%)

473

b

(26

%)

105

a

(26

%)

135

a

(29

%)

101a

(22

%)

132

a

(30

%)

25–3

49

99

a

(36

%)

263

a

(38

%)

256

a

(37%

)25

0a

(32

%)

230

a

(36

%)

64

2a

(38

%)

147

a

(36

%)

150

a

(34

%)

198

b

(44

%)

147

a

(31%

)

35–4

98

38a

(30

%)

209

a

(31%

)20

2a

(30

%)

214

a

(28

%)

213

a

(32

%)

65

8b

(36

%)

164

a

(38

%)

163

a

(37%

)14

9a

(33%

)18

2a

(38

%)

Type

of p

arti

cipan

t

Curr

entl

y p

regnan

t23

5a

(8%

)39

a

(6%

)8

0b

(12

%)

60

a,b

(8%

)5

6a,

b

(8%

)14

8a

(8%

)33

a

(8%

)4

2a

(9%

)36

a

(8%

)37

a

(8%

)

Wit

h c

hild u

nder

2 y

ears

old

724

a

(25

%)

172

a

(26

%)

170

a

(25

%)

192

a

(24

%)

190

a

(29

%)

45

4a

(25

%)

110

a,b

(26

%)

134

a

(30

%)

89

b

(18

%)

121a,

b (2

7%)

Wit

h c

hild 3

–5 y

ears

old

64

3a

(23%

)15

8a,

b

(23%

)18

4a

(26

%)

151b

(20

%)

150

a,b

(23%

)36

4b

(20

%)

79a

(19

%)

83

a

(19

%)

96

a

(22

%)

106

a

(23%

)

Oth

er w

omen

aged

15–4

9 y

ears

1,16

8a

(43%

)30

5a,

c

(45

%)

254

b

(37%

)35

7a

(48

%)

252

b,c

(39

%)

80

7b

(46

%)

194

a

(46

%)

189

a

(42

%)

227

a

(51%

)19

7a

(43%

)

Educa

tion

No

form

al e

duca

tion

1,637

a

(58

%)

414

a

(63%

)4

81b

(72

%)

321c

(40

%)

42

1a,b

(65

%)

1,09

6a

(62

%)

283

a

(67%

)30

7a

(69

%)

226

b

(50

%)

280

a

(63%

)

Pri

mar

y

86

3a

(32

%)

191a

(28

%)

168

a

(23%

)3

44

b

(47%

)16

0a

(25

%)

516

a

(29

%)

96

a

(23%

)12

3a

(27%

)17

3b

(38

%)

124

a

(25

%)

Sec

ondar

y o

r hig

her

270

a

(9%

)6

9a

(10

%)

39b

(5%

)9

5a

(13%

)6

7a

(10

%)

161a

(9%

)37

a

(10

%)

18b

(4%

)4

9a

(12

%)

57

a

(12

%)

Rel

igio

n

Chri

stia

n (O

rthod

ox, P

rote

stan

t,

Cat

hol

ic, et

c.)

1,94

4a

(68

%)

439

a

(70

%)

214

b

(34

%)

68

7c

(94

%)

60

4c

(93%

)13

68

b

(78

%)

416

(1

00

%)

143

a

(39

%)

376

b

(90

%)

433

c

(93%

)

Musl

im8

26a

(32

%)

235

a

(30

%)

474

b

(66

%)

73c

(6%

)4

4c

(7%

)4

05

b

(22

%)

- (0%

)30

5a

(61%

)72

b

(10

%)

28c

(7%

)

EVALUATION REPORT

56

Dem

ogra

phic

Char

acte

rist

ic

Bas

elin

eM

idte

rm

Tota

l N

=2

,770

Am

har

a N

=674

Oro

mia

N

=6

88

SN

NP

R

N=76

0Tig

ray

N=6

48

Tota

l N

=1,

773

Am

har

a N

=4

16O

rom

ia

N=4

48

SN

NP

R

N=4

48

Tig

ray

N=4

61

Inco

me

(mon

thly

)

Low

(<500 b

irr)

90

7a

(37%

)10

1a

(18

%)

289

b

(49

%)

315

b

(44

%)

202

c

(33%

)6

23b

(4

6%

)8

3a

(24

%)

207

b

(61%

)28

2b

(65

%)

51c

(12

%)

Mid

dle

(501–1

,300 b

irr)

e8

36a

(33%

)31

2a

(50

%)

135

b

(21%

)18

9b

(27%

)20

0c

(35

%)

50

8a

(28

%)

153

a

(40

%)

59

b

(16

%)

100

b

(23%

)19

6a

(46

%)

Hig

h (>1

,300 b

irr)

792

a

(30

%)

210

a

(31%

)18

6a

(30

%)

206

a

(29

%)

190

a

(33%

)4

22b

(25

%)

125

a

(37%

)77

b

(23%

)6

2c

(13%

)15

8a

(42

%)

Mar

ital

sta

tus

Mar

ried

, co

hab

itat

ing

2,0

59

a

(74

%)

515

a

(76

%)

56

6b

(81%

)5

11c

(66

%)

46

7a,

c

(72

%)

1,36

8b

(79

%)

329

a,b

(79

%)

361a

(80

%)

351a,

b

(78

%)

327

b

(71%

)

Div

orce

d, w

idow

ed, si

ngle

711

a

(26

%)

159

a

(24

%)

122

b

(19

%)

249

c

(34

%)

181a,

c

(28

%)

396

b

(21%

)8

6a,

b

(21%

)8

6a

(20

%)

97

a,b

(22

%)

127

b

(29

%)

Vuln

erab

ilit

y Index

e

Low

(not

vuln

erab

le)

1,176

a

(49

%)

314

a

(49

%)

384

b

(57%

)25

6c

(42

%)

222

c

(43%

)1,0

01b

(54

%)

215

a

(52

%)

288

b

(62

%)

182

c

(42

%)

316

b

(71%

)

Mod

erat

e (v

uln

erab

le)

706

a

(29

%)

168

a

(28

%)

167

a

(27%

)20

4a

(32

%)

167

a

(31%

)4

55

b

(28

%)

116

a

(31%

)10

4a

(24

%)

126

a

(29

%)

109

a

(22

%)

Hig

h (hig

hly

vuln

erab

le)

55

2a

(22

%)

130

a

(23%

)9

8b

(16

%)

183

c

(27%

)14

1a,c

(25

%)

284

b

(19

%)

69

a

(17%

)5

1a,c

(14

%)

132

b

(29

%)

32c

(7%

)

Sta

ndar

d o

f Liv

ing Index

e

Low

1,03

4a

(38

%)

296

a

(49

%)

198

b

(33%

)17

6b

(26

%)

364

c

(68

%)

829

b

(45

%)

233

a

(55

%)

215

b

(52

%)

102

c

(23%

)27

9a

(59

%)

Mod

erat

e8

60

a

(37%

)24

8a

(39

%)

220

a

(34

%)

253

a

(40

%)

139

b

(26

%)

55

9b

(32

%)

114

a

(30

%)

129

a

(28

%)

170

b

(40

%)

146

a,b

(33%

)

Hig

h5

40

a

(25

%)

68

a

(12

%)

231b

(32

%)

214

b

(34

%)

27c

(6%

)35

1a

(23%

)5

3a

(14

%)

99

b

(20

%)

168

c

(38

%)

31d

(8%

)

Not

es:

SN

NP

R=

So

uth

ern

Nat

ion

s, N

atio

nal

itie

s, a

nd

Peo

ple

’s R

egio

n.

Sour

ce:

a Dat

a so

urc

e m

erg

ed S

PS

S d

atas

et. b W

eig

hte

d p

erce

nta

ges

. c Val

ues

in t

he

sam

e ro

w a

nd

su

bta

ble

no

t sh

arin

g t

he

sam

e su

bscr

ipt

are

sig

nif

ican

tly

dif

fere

nt

at p

<.0

5. d T

est

of s

ign

ific

ance

(tw

o-w

ay).

Acr

oss

reg

ion

s w

ith

in t

he

sam

e T

ER

M a

nd

bet

wee

n b

asel

ine

and

mid

term

val

ues

fo

r “T

ota

l” c

olu

mn

. e Val

ues

at

base

line

are

dif

fere

nt

fro

m t

ho

se r

epo

rted

in t

he

base

line

rep

ort

do

cum

ent

(du

mm

y ta

ble

s). f T

he

vuln

erab

ility

ind

ex w

as c

on

stru

cted

usi

ng

th

e fo

llow

ing

fo

ur

item

s: la

cked

en

ou

gh

fo

od

to

eat

, lac

ked

sh

elte

r/h

ou

se t

o s

tay

in, n

ot

able

to

aff

ord

to

sen

d c

hild

ren

sch

oo

l, an

d la

cked

mo

ney

to

bu

y m

edic

ines

/

med

ical

tre

atm

ent

(exp

erie

nce

d b

y th

e pa

rtic

ipan

t in

th

e pa

st 1

2 m

on

ths)

. Low

≤4; M

od

erat

e=5

–7; a

nd

Hig

h=

8–1

2. g T

he

stan

dar

d o

f liv

ing

ind

ex w

as c

on

stru

cted

fro

m h

ou

seh

old

ow

ner

ship

of

the

follo

win

g it

ems:

elec

tric

ity,

wo

rkin

g r

adio

, wo

rkin

g t

elev

isio

n, n

on

mo

bile

tel

eph

on

e, m

ob

ile t

elep

ho

ne,

iro

n, r

efri

ger

ato

r, ta

ble

, ch

air,

bed

wit

h c

ott

on

/sp

on

ge/

spri

ng

mat

tres

s, f

lush

/po

ur

flu

sh t

oile

t, p

it la

trin

e, a

nd

fo

ur

item

s of

the

vuln

erab

ility

ind

ex. L

ow≤6

; Mo

der

ate=

7–8

; an

d H

igh≥9

.


57

Anne

x 4:

An

tena

tal c

are

prac

tice

, kno

wle

dge,

sel

f-ef

ficac

y, a

nd o

utco

me

expe

ctan

cy a

mon

g w

omen

wit

h ch

ildre

n un

der

2 ye

ars

old,

by

regi

on, m

idlin

e su

rvey

(Ap

ril 2

019)

(pe

rcen

tage

s)

Char

acte

rist

ic

Am

har

aO

rom

iaS

NN

PR

Tig

ray

Bas

elin

e N

=17

7M

idline

N=11

4B

asel

ine

N=17

6M

idline

N=14

7B

asel

ine

N=17

7M

idline

N=11

4B

asel

ine

N=17

6M

idline

N=14

7

Num

ber

of

ante

nat

al c

are

upta

kes

None

23.1

18.0

39.6

53.

417

.38

.39

.24

.0

1–3

31

.732

.731

.824

.030

.13

4.1

44

.839

.9

≥44

5.2

49

.328

.622

.65

2.6

57.

54

6.0

56

.0

Wom

en w

ho

Had

ante

nat

al c

are

duri

ng f

irst

12 w

eeks

of p

regnan

cy

33.1

52

.4*

30.4

48

.1**2

1.94

3.5

***

44

.538

.4

Know

the

right

num

ber

of

ante

nat

al c

are

visi

ts t

hat

a

pre

gnan

t w

oman

shou

ld h

ave

≥46

8.5

75.6

59

.65

5.5

84

.273

.7*

78.8

86

.3

Know

it

is im

por

tant

for

pre

gnan

t w

omen

to

hav

e at

le

ast

one

ante

nat

al c

are

visi

t w

ith a

skille

d p

rovi

der

(K

now

ledge)

Moder

ate/

Hig

h9

9.5

92

.0**

*9

9.0

98

.29

5.7

92

.39

4.6

92

.6

Know

att

endin

g a

nte

nat

al c

are

at lea

st 4

tim

es d

uri

ng

pre

gnan

cy b

egin

nin

g in t

he

firs

t tr

imes

ter

is p

ossi

ble

(S

elf-

effi

cacy

)M

oder

ate/

Hig

h9

5.4

89

.79

2.4

96

.99

1.29

3.4

96

.578

.1***

Know

that

pre

gnan

t w

omen

who

visi

t an

tenat

al c

are

at

leas

t fo

ur

tim

es d

uri

ng p

regnan

cy w

ill hav

e bet

ter

bir

th

outc

omes

(O

utc

ome

expec

tancy

)M

oder

ate/

Hig

h9

9.4

91.2

***

95

.49

7.2

98

.29

6.4

96

.19

9.2

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.

EVALUATION REPORT

58

Anne

x 5:

An

tena

tal c

are

prac

tice

, kno

wle

dge,

sel

f-ef

ficac

y, a

nd o

utco

me

expe

ctan

cy a

mon

g w

omen

wit

h ch

ildre

n un

der

2 ye

ars

old,

by

age,

ed

ucat

ion

and

vuln

erab

ility

, mid

line

surv

ey (

Apri

l 201

9) (

perc

enta

ges)

Char

acte

rist

ic

Age

Educa

tion

V

uln

erab

ilit

y

15–2

4

N=10

32

5–3

4

N=2

61

35

–49

N

=11

7N

one

N=3

07

Pri

mar

y

N=14

1

Sec

ondar

y

or

abov

e N

=3

3

Not

vuln

erab

le

N=2

70

Vuln

erab

le

N=13

4

Hig

hly

vuln

erab

le

N=67

Ante

nat

al c

are

visi

ts0

25.8

25.6

36.6

35.9

***

13.3

17.9

23.5

**37

.331

.9

1–3

32.9

31.5

25.0

30.5

32.6

17.6

25.2

30.7

41.1

≥44

1.3

42

.938

.433

.65

4.1

64

.55

1.3

32.0

27.1

Ear

ly init

iati

on o

f an

tenat

al c

are

≤12

wee

ks5

4.3

47.

84

0.4

47.

94

6.9

48

.84

5.8

46

.05

5.5

Know

ledge

on t

he

right

num

ber

of

ante

nat

al c

are

visi

ts t

hat

a p

regnan

t w

oman

shou

ld h

ave

≥46

9.2

69

.06

6.4

62

.479

.679

.775

.96

0.6

64

.1

It is

impor

tant

for

pre

gnan

t w

omen

to

hav

e at

lea

st o

ne

ante

nat

al c

are

visi

t w

ith

a sk

ille

d p

rovi

der

(K

now

ledge)

Moder

ate/

hig

h9

3.4

95

.79

2.7

94

.4*

94

.69

4.4

96

.0*

93.

59

2.2

Att

endin

g a

nte

nat

al c

are

at lea

st f

our

tim

es b

egin

nin

g in t

he

firs

t tr

imes

ter

is

pos

sible

(S

elf-

effi

cacy

)M

oder

ate/

hig

h9

2.8

92

.99

0.6

92

.99

3.1

83.

99

2.3

93.

09

2.2

Pre

gnan

t w

omen

who

rece

ive

ante

nat

al

care

at

leas

t fo

ur

tim

es w

ill hav

e bet

ter

bir

th o

utc

omes

(O

utc

ome

expec

tancy

)M

oder

ate/

hig

h9

3.1

95

.89

5.4

95

.59

4.4

95

.09

5.6

97.

19

1.3

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.


59

Anne

x 6:

In

stit

utio

nal d

eliv

ery,

pos

tnat

al c

are

prac

tice

, kno

wle

dge,

sel

f-ef

ficac

y, a

nd o

utco

me

expe

ctan

cy a

mon

g w

omen

wit

h ch

ildre

n un

der

2 ye

ars

old,

by

regi

on, m

idlin

e su

rvey

(Ap

ril 2

019)

(pe

rcen

tage

s)

Char

acte

rist

ic

Am

har

aO

rom

iaS

NN

PR

Tig

ray

Bas

elin

e

N=17

7M

idline

N

=11

4B

asel

ine

N=17

6M

idline

N

=14

7B

asel

ine

N=19

6M

idline

N

=9

5B

asel

ine

N=19

6M

idline

N

=12

5

Inst

ituti

onal

del

iver

yYes

49

.15

8.4

27.8

19.6

50

.57

1.8**

*5

1.979

.0**

*

Hea

lth/va

ccin

atio

n c

ard w

ith d

ate

reco

rded

Yes

63.

772

.430

.737

.97

1.3

76.0

72.8

89

.1***

Pos

tnat

al c

are

wit

hin

7 d

ays

afte

r del

iver

yN

o

72.0

57.

48

3.0

79.3

65

.33

4.2

56

.130

.3

Yes

28.0

42

.617

.020

.7*

34

.76

5.8

***

43.

96

9.7

***

Know

ledge

on p

regnan

cy d

anger

sig

ns

Low

42

.2**

*4

7.3

31.9

49

.54

1.139

.24

8.9

***

20.2

Med

ium

49

.74

0.6

41.7

32.1

43.

54

3.5

43.

85

4.7

Hig

h8

.112

.126

.418

.415

.417

.37.

325

.0

Tim

e of

fir

st c

hec

kup a

fter

del

iver

y f

or p

ostn

atal

car

eW

ithin

2 d

ays

5.3

40

.6**

*5

.918

.1***

4.7

48

.6**

*5

.66

1.3

***

Wit

hin

7 d

ays

22.7

42

.6**

*11

.120

.8**

*30

.16

5.8

***

38.3

69

.8**

*

≥8 d

ays

afte

r11

.011

.3**

*13

.76

.4**

*19

.08

.6**

*13

.711

.7**

*

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.

EVALUATION REPORT

60

Anne

x 7:

In

stit

utio

nal d

eliv

ery,

pos

tnat

al c

are,

kno

wle

dge,

sel

f-ef

ficac

y, a

nd o

utco

me

expe

ctan

cy a

mon

g w

omen

wit

h ch

ildre

n un

der

2 ye

ars

old,

by

age,

edu

cati

on, a

nd v

ulne

rabi

lity,

mid

line

surv

ey (

Apri

l 201

9) (

perc

enta

ges)

Char

acte

rist

ic

Age

Educa

tion

V

uln

erab

ilit

y Index

15–2

4

N=

103

25–3

4

N=

261

35–4

9

N=

117

No

ne

N=

307

Pri

mar

y

N=

141

Sec

on

dar

y

or

abov

e

N=

33

No

t

vuln

erab

le

N=

270

Vu

lner

able

N=

134

Hig

hly

vuln

erab

le

N=

67

Inst

ituti

onal

del

iver

y5

6.4

45

.64

6.4

37.7

***

64

.778

.35

2.6

**4

2.0

37.3

Hea

lth/va

ccin

atio

n c

ard w

ith d

ate

reco

rded

66

.36

2.8

53.

95

9.1

62

.279

.26

5.3

57.

25

3.6

Pos

tnat

al c

are

wit

hin

7 d

ays

afte

r del

iver

y

No

51.0

61.6

59

.56

6.6

47.

630

.65

7.1

62

.26

5.7

Yes

49

.038

.44

0.5

33.4

52

.4**

69

.4**

*4

2.9

37.8

34

.3

Know

ledge

on p

regnan

cy d

anger

sig

ns

Hig

h20

.531

.53

4.3

29.1

29.3

38.4

29.0

32.6

29.9

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.

Anne

x 8:

Pr

even

tion

of m

othe

r-to

-chi

ld H

IV t

rans

mis

sion

, HIV

cou

nsel

ing

and

test

ing,

kno

wle

dge,

sel

f-ef

ficac

y, a

nd o

utco

me

expe

ctan

cy

amon

g w

omen

wit

h ch

ildre

n un

der

2 ye

ars

old,

by

regi

on, m

idlin

e su

rvey

(Ap

ril 2

019)

(pe

rcen

tage

s)

Char

acte

rist

ic

Am

har

aO

rom

iaS

NN

PR

Tig

ray

Bas

elin

e

N=

177

Mid

line

N=

114

Bas

elin

e

N=

176

Mid

line

N=

147

Bas

elin

e

N=

196

Mid

line

N=

95

Bas

elin

e

N=

196

Mid

line

N=

125

HIV

tes

t at

rec

ent

pre

gnan

cy5

8.9

69

.329

.838

.65

3.9

61.5

83.

98

8.2

A p

regnan

t w

oman

wit

h H

IV c

an t

ransm

it it

to h

er b

aby

80

.577

.16

0.5

***

76.2

83.

18

7.1

73.8

***

96

.0

A p

regnan

t w

oman

wit

h H

IV c

an p

reve

nt

tran

smit

ting it

to h

er b

aby if

she

takes

anti

retr

ovir

als

74.4

73.8

71.8

71.9

71.4

**8

5.6

81.

3**

91.6

Sel

f-ef

fica

cy o

n H

IV/A

IDS

86

.08

2.5

83.

18

2.7

94

.59

1.29

4.2

98

.2

Outc

ome

expec

tancy

79

.276

.678

.670

.876

.8*

89

.49

0.4

96

.0

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.


61

Anne

x 9:

Pr

even

tion

of m

othe

r-to

-chi

ld H

IV t

rans

mis

sion

, HIV

cou

nsel

ing

and

test

ing,

kno

wle

dge,

sel

f-ef

ficac

y, a

nd o

utco

me

expe

ctan

cy

amon

g w

omen

wit

h ch

ildre

n un

der

2 ye

ars

old,

by

age,

edu

cati

on, a

nd v

ulne

rabi

lity,

mid

line

surv

ey (

Apri

l 201

9) (

perc

enta

ges)

Char

acte

rist

ics

Age

Educa

tion

V

uln

erab

ilit

y Index

15–2

4

N=10

32

5–3

4

N=2

61

35

–49

N

=11

7N

one

N=3

07

Pri

mar

y

N=14

1

Sec

ondar

y

and a

bov

e N

=3

3

Not

vuln

erab

le

N=2

70

Vuln

erab

le

N=13

4

Hig

hly

vuln

erab

le

N=67

HIV

tes

t at

rec

ent

pre

gnan

cy70

.96

2.1

59

.05

5.7

***

74.5

84

.870

.7**

*5

5.2

46

.3

A p

regnan

t w

oman

wit

h H

IV c

an t

ransm

it it

to h

er b

aby

80

.68

3.5

84

.68

1.18

6.5

87.

98

3.3

85

.176

.1

A p

regnan

t w

oman

wit

h H

IV c

an p

reve

nt

tran

smit

ting it

to h

er b

aby if

she

takes

anti

retr

ovir

als

77.7

80

.88

1.276

.5**

84

.49

7.0

82

.2*

82

.16

8.7

Sel

f-ef

fica

cy o

n H

IV/A

IDS

87.

48

9.3

88

.08

6.6

90

.89

7.0

89

.38

8.8

86

.6

Outc

ome

expec

tancy

76

.78

2.8

86

.38

0.8

83.

09

3.9

83.

38

4.3

74.6

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.

Anne

x 10

: M

oder

n fa

mily

pla

nnin

g us

e, k

now

ledg

e, s

elf-

effic

acy,

and

out

com

e ex

pect

ancy

am

ong

mar

ried

wom

en a

ged

15–4

9 ye

ars,

bas

elin

e (S

epte

mbe

r 20

16)

and

mid

line

(Apr

il 20

18)

surv

eys

Char

acte

rist

ic

Am

har

a (%

)O

rom

ia (%)

SN

NP

R (%)

Tig

ray (%)

Bas

elin

e N

=4

69

Mid

line

N=2

90

Bas

elin

e N

=4

80

Mid

line

N=3

19B

asel

ine

N=4

45

Mid

line

N=3

08

Bas

elin

e N

=4

45

Mid

line

N=2

89

Ever

use

d m

oder

n c

ontr

acep

tive

met

hod

(m

arri

ed w

omen

)79

.776

.75

3.8

52

.673

.96

7.4

66

.575

.7**

Curr

ent

mod

ern f

amily p

lannin

g u

se r

ate

(mar

ried

wom

en)

58

.6**

*4

3.6

31.3

33.0

55

.4*

49

.04

1.4**

52

.6

N=

674

N=

416

N=

68

8N

=4

48

N=7

60

N=

44

8N

=6

48

N=

46

1

Wom

en w

ho

know

any m

oder

n c

ontr

acep

tive

met

hod

s9

3.9

93.

09

0.8

90

.68

8.5

89

.99

8.5

96

.9

Wom

en w

ho

know

abou

t m

oder

n lon

g-ac

ting c

ontr

acep

tive

met

hod

s***

74.1

77.4

74.7

***

54

.26

9.9

69

.48

4.5

82

.5

Wom

en w

ho

know

abou

t m

oder

n s

hor

t-ac

ting c

ontr

acep

tive

met

hod

s***

87.

99

2.4

87.

3**

83.

68

7.4

***

81.

39

8.0

**9

4.1

N=

674

N=

378

N=

68

8N

=37

8N

=76

0N

=39

3N

=6

48

N=

44

5

Wom

en w

ho

bel

ieve

they

are

able

to

use

mod

ern c

ontr

acep

tive

m

ethod

s (S

elf-

effi

cacy

)9

2.0

94

.56

0.9

97.

9**

*8

3.9

96

.4**

*9

7.4

99

.1*

Wom

en w

ho

bel

ieve

thei

r use

of

mod

ern c

ontr

acep

tive

met

hod

s im

pro

ved q

ual

ity o

f fa

mily lif

e (O

utc

ome

expec

tati

on)

93.

39

4.3

77.0

98

.4**

*8

4.0

96

.6**

*9

8.0

99

.0

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.

EVALUATION REPORT

62

Anne

x 11:

Cu

rren

t m

oder

n fa

mily

pla

nnin

g us

e, k

now

ledg

e, s

elf-

effic

acy,

and

out

com

e ex

pect

ancy

am

ong

mar

ried

wom

en a

ged

15–4

9 ye

ars,

m

idlin

e su

rvey

, 201

9 (p

erce

ntag

es)

Char

acte

rist

ic

Age

Educa

tion

Vuln

erab

ilit

y

15–2

4

N=2

20

25

–34

N

=5

84

35

–49

N

=3

64

None

N=9

46

Pri

mar

y

N=35

0

Sec

ondar

y

and a

bov

e N

=72

Not

Vuln

erab

le

N=7

74

Vuln

erab

le

N=35

6

Hig

hly

V

uln

erab

le

N=2

19

Ever

use

d m

oder

n f

amily p

lannin

g m

ethod

6

3.2

**7

1.15

9.8

61.8

***

71.5

82

.770

.9**

*5

8.2

58

.9

N=

185

N=

515

N=

513

N=

85

3N

=30

8N

=6

2N

=6

91

N=

312

N=

202

Curr

ent

use

of

mod

ern f

amily p

lannin

g m

ethod

4

8.7

***

54

.827

.938

.6**

*5

2.5

51.7

48

.0**

*38

.335

.0

N=

473

N=

64

2N

=6

58

N=

1,09

6N

=5

16N

=16

1N

=1,0

91

N=

45

5N

=28

4

Any f

amily p

lannin

g m

ethod

8

0.5

***

96

.59

2.4

92

.08

8.6

87.

98

8.9

**9

4.4

92

.2

Any m

oder

n m

ethod

65

.1**79

.970

.778

.6**

*74

.66

1.773

.5**

*76

.48

3.6

Any t

radit

ional

met

hod

15.4

16.7

12.7

13.4

14.0

28.1

15.4

18.0

8.6

Any m

oder

n s

hor

t-ac

ting m

ethod

18.2

**17

.223

.22

1.5**

*17

.613

.116

.2**

23.8

23.1

Any m

oder

n lon

g-ac

ting m

ethod

46

.96

2.5

56

.55

7.1

56

.94

8.5

57.

25

2.6

60

.5

One

to t

hre

e m

ethod

s4

1.3

**5

0.9

51.5

53.

8**

44

.128

.94

3.9

**4

7.7

63.

1

Fou

r or

mor

e m

ethod

s39

.24

5.6

40

.938

.24

4.4

62

.94

5.0

46

.729

.1

Bel

ieve

s th

ey a

re a

ble

to

use

mod

ern c

ontr

acep

tive

m

ethod

s (S

elf-

effi

cacy

)75

.29

2.3

***

86

.78

7.0

83.

88

4.1

84

.38

8.0

88

.4

Bel

ieve

s th

eir

use

of

mod

ern c

ontr

acep

tive

m

ethod

s im

pro

ved q

ual

ity o

f fa

mily lif

e (O

utc

ome

expec

tati

on)

77.1

92

.5**

*8

5.3

86

.18

4.8

87.

68

4.5

89

.08

6.6

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.


63

Anne

x 12

: Le

vel o

f ear

ly in

itia

tion

of b

reas

tfee

ding

and

exc

lusi

ve b

reas

tfee

ding

am

ong

mot

hers

of c

hild

ren

unde

r 23

mon

ths,

by

regi

on,

Com

mun

icat

ion

for

Hea

lth

proj

ect

base

line

(Sep

tem

ber

2016

) an

d m

idlin

e (A

pril

2019

) su

rvey

s

Char

acte

rist

ic

Am

har

a (%

)O

rom

ia (%)

SN

NP

R (%)

Tig

ray (%)

Bas

elin

e N

=17

1M

idline

N=10

6B

asel

ine

N=17

0M

idline

N=13

0B

asel

ine

N=19

1M

idline

N=8

2B

asel

ine

N=18

5M

idline

N=11

4

Ear

ly init

iati

on o

f bre

astf

eedin

g a

mon

g c

hildre

n u

nder

5 y

ears

*

69

.36

5.7

61.8

*73

.375

.78

3.5

71.9

*79

.4

N=

43

N=

39N

=5

2N

=28

N=

42

N=

32N

=4

5N

=28

Excl

usi

ve b

reas

tfee

din

g a

mon

g c

hildre

n u

nder

6 m

onth

s

95

.06

2.0

**8

5.6

68

.88

6.5

59

.0**

57.

624

.9*

N=

674

N=

414

N=

68

2N

=4

44

N=7

57

N=

44

5N

=6

45

N=

45

6

Str

ongly

agre

e th

at c

hildre

n s

hou

ld h

ave

at lea

st f

our

food

gro

ups

a day

(S

elf-

effi

cacy

)9

9.5

**9

7.4

97.

29

8.7

99

.09

9.4

99

.9*

98

.9

Str

ongly

bel

ieve

that

excl

usi

ve b

reas

tfee

din

g in f

irst

6 m

onth

s w

ill

lead

to

hea

lthy n

eonat

al o

utc

omes

(O

utc

ome

expec

tati

on)

95

.19

6.7

97.

39

8.2

96

.4*

98

.79

5.6

96

.3

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.

Anne

x 13

: Ea

rly

init

iati

on o

f bre

astf

eedi

ng, e

xclu

sive

bre

astf

eedi

ng, f

amily

pla

nnin

g se

lf-ef

ficac

y, a

nd fa

mily

pla

nnin

g ou

tcom

e ex

pect

ancy

am

ong

mar

ried

wom

en a

ged

15–4

9 ye

ars,

mid

line

surv

ey (

Apri

l 201

9) (

perc

enta

ges)

Char

acte

rist

ic

Age

Educa

tion

Vuln

erab

ilit

y

15–2

4

N=10

32

5–3

4

N=2

61

35

–49

N

=11

7N

one

N=3

07

Pri

mar

y

N=14

1

Sec

ondar

y

and a

bov

e N

=3

3

Not

Vuln

erab

le

N=2

70

Vuln

erab

le

N=13

4

Hig

hly

V

uln

erab

le

N=67

Ear

ly init

iati

on o

f bre

astf

eedin

g a

mon

g c

hildre

n u

nder

5 y

ears

71.0

70.1

62

.56

5.4

73.4

77.4

71.2

68

.15

6.9

N=

36N

=77

N=

31N

=8

5N

=4

5N

=12

N=

88

N=

28N

=22

Excl

usi

ve b

reas

tfee

din

g a

mon

g c

hildre

n u

nder

6 m

onth

s6

0.2

47.

64

5.7

50

.25

0.2

52

.55

2.4

39.1

54

.1

N=

103

N=

261

N=

117

N=

307

N=

141

N=

33N

=27

0N

=13

4N

=6

7

Agre

e th

at c

hildre

n s

hou

ld h

ave

at lea

st f

our

food

gro

ups

a day

(S

elf-

effi

cacy

)9

8.4

98

.49

8.0

98

.8*

98

.19

4.4

99

.79

6.2

99

.3

Bel

ieve

that

excl

usi

ve b

reas

tfee

din

g in t

he

firs

t 6 m

onth

s w

ill le

ad t

o hea

lthy n

eonat

al o

utc

omes

(O

utc

ome

expec

tati

on)

93.

79

8.0

99

.59

8.6

95

.39

5.0

98

.79

8.1

93.

8

* p<0

.05.

EVALUATION REPORT

64

Anne

x 14

: Sa

mpl

e w

ored

a cl

assi

ficat

ion

base

d on

mal

aria

inci

denc

e, r

egio

nal d

isag

greg

atio

n

Char

acte

rist

ic

Am

har

aO

rom

iaS

NN

PR

Tig

ray

Bas

elin

eM

idline

Bas

elin

eM

idline

Bas

elin

eM

idline

Bas

elin

eM

idline

Mal

aria

inci

den

ceFre

e/Low

40

%20

%8

0%

100

%2

1%0

%18

%27

%

Moder

ate/

Hig

h6

0%

80

%20

%0

%79

%10

0%

82

%73

%

Anne

x 15

: Kn

owle

dge,

sel

f-ef

ficac

y, a

nd o

utco

me

expe

ctan

cy o

n m

alar

ia a

mon

g w

omen

age

d 15

–49

year

s w

ho li

ve in

mal

aria

-pro

ne a

reas

, by

reg

ion,

Com

mun

icat

ion

for

Hea

lth

proj

ect

base

line

(Sep

tem

ber

2016

) an

d m

idlin

e (A

pril

2019

) su

rvey

s (p

erce

ntag

es)

Char

acte

rist

ic

Am

har

aS

NN

PR

Tig

ray

Bas

elin

e N

=3

48

Mid

line

N=3

15B

asel

ine

N=6

21

Mid

line

N=4

48

Bas

elin

e N

=5

43

Mid

line

N=3

44

Know

s th

ree

or m

ore

signs

or s

ym

pto

ms

29.7

31.7

37.6

**4

4.8

27.9

***

43.

0

Know

s ca

use

of

mal

aria

27.4

***

10.6

28.1**

*5

0.7

24.9

***

35.9

Know

s th

at b

ed n

ets

can p

reve

nt

mal

aria

(O

utc

ome

expec

tancy

; ag

ree/

stro

ngly

ag

ree)

94

.9*

92

.19

3.9

95

.59

8.4

98

.9

Hav

ing m

y c

hildre

n s

leep

under

lon

g-la

stin

g inse

ctic

idal

net

s ea

ch n

ight

will

pre

vent

mal

aria

94

.49

2.4

93.

79

5.1

95

.7**

98

.9

I am

able

to

hav

e ch

ildre

n u

nder

5 s

leep

under

bed

net

eac

h n

ight

(Sel

f ef

fica

cy;

agre

e/st

rongly

agre

e)9

2.3

***

81.4

83.

2**

*9

2.3

85

.2**

*9

4.9

I am

able

to

slee

p u

nder

a lon

g-la

stin

g inse

ctic

idal

net

eac

h n

ight

(Sel

f-ef

fica

cy;

agre

e/st

rongly

agre

e)9

0.0

85

.08

5.1**

*9

2.2

88

.0**

94

.2

I sh

ould

see

k t

reat

men

t fo

r ch

ildre

n u

nder

5 w

ithin

24 h

ours

of

feve

r (K

now

ledge;

ag

ree/

stro

ngly

agre

e)9

5.5

***

90

.39

1.3

94

.19

3.2

95

.1

I ca

n t

ake

my c

hild t

o tr

eatm

ent

wit

hin

24 h

ours

of

feve

r on

set

(Sel

f-ef

fica

cy;

agre

e/st

rongly

agre

e)9

6.0

***

89

.98

6.0

***

93.

49

0.5

*9

5.3

See

kin

g t

reat

men

t w

ithin

24 h

ours

of

feve

r fo

r m

y c

hildre

n u

nder

age

5 w

ill im

pro

ve

thei

r hea

lth

96

.6*

94

.49

7.3

95

.79

3.9

*9

6.3

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.


65

Anne

x 16

: Kn

owle

dge,

sel

f-ef

ficac

y, a

nd o

utco

me

expe

ctan

cy o

n m

alar

ia a

mon

g w

omen

age

d 15

–49

year

s w

ho li

ve in

mal

aria

-pro

ne a

reas

, by

age

, edu

cati

on, a

nd v

ulne

rabi

lity,

Com

mun

icat

ion

for

Hea

lth

mid

line

surv

ey (

Apri

l 201

9) (

perc

enta

ges)

Char

acte

rist

ic

Age

Educa

tion

V

uln

erab

ilit

y Index

15–2

4

N=2

78

25

–34

N

=4

20

35

–49

N

=4

09

None

N=6

41

Pri

mar

y

N=3

47

Sec

ondar

y

or

abov

e N

=11

9

Not

vuln

erab

le

N=5

91

Vuln

erab

le

N=3

00

Hig

hly

vuln

erab

le

N=19

8

Know

s th

ree

or m

ore

mal

aria

sig

ns

or s

ym

pto

ms

34

.14

2.2

38.6

38.0

38.7

44

.04

1.130

.74

8.2

Know

s ca

use

of

mal

aria

31.2

34

.926

.926

.237

.139

.239

.023

.522

.0

Know

s bed

net

s ca

n p

reve

nt

mal

aria

(O

utc

ome

expec

tancy

; ag

ree/

stro

ngly

agre

e)9

2.6

94

.49

5.3

93.

89

4.6

96

.29

4.7

93.

39

5.5

Hav

ing m

y c

hildre

n s

leep

under

lon

g-la

stin

g

inse

ctic

idal

net

s ea

ch n

ight

will pre

vent

mal

aria

92

.29

4.4

95

.39

3.9

94

.09

6.2

94

.99

2.5

95

.8

I am

able

to

hav

e m

y c

hildre

n u

nder

5 s

leep

under

a

bed

net

eac

h n

ight

(Sel

f-ef

fica

cy; ag

ree/

stro

ngly

ag

ree)

84

.18

9.6

88

.28

9.0

84

.98

8.5

88

.58

6.7

90

.2

I am

able

to

slee

p u

nder

a lon

g-la

stin

g inse

ctic

idal

net

ea

ch n

ight

(Sel

f-ef

fica

cy; ag

ree/

stro

ngly

agre

e)8

8.4

90

.58

8.3

89

.68

8.4

89

.69

0.8

86

.99

1.8

I sh

ould

see

k t

reat

men

t w

ithin

24 h

ours

of

fever

onse

t fo

r ch

ildre

n u

nder

age

5 (K

now

ledge;

agre

e/st

rongly

ag

ree)

85

.89

5.5

93.

79

3.6

90

.09

3.9

92

.69

3.0

92

.7

I ca

n t

ake

my c

hild t

o tr

eatm

ent

wit

hin

24 h

ours

of

feve

r on

set

(Sel

f-ef

fica

cy; ag

ree/

stro

ngly

agre

e)8

5.6

95

.49

2.7

93.

38

9.4

92

.49

2.3

91.4

93.

1

See

kin

g t

reat

men

t fo

r m

y c

hildre

n u

nder

age

5 w

ithin

24 h

ours

of

feve

r on

set

will im

pro

ve t

hei

r hea

lth

89

.79

8.7

95

.19

5.9

94

.09

4.8

95

.49

5.1

96

.1

EVALUATION REPORT

66

Anne

x 17

: Pr

acti

ce, k

now

ledg

e, s

elf-

effic

acy,

and

out

com

e ex

pect

ancy

on

hand

was

hing

am

ong

mar

ried

wom

en a

ged

15–4

9 ye

ars,

by

regi

on

(per

cent

ages

)

Char

acte

rist

ic

Am

har

aO

rom

iaS

NN

PR

Tig

ray

Bas

elin

e N

=674

Mid

line

N=4

16B

asel

ine

N

=6

88

Mid

line

N=4

48

Bas

elin

e N

=76

0M

idline

N=4

48

Bas

elin

e N

=6

48

Mid

line

N=4

61

Pra

ctic

es h

andw

ashin

g a

t al

l key

cir

cum

stan

ces

54

.4**

*37

.872

.6**

*79

.56

0.0

***

84

.66

5.9

***

47.

2

Pre

sence

of

pro

per

han

dw

ashin

g p

lace

wit

h s

oap a

nd w

ater

1.8**

*10

.82

.33.

035

.5*

40

.71.2

***

5.0

Com

pre

hen

sive

know

ledge

on h

andw

ashin

g a

t key

tim

esK

now

s al

l 5

key

tim

es8

.49

.522

.623

.212

.25

7.1

4.9

0.9

Know

s 3

–4 k

ey t

imes

27.9

29.7

19.8

37.6

41.8

29.3

18.8

34

.9

Know

s <2

key

tim

es6

3.7

60

.75

7.6

39.1**

*4

6.0

13.7

***

76.3

64

.2**

*

I ca

n p

ract

ice

pro

per

han

dw

ashin

g9

3.3

***

80

.39

5.0

***

99

.39

2.6

***

97.

29

5.8

**9

9.0

Pro

per

han

dw

ashin

g p

reve

nts

dis

ease

s su

ch a

s dia

rrhea

98

.6**

*9

4.6

97.

1***

100

.09

9.1

98

.59

9.5

100

.0

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.

Anne

x 18

: Pr

acti

ce, k

now

ledg

e, s

elf-

effic

acy,

and

out

com

e ex

pect

ancy

on

hand

was

hing

am

ong

mar

ried

wom

en a

ged

15–4

9 ye

ars,

by

age,

ed

ucat

ion,

and

vul

nera

bilit

y (p

erce

ntag

es)

Char

acte

rist

ic

Age

Educa

tion

V

uln

erab

ilit

y Index

15–2

4

N=4

73

25

–34

N

=6

42

35

–49

N

=6

58

None

N=1,

09

6P

rim

ary

N=5

16

Sec

ondar

y

or

Abov

e N

=16

1

Not

Vuln

erab

le

N=1,

00

1V

uln

erab

le

N=4

55

Hig

hly

V

uln

erab

le

N=2

84

Pra

ctic

es h

andw

ashin

g a

t al

l key

cir

cum

stan

ces

61.7

69

.26

2.4

63.

96

7.0

63.

26

5.4

60

.270

.9

Pre

sence

of

pro

per

han

dw

ashin

g p

lace

wit

h s

oap a

nd

wat

er16

.418

.515

.314

.418

.826

.917

.120

.612

.0

Com

pre

hen

sive

know

ledge

on

han

dw

ashin

g a

t key

tim

esK

now

s al

l 5

key

tim

es2

1.233

.025

.025

.531

.124

.426

.622

.937

.1

Know

s 3

–4 k

ey t

imes

37.6

29.1

31.9

31.2

30.8

45

.829

.64

2.6

24.1

Know

s <2

key

tim

es4

1.237

.94

3.1

43.

438

.229

.84

3.9

34

.538

.9

I ca

n p

ract

ice

pro

per

han

dw

ashin

g9

1.99

3.2

91.7

91.9

92

.29

5.3

91.9

92

.99

3.5

Pro

per

han

dw

ashin

g p

reve

nts

dis

ease

s su

ch a

s dia

rrhea

97.

09

7.9

98

.19

8.1

96

.99

7.9

98

.29

7.6

97.

7


67

Anne

x 19

: Tu

berc

ulos

is (

TB)

know

ledg

e, s

elf-

effic

acy,

and

out

com

e ex

pect

ancy

am

ong

all w

omen

age

d 15

–49

year

s, C

omm

unic

atio

n fo

r H

ealt

h pr

ojec

t ba

selin

e (S

epte

mbe

r 20

16)

and

mid

line

(Apr

il 20

19)

surv

eys

(per

cent

ages

)

Char

acte

rist

ics

Am

har

a (%

)O

rom

ia (%)

SN

NP

R (%)

Tig

ray (%)

Bas

elin

e N

=6

60

Mid

line

N=4

14B

asel

ine

N=674

Mid

line

N=4

45

Bas

elin

e N

=75

2M

idline

N=4

48

Bas

elin

e N

=6

26

Mid

line

N=4

61

Has

hea

rd o

f an

illnes

s ca

lled

tuber

culo

sis

or T

B77

.472

.0*

72.3

52

.6**

*8

3.2

70.8

***

85

.18

9.2

*

Know

cou

ghin

g t

hro

ugh a

ir is

mea

ns

of T

B t

ransm

issi

on36

.931

.0*

37.7

37.1

53.

16

6.4

***

47.

75

6.3

**

Know

thre

e or

mor

e T

B s

ym

pto

ms

13.9

12.8

13.9

9.1*

16.8

47.

9**

*12

.7*

19.6

Str

ongly

agre

e th

at t

hey

can

be

imm

edia

tely

scr

eened

on

susp

ecte

d T

B (S

elf-

effi

cacy

)76

.770

.8**

70.1

52

.1***

79.7

69

.5**

*8

4.0

89

.1*

Str

ongly

bel

ieve

that

ear

ly s

cree

nin

g o

f T

B m

ay lea

d t

o fu

ll

reco

very

(O

utc

ome

expec

tati

on)

75.3

61.8

***

69

.35

0.2

***

79.6

68

.3**

*8

3.3

88

.7*

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.

Anne

x 20

: Tub

ercu

losi

s (T

B) k

now

ledg

e, s

elf-

effic

acy,

and

out

com

e ex

pect

ancy

am

ong

all w

omen

age

d 15

–49

year

s, m

idlin

e su

rvey

(Ap

ril

2019

) (p

erce

ntag

es)

Char

acte

rist

ic

Age

Educa

tion

Vuln

erab

ilit

y

15–2

4

N=4

72

25

–34

N

=6

39

35

–49

N

=6

57

None

N=1,

09

1P

rim

ary

N=5

16

Sec

ondar

y

and A

bov

e N

=16

1

Not

Vuln

erab

le

N=9

98

Vuln

erab

le

N=4

53

Hig

hly

V

uln

erab

le

N=2

84

Hav

e hea

rd o

f an

illnes

s ca

lled

tuber

culo

sis

or T

B6

6.2

69

.86

4.8

62

.2**

*7

1.78

5.2

67.

46

3.1

72.7

Know

cou

ghin

g t

hro

ugh a

ir is

mea

ns

of T

B

tran

smis

sion

45

.5**

*4

7.9

41.8

38.5

***

53.

06

4.8

43.

94

3.0

51.2

Know

thre

e or

mor

e T

B s

ym

pto

ms

19.7

23.5

23.4

18.7

***

26.1

37.0

18.8

***

25.7

29.5

Str

ongly

agre

e th

at t

hey

can

be

imm

edia

tely

sc

reen

ed o

n s

usp

ecte

d T

B (S

elf-

effi

cacy

)6

5.1

69

.16

3.6

61.7

***

70.0

84

.06

6.4

61.9

72.5

Str

ongly

bel

ieve

s th

at e

arly

scr

eenin

g o

f T

B m

ay

lead

to

full r

ecov

ery (O

utc

ome

expec

tati

on)

61.8

64

.06

0.4

57.

8**

*6

6.0

80

.06

3.1

57.

36

7.9

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.

EVALUATION REPORT

68

Anne

x 21

: Ge

nder

Equ

itab

le M

en (

GEM

) sc

ale,

adj

uste

d fo

r w

omen

age

d 15

–49

year

s, C

omm

unic

atio

n fo

r H

ealt

h pr

ojec

t ba

selin

e (S

epte

mbe

r 20

16)

and

mid

line

(Apr

il 20

19)

surv

eys

GEM

sca

le ite

m, ad

apte

d f

or w

omen

(% low

ineq

ual

ity

*** )

Am

har

a (%

)O

rom

ia (%)

SN

NP

R (%)

Tig

ray (%)

Bas

elin

e N

=674

Mid

line

N=4

16B

asel

ine

N=6

88

Mid

line

N=4

48

Bas

elin

e N

=76

0M

idline

N=4

48

Bas

elin

e N

=6

48

Mid

line

N=4

61

Sca

le d

eriv

ed f

rom

21 v

aria

ble

s20

.522

.1***

24.6

25.1**

*6

.25

6.2

***

17.2

40

.5**

*

Par

tner

vio

lence

47.

44

7.5

47.

25

6.3

***

41.5

67.

1***

54

.577

.9**

*

Sex

ual

rel

atio

nsh

ip

5.2

6.6

)9

.07.

3**

*0

.838

.9**

*2

.813

.6**

*

Rep

roduct

ive

hea

lth a

nd d

isea

se p

reve

nti

on index

69

.7**

*6

8.3

60

.270

.6**

*70

.96

1.56

7.9

73.7

***

Dom

esti

c ch

ores

and d

aily

lif

e in

dex

***

26.2

33.6

***

26.2

31.2

***

10.2

33.6

***

17.2

37.0

***

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.

Anne

x 22

: Pe

rcen

tage

of l

ow in

equa

lity,

Gen

der

Equi

tabl

e M

en (

GEM

) sc

ale,

adj

uste

d fo

r w

omen

age

d 15

–49

year

s, m

idlin

e su

rvey

(Ap

ril

2019

)

GEM

Sca

le, A

dap

ted f

or W

omen

, % low

ineq

ual

ity

***

Age

Educa

tion

Vuln

erab

ilit

y

15–2

4

N=3

62

25

–34

N

=5

88

35

–49

N

=6

07

None

N=1,

00

9P

rim

ary

N=4

14

Sec

ondar

y

and a

bov

e N

=13

4

Not

Vuln

erab

le

N=8

77

Vuln

erab

le

N=4

17

Hig

hly

V

uln

erab

le

N=24

1

Der

ived

fro

m 2

1 v

aria

ble

s4

5.2

***

36.7

23.4

24.1**

*4

8.3

60

.335

.9**

*25

.94

2.2

N=

439

N=

635

N=

64

7N

=1,0

76N

=4

94

N=

151

N=

972

N=

45

0N

=27

0

Der

ived

fro

m 2

1 v

aria

ble

s6

8.9

***

60

.74

7.4

50

.4**

*6

7.2

82

.05

8.1**

*5

0.7

67.

7

N=

367

N=

59

7N

=6

20N

=1,0

23N

=4

25N

=13

6N

=8

93

N=

42

1N

=24

8

* p<0

.05,

**p<

0.01

, and

*** p

<0.0

01.

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