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C-Channel Issue 9

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C-Channel header  May 2009

Dear Colleagues,  

C-Channel 9, the monthly e-newsletter from C-Change, provides peer-reviewed literature focused on social and behavior  change communication in the health sector--malaria, family planning/reproductive health, HIV and AIDS, maternal health and antenatal care--areas where C-Change is implementing programs and conducting research.

This issue highlights research on malaria in pregnancy and features five peer-reviewed articles on the topic–including the use of insecticide-treated nets (ITNs) by pregnant women and delivery of intermittent preventive treatment during pregnancy (IPTp). Three articles on HIV and AIDS look specifically at issues around prevention of mother-to-child transmission of HIV (PMTCT) services, including how to more effectively reach out to fathers. Finally, three articles on family planning/reproductive health explore efforts to change harmful postpartum practices that involve including husbands in antenatal care and engaging the community. The eleven articles cover research carried out in Cameroon, China, DR Congo, Ethiopia, India, Nepal, Tanzania, and Ukraine.

C-Change is implementing programs in malaria prevention in Ethiopia and Kenya with emphasis on communication for behavior change at the community level. Additional information is available at the program's website www.c-changeprogram.org.

Thank you,
The Knowledge Management Team at C-Change


To view archived issues, visit http://c-changeprogram.org/c-channel


MALARIA

1. Monitoring and evaluation of malaria in pregnancy – developing a rational basis for control

2. Use of insecticide treated nets by pregnant women and associated factors in a pre-dominantly rural population in northern Ethiopia 

3. Bed net ownership, use and perceptions among women seeking antenatal care in Kinshasa, Democratic Republic of the Congo (DRC): Opportunities for improved maternal and child health

4. Malaria in pregnant women in an area with sustained high coverage of insecticide-treated bed nets 

5. Malaria and anaemia among pregnant women at first antenatal clinic visit in Kisumu, western Kenya
 

HIV and AIDS

6. Progress in prevention of mother-to-child transmission of HIV infection in Ukraine: Results from a birth cohort study 

7. Male involvement in PMTCT services in Mbeya Region, Tanzania

8. Early assessment of the implementation of a national programme for the prevention of mother-to-child transmission of HIV in Cameroon and the effects of staff training: A survey in 70 rural health care facilities
 

FAMILY PLANNING/REPRODUCTIVE HEALTH

9. The effect of health and nutrition education intervention on women's postpartum beliefs and practices: A randomized controlled trial 

10. The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: Results from a randomized controlled trial

11. Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: A cluster-randomised controlled trial
 


MALARIA

1. Monitoring and evaluation of malaria in pregnancy – developing a rational basis for control

Authors: Brabin, BJ; Wasame, M; Uddenfeldt-Wor, U; Dellicour, S; Hill, J; Gies, S
Source: Malaria Journal 11 Dec 2008, 7(Suppl 1):S6.

ABSTRACT

Monitoring and evaluation of malaria control in pregnancy is essential for assessing the efficacy and effectiveness of health interventions aimed at reducing the major burden of this disease on women living in endemic areas. Yet there is no currently integrated strategic approach on how this should be achieved. Malaria control in pregnancy is formulated in relation to epidemiological patterns of exposure. Current emphasis is on intermittent preventive treatment (IPTp) during pregnancy with sulphadoxine-pyrimethamine in higher transmission areas, combined with insecticide treated bed nets (ITNs) and case management. Emphasis in lower transmission areas is primarily on case management. This paper discusses a rational basis for monitoring and evaluation based on: assessments of therapeutic and prophylactic drug efficacy; proportional reductions in parasite prevalence; seasonal effects; rapid assessment methodologies; birthweight and/or anaemia nomograms; case-coverage methods; maternal mortality indices; operational and programmatic indicators; and safety and pharmacovigilance of antimalarials in pregnancy. These approaches should be incorporated more effectively within National Programmes in order to facilitate surveillance and improve identification of high-risk women. Systems for utilizing routinely collected data should be strengthened, with greater attention to safety and pharmacovigilance with the advent of artemisinin combination therapies, and prospects of inadvertent exposures to artemisinins in the first trimester. Integrating monitoring activities within malaria control, reproductive health and adolescent-friendly services will be critical for implementation. Large-scale operational research is required to further evaluate the validity of currently proposed indicators, and in order to clarify the breadth and scale of implementation to be deployed.

To link to the website containing this article, click here. Full Text is freely available.

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2. Use of insecticide treated nets by pregnant women and associated factors in a pre-dominantly rural population in northern Ethiopia

Authors: Belay, M; Deressa, W
Source: Tropical Medicine & International Health 8 Oct 2008, 13(10): 1303-13.

ABSTRACT

OBJECTIVE: To describe the use of insecticide treated nets (ITNs) among pregnant women and examine factors associated with its access and use.

METHODS: Community-based cross-sectional study of 815 pregnant women in eight malarious kebeles in northern Ethiopia based on two-stage cluster design from May to June 2006. Knowledge on malaria, its cause and preventive measures; treatment seeking behaviour; possession and use of ITNs by pregnant women and under-five children were ascertained through interview and observation. Logistic regression was used to determine factors associated with ITNs use.

RESULTS: Knowledge about the cause, transmission and preventive measures of malaria was relatively good; 90.2% of women associated malaria with mosquito bites and 94.2% with living near water ponds. Ten per cent reported malaria illness within the 14 days before the survey, and sought treatment mainly from public health facilities (56.5%) and community health workers (37.6%). Of 815 households surveyed, 59% owned at least one non-long lasting or long-lasting ITN (59.5% rural vs. 54.5% urban; P = 0.401). Lack of access to ITNs (68.3%) and the perception that nets could not prevent malaria (27%) were the main reasons for non-ownership of nets. A total of 58.4% of 481 pregnant women from households owning at least one ITN had slept under it during the previous night. Fewer rural (56.7%) than urban women (76.2%) used ITNs (P = 0.001). In 57.6% of households with at least one ITN, under-five children had used it the night before. Higher educational attainment was an important predictor of ITNs use (OR = 3.1, 95% CI = 2.1, 4.6).

CONCLUSIONS: Household ownership of ITNs and their use by pregnant women is promising with the current efforts to scale-up ITNs implementation, but the gap between ownership and use remains high. Consistent and proper use of nets by pregnant women should be ensured through information campaigns. Rapid expansion of access to long lasting ITNs requires that government and NGOs supply them in adequate numbers.

KEYWORDS: malaria, insecticide treated nets, pregnant women, Ethiopia

To link to the website containing this article, click here.

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3. Bed net ownership, use and perceptions among women seeking antenatal care in Kinshasa, Democratic Republic of the Congo (DRC): Opportunities for improved maternal and child health

Authors: Pettifor, A; Taylor, E; Nku, D; Duvall, S; Tabala, M; Meshnick, S; Behets, F
Source: BMC Public Health 24 Sep 2008, 8:331.

ABSTRACT

BACKGROUND: To describe malaria knowledge, attitudes toward malaria and bed net use, levels of ownership and use of bed nets, and factors associated with ownership and use among pregnant women attending their first antenatal care (ANC) visit in Kinshasa, DRC.

METHODS: Women attending their first ANC visit at one maternity in Kinshasa were recruited to take part in a study where they were given free insecticide treated bed nets (ITNs) and then followed up at delivery and 6 months post delivery to assess ITN use. This study describes the baseline levels of bed net ownership and use, attitudes towards net use and factors associated with net use.

RESULTS: Among 351 women interviewed at baseline, 115 (33%) already owned a bed net and 86 (25%) reported to have slept under the net the previous night. Cost was reported as the reason for not owning a net by 48% of the 236 women who did not own one. In multivariable analyses, women who had secondary school or higher education were 3.4 times more likely to own a net (95% CI 1.6–7.3) and 2.8 times more likely to have used a net (95% CI 1.3–6.0) compared to women with less education.

CONCLUSION: Distribution of ITNs in antenatal clinics in this setting is needed and feasible. The potential for ITN use by this target population is high.

To link to the website containing this article, click here. Full Text is freely available.

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4. Malaria in pregnant women in an area with sustained high coverage of insecticide-treated bed nets

Authors: Kabanywanyi, AM; Macarthur, JR; Stolk, WA; Habbema, JD; Mshinda, H; Bloland, PB; Abdulla, S; Kachur, SP
Source: Malaria Journal 21 July 2008, 7:133.

ABSTRACT

BACKGROUND: Since 2000, the World Health Organization has recommended a package of interventions to prevent malaria during pregnancy and its sequelae that includes the promotion of insecticide-treated bed nets (ITNs), intermittent preventive treatment in pregnancy (IPTp), and effective case management of malarial illness. It is recommended that pregnant women in malaria-endemic areas receive at least two doses of sulphadoxine-pyrimethamine in the second and third trimesters of pregnancy. This study assessed the prevalence of placental malaria at delivery in women during 1st or 2nd pregnancy, who did not receive intermittent preventive treatment for malaria (IPTp) in a malaria-endemic area with high bed net coverage.

METHODS: A hospital-based cross-sectional study was done in Ifakara, Tanzania, where bed net coverage is high. Primi- and secundigravid women, who presented to the labour ward and who reported not using IPTp were included in the study. Self-report data were collected by questionnaire; whereas neonatal birth weight and placenta parasitaemia were measured directly at the time of delivery.

RESULTS: Overall, 413 pregnant women were enrolled of which 91% reported to have slept under a bed net at home the previous night, 43% reported history of fever and 62% were primigravid. Malaria parasites were detected in 8% of the placenta samples; the geometric mean (95%CI) placental parasite density was 3,457 (1,060–11,271) parasites/μl in primigravid women and 2,178 (881–5,383) parasites/μl in secundigravid women. Fifteen percent of newborns weighed <2,500 g at delivery. Self-reported bed net use was statistically associated with lower risk for low birth weight [OR 0.34 (95% CI: 0.16–0.74) and OR 0.22 (95% CI: 0.08–0.59) for untreated and treated bed nets, respectively], but was not associated with placental parasitaemia [OR 0.74 (0.21–2.68) and OR 1.64 (0.44–6.19) for untreated and treated bed nets, respectively].

CONCLUSION: The observed incidence of LBW and prevalence of placental parasitaemia at delivery suggests that malaria remains a problem in pregnancy in this area with high bed net coverage when eligible women do not receive IPTp. Delivery of IPTp should be emphasized at all levels of implementation to achieve maximum community coverage.

To link to the website containing this article, click here. Full Text is freely available.

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5. Malaria and anaemia among pregnant women at first antenatal clinic visit in Kisumu, western Kenya

Authors: Ouma, P; van Eijk, AM; Hamel, MJ; Parise, M; Ayisi, JG; Otieno, K; Kager, PA; Slutsker, L
Source: Tropical Medicine and International Health 7 Dec 2007, 12(12): 1515-23.

SUMMARY

OBJECTIVE: To determine the prevalence of malaria and anaemia among urban and peri-urban women attending their first antenatal clinic (ANC) in an area of perennial malaria transmission.

METHODS: Between November 2003 and May 2004 we screened first ANC attenders for malaria and anaemia in a large urban hospital in Kisumu (western Kenya) and interviewed them to obtain demographic and medical information. Results Among the 685 study participants, prevalence of malaria parasitaemia was 18.0%, prevalence of any anaemia (haemoglobin < 11 g/dl) was 69.1% and prevalence of moderate anaemia was (haemoglobin < 8 g/dl) 11.8%. Sixteen women were hospitalized during pregnancy, eight because of malaria. In multivariate analysis, young age, living in a house with mud walls, a visit to rural area, peri-urban residence, second trimester of pregnancy and Luo ethnicity were significant risk factors for malaria parasitaemia. Malaria was an important risk factor for any and moderate anaemia; use of an insecticide-treated net (ITN) was a protective factor for any anaemia. Married women with a higher level of education, better-quality housing and full-time employment were more likely to use an ITN.

CONCLUSION: Malaria and anaemia are established problems by the time of the first ANC visit. Mechanisms to deliver ITNs to women of child-bearing age before they become pregnant need to be explored. Early ANC visits are warranted in order for women to benefit from policies aimed at reducing the burden of malaria and anaemia.

KEYWORDS: malaria, anaemia, pregnancy, antenatal, insecticide-treated nets, Kenya

To link to the website containing this article, click here. Full Text is freely available.

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HIV and AIDS

6. Progress in prevention of mother-to-child transmission of HIV infection in Ukraine: Results from a birth cohort study

Authors: Thorne, C; Semenenko, I; Pilipenko, T; Malyuta, R; Ukraine European Collaborative Study Group
Source: BMC Infectious Diseases 7 April 2009, 9:40.

ABSTRACT

BACKGROUND: Ukraine was the epicentre of the HIV epidemic in Eastern Europe, which has the most rapidly accelerating HIV epidemic world-wide today; national HIV prevalence is currently estimated at 1.6%. Our objective was to evaluate the uptake and effectiveness of interventions for prevention of mother-to-child transmission (PMTCT) over an eight year period within operational settings in Ukraine, within the context of an ongoing birth cohort study.

METHODS: The European Collaborative Study (ECS) is an ongoing birth cohort study in which HIV-infected pregnant women identified before or during pregnancy or at delivery were enrolled and their infants prospectively followed. Three centres in Ukraine started enrolling in 2000, with a further three joining in September 2006.

RESULTS: Of the 3356 women enrolled, 21% (689) reported current or past injecting drug use (IDU). Most women were diagnosed antenatally and of those, the proportion diagnosed in the first/second trimester increased from 47% in 2000/01 (83/178) to 73% (776/1060) in 2006/07 (p<0.001); intrapartum diagnosis was associated with IDU (Adjusted odds ratio 4.38; 95%CI 3.19-6.02). The percentage of women not receiving any antiretroviral prophylaxis declined from 18% (36/205) in 2001 to 7% in 2007 (61/843) (p<0.001). Use of sdNVP alone substantially declined after 2003, with a concomitant increase in zidovudine prophylaxis. Median antenatal zidovudine prophylaxis duration increased from 24 to 72 days between 2000 and 2007. Elective caesarean section (CS) rates were relatively stable over time and 34% overall. Mother-to-child transmission (MTCT) rates decreased from 15.2% in 2001 (95%CI 10.2-21.4) to 7.0% in 2006 (95%CI 2.6-14.6). In adjusted analysis, MTCT risk was reduced by 43% with elective CS versus vaginal delivery and by 75% with zidovudine versus no prophylaxis.

CONCLUSIONS: There have been substantial improvements in use of PMTCT interventions in Ukraine, including earlier diagnosis of HIV-infected pregnant women and increasing coverage with antiretroviral prophylaxis and the initial MTCT rate has more than halved. Future research should focus on hard-to-reach populations such as IDU and on missed opportunities for further reducing the MTCT rate.

To link to the website containing this article, click here. Full Text is freely available.

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7. Male involvement in PMTCT services in Mbeya Region, Tanzania

Authors: Theuring, S; Mbezi, P; Luvanda, H; Jordan-Harder, B; Kunz A; Harms, G
Source: AIDS and Behavior 2009 Mar 24. [Epub ahead of print]

ABSTRACT

Throughout all stages of programmes for the prevention of mother-to-child-transmission of HIV (PMTCT), high dropout rates are common. Increased male involvement and couples' joint HIV counselling/testing during antenatal care (ANC) seem crucial for improving PMTCT outcomes. Our study assessed male attitudes regarding partner involvement into ANC/PMTCT services in Mbeya Region, Tanzania, conducting 124 individual interviews and six focus group discussions. Almost all respondents generally supported PMTCT interventions. Mentioned barriers to ANC/PMTCT attendance included lacking information/knowledge, no time, neglected importance, the services representing a female responsibility, or fear of HIV-test results. Only few perceived couple HIV counselling/testing as disadvantageous. Among fathers who had refused previous ANC/PMTCT attendance, most had done so even though they were not perceiving a disadvantage about couple counselling/testing. The contradiction between men's beneficial attitudes towards their involvement and low participation rates suggests that external barriers play a large role in this decision-making process and that partner's needs should be more specifically addressed in ANC/PMTCT services.

To link to the website containing this article, click here.

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8. Early assessment of the implementation of a national programme for the prevention of mother-to-child transmission of HIV in Cameroon and the effects of staff training: A survey in 70 rural health care facilities

Authors: Labhardt, ND; Manga, E; Ndam, M; Balo, JR; Bischoff, A; Stoll, B
Source: Tropical Medicine International Health Mar 2009, 14(3): 288-93.

ABSTRACT

OBJECTIVES: To assess the availability of equipment and the staff's knowledge to prevent Mother-To-Child Transmission (PMTCT) in rural healthcare facilities recently covered by the national PMTCT programme in Cameroon.

METHODS: In eight districts inventories of antiviral drugs and HIV test kits were made on site, using a standardised check-list. Knowledge of HIV and PMTCT was evaluated with a multiple-choice (MC) questionnaire based on typical clinical PMTCT cases. Staff participated subsequently in a 2-day training on HIV/AIDS and the Cameroon PMTCT guidelines. Immediately after training and after 7 months, retention of knowledge was tested with the same questions but in different order and layout.

RESULTS: Sixty two peripheral nurse-led clinics and the eight district hospitals were assessed. Whereas all district hospitals presented complete equipment, only six of the peripheral clinics (10%) were equipped with both complete testing materials and a full set of drugs to provide PMTCT. Thirty six peripheral facilities (58%) possessed full equipment for HIV-testing and 8 (13%) stocked all PMTCT drugs. Of 137 nurses, 102 (74%) agreed to the two knowledge tests. Fewer than 66% knew that HIV-diagnosis requires positive results in two different types of rapid tests and only 19% chose the right recommendation on infant-feeding for HIV-positive mothers. Correct answers on drug regimens in different PMTCT settings varied from 25% to 56%. All percentages of correct answers improved greatly with training (P < 0.001) and retention remained high 7 months after training (P < 0.001).

CONCLUSIONS: Prevent Mother-To-Child Transmission programmes in settings such as rural Cameroon need to be adapted to the special needs of peripheral nurse-led clinics. Appropriate short training may considerably improve nurses' competence in PMTCT. Other important components are regular supervision and measures to guarantee supply of equipment in rural areas.

To link to the website containing this article, click here.

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FAMILY PLANNING/REPRODUCTIVE HEALTH

9. The effect of health and nutrition education intervention on women's postpartum beliefs and practices: A randomized controlled trial

Authors: Liu, N; Mao, L; Sun, X; Liu, L; Yao P; Chen, B
Source: BMC Public Health 1 Feb 2009, 9:45.

ABSTRACT

BACKGROUND: 'Sitting month' is the Chinese tradition for postpartum customs. Available studies indicate that some of the traditional postpartum practices are potentially harmful for women's health. However, no intervention study aiming at postpartum practices has been performed. In this paper we evaluated the effect of a health and nutrition education intervention, which focused on improving postpartum dietary quality and optimal health behaviors.

METHODS: The study design was a randomized controlled trial conducted in both urban and rural area of Hubei between August 2003 and June 2004. A total of 302 women who attended the antenatal clinic during the third trimester with an uncomplicated pregnancy were recruited. Women randomized to the education intervention group in both urban and rural area received two two-hour prenatal education sessions and four postpartum counseling visits. Control group women received usual health care during pregnancy and postpartum period. Women were followed up until 42 days postpartum. Outcome measures were nutrition and health knowledge, dietary behavior, health behavior and health problems during the postpartum period.

RESULTS: Women in the intervention groups exhibited significantly greater improvement in overall dietary behaviors such as consumption of fruits, vegetables, soybean and soybean products as well as nutrition and health knowledge than those in the control groups. Significantly more women in the intervention groups give up the traditional behavior taboos. The incidence of constipation, leg cramp or joint pain and prolonged lochia rubra was significantly lower in the intervention groups as compared with the control groups.

CONCLUSION: The study shows that health and nutrition education intervention enable the women to take away some of the unhealthy traditional postpartum practices and decrease the prevalence of postpartum health problems. The intervention has potential for adaptation and development to large-scale implementation.

To link to the website containing this article, click here. Full Text is freely available.

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10. The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: Results from a randomized controlled trial

Authors: Mullany, BC; Becker, S; Hindin, MJ
Source: Health Education Research Apr 2007, 22(2): 166-176.

Observational studies suggest that including men in reproductive health interventions can enhance positive health outcomes. A randomized controlled trial was designed to test the impact of involving male partners in antenatal health education on maternal health care utilization and birth preparedness in urban Nepal. In total, 442 women seeking antenatal services during second trimester of pregnancy were randomized into three groups: women who received education with their husbands, women who received education alone and women who received no education. The education intervention consisted of two 35-min health education sessions. Women were followed until after delivery. Women who received education with husbands were more likely to attend a post-partum visit than women who received education alone [RR = 1.25, 95% CI = (1.01, 1.54)] or no education [RR = 1.29, 95% CI = (1.04, 1.60)]. Women who received education with their husbands were also nearly twice as likely as control group women to report making >3 birth preparations [RR = 1.99, 95% CI = (1.10, 3.59)]. Study groups were similar with respect to attending the recommended number of antenatal care checkups, delivering in a health institution or having a skilled provider at birth. These data provide evidence that educating pregnant women and their male partners yields a greater net impact on maternal health behaviors compared with educating women alone.

To link to the website containing this article, click here. Full Text is freely available.

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11. Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: A cluster-randomised controlled trial

Authors: Kumar, V; Mohanty, S; Kumar, A; Misra, RP; Santosham, M; Awasthi, S; Baqui, A; Singh, P; Singh, V; Ahuja, RC; Singh, JV; Malik, GK; Ahmed, S; Black, RE; Bhandari, M; Darmstadt, GL; Saksham Study Group
Source: The Lancet 27 Sep 2008, 372(9644): 1151-62.

BACKGROUND: In rural India, most births take place in the home, where high-risk care practices are common. We developed an intervention of behaviour change management, with a focus on prevention of hypothermia, aimed at modifying practices and reducing neonatal mortality.

METHODS: We did a cluster-randomised controlled efficacy trial in Shivgarh, a rural area in Uttar Pradesh. 39 village administrative units (population 104,123) were allocated to one of three groups: a control group, which received the usual services of governmental and non-governmental organisations in the area; an intervention group, which received a preventive package of interventions for essential newborn care (birth preparedness, clean delivery and cord care, thermal care [including skin-to-skin care], breastfeeding promotion, and danger sign recognition); or another intervention group, which received the package of essential newborn care plus use of a liquid crystal hypothermia indicator (ThermoSpot). In the intervention clusters, community health workers delivered the packages via collective meetings and two antenatal and two postnatal household visitations. Outcome measures included changes in newborn-care practices and neonatal mortality rate compared with the control group. Analysis was by intention to treat. This study is registered as International Standard Randomised Control Trial, number NCT00198653.

FINDINGS: Improvements in birth preparedness, hygienic delivery, thermal care (including skin-to-skin care), umbilical cord care, skin care, and breastfeeding were seen in intervention arms. There was little change in care-seeking. Compared with controls, neonatal mortality rate was reduced by 54% in the essential newborn-care intervention (rate ratio 0.46 [95% CI 0.35-0.60], p<0.0001) and by 52% in the essential newborn care plus ThermoSpot arm (0.48 [95% CI 0.35-0.66], p<0.0001).

INTERPRETATION: A socioculturally contextualised, community-based intervention, targeted at high-risk newborn-care practices, can lead to substantial behavioural modification and reduction in neonatal mortality. This approach can be applied to behaviour change along the continuum of care, harmonise vertical interventions, and build community capacity for sustained development.

FUNDING: USAID and Save the Children-US through a grant from the Bill & Melinda Gates Foundation.

To link to the website containing this article, click here.

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C-Change, managed by AED, is USAID's flagship program to improve the effectiveness and sustainability of communication programs for behavior and social change in low and middle income countries.
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