1. PSI BCC DALYs Washington DC March 18, 2009

2. 2 BCC DALYs in PSI Balanced Scorecard 10% of annual DALYs in 2011 from BCC DALYs. 10% of annual DALYs in 2011 from BCC DALYs. 2.2 million BCC DALYs in 2011. 2.2 million BCC DALYs in 2011.

3. 3 BCC DALYs averted in 2008 PSI activities averted 13,540 BCC DALYs. PSI activities averted 13,540 BCC DALYs. 13,440 DALYs from BCC in India to increase consistent condom use among male clients of FSWs. 13,440 DALYs from BCC in India to increase consistent condom use among male clients of FSWs. 100 DALYs from BCC in Kenya to increase frequency of condom use among male youth 15-24 yrs old. 100 DALYs from BCC in Kenya to increase frequency of condom use among male youth 15-24 yrs old.

4. 4 What is a BCC DALY? A BCC DALY is a DALY averted from behaviour change communications aimed at changing a behaviour of interest, e.g. increase in consistent condom use among young people. A BCC DALY is a DALY averted from behaviour change communications aimed at changing a behaviour of interest, e.g. increase in consistent condom use among young people. Examples to differentiate between a product DALY and a BCC DALY. Communication without product distribution, will get BCC DALYs (if there is evidence of impact) Communication without product distribution, will get BCC DALYs (if there is evidence of impact) Communication with product distribution, you get product DALYs & BCC DALYs (if there is evidence of impact. BCC DALYs are adjusted to avoid double-counting of product DALYs) Communication with product distribution, you get product DALYs & BCC DALYs (if there is evidence of impact. BCC DALYs are adjusted to avoid double-counting of product DALYs) Counseling and Testing service will get product DALYs Counseling and Testing service will get product DALYs Male Circumcision cutting/procedure will get product DALY Male Circumcision cutting/procedure will get product DALY

5. 5 BCC DALYs models currently available We have 5 DALY models estimating the impact of BCC on: 1. Reducing sharing of needles/syringes among injecting drug users (IDUs) 2. Reducing initiation of injection 3. Preventing heterosexual transmission of HIV among female sex workers (FSWs) 4. Preventing heterosexual transmission of HIV among non-FSWs 5. Preventing homosexual transmission of HIV among men having sex with men (MSMs)

6. 6 BCC DALY models in the pipeline We plan to build 5 additional DALY models in 2009 estimating the impact of BCC on: Male Circumcision Male Circumcision Counseling and Testing Counseling and Testing Multiple Concurrent Partnerships Multiple Concurrent Partnerships Blood Donations (Haiti only) Blood Donations (Haiti only) Overdose deaths from IDU (Russia only) Overdose deaths from IDU (Russia only)

7. 7 Non-HIV BCC DALYs Do we have BCC interventions in this health area? MalariaSeveral interventions taking place – we will follow-up Chris White RHDemand creation for clinics inserting IUDs and Implants. Child Survival? TBYes

8. 8 How are BCC models built? Example: Reducing number of sexual partners among youth Pre InterventionPost Intervention Number of sexual contacts Condom use Sexual Behavior Abstinence Number of partners Probability of HIV infection before intervention Probability of HIV infection after intervention - DALYs averted Number of infections averted Number of people covered by your program

9. 9 How can you feed the beast? Implement behaviour change communication interventions Implement behaviour change communication interventions Conduct 2 rounds of TRaC surveys to measure change in behavior of interest. Conduct 2 rounds of TRaC surveys to measure change in behavior of interest. Baseline survey to measure behavior of interest pre-intervention and Baseline survey to measure behavior of interest pre-intervention and Follow-up survey to measure behavior of interest post-intervention. Follow-up survey to measure behavior of interest post-intervention. Submit required data Submit required data

10. 10 Data Requirements  Conduct pre-intervention (1 st round) and post-intervention (2 nd round) TRaC surveys  Behavior of interest of the intervention has to be collected in both rounds of TRaCs  Model parameters have to be collected in at least one round of data (most recent round preferred). Suggested questions for various BCC models are available on PSI website.  Clean your data  Conduct monitoring and evaluation analysis.  If you detect a desired change in behavior of interest over time, upload the following to Research & Metrics KIX monthly marking them with an X (in red):  Cleaned data sets  Questionnaires   A brief description of the intervention, including purpose of the intervention, target population, behavior of interest, intervention approach and activities, and time period of intervention  Suggestion on which variables to use for creating exposure variable  Evaluation table

11. 11 What happens to data after you upload them to KIX R&M performs monitoring and evaluation analysis R&M performs monitoring and evaluation analysis If impact is detected… We work with field researchers & programmers on population size estimation We work with field researchers & programmers on population size estimation Translate behavior change resulting from the intervention to BCC DALYs averted Translate behavior change resulting from the intervention to BCC DALYs averted Share the results and analyses with you Share the results and analyses with you

12. 12 When do you get BCC DALYs? Evidence of desired change in behavior of interest AND this change is attributable to PSI intervention  BCC DALYs accrue. Evidence of desired change in behavior of interest AND this change is attributable to PSI intervention  BCC DALYs accrue. No evidence of desired change in behavior of interest as a result of PSI intervention  no BCC DALYs accrual, sorry. No evidence of desired change in behavior of interest as a result of PSI intervention  no BCC DALYs accrual, sorry.

13. 13 Why some countries have BCC DALYs and others do not? Country Target Pop Behavior of interest of intervention Time Trend s Impact BCC DALYs BaselineFollow-up Non-Exposed Follow-up Exposed India Cliens of FSWs Consistent condom use with FSWsY63.2a67.4a81.0b13,440 Kenya Male YouthFrequency of C use w casual partnerY57.8a63.5a74.2b100 Male Youth Frequency of C use w other types of partnerN 0 ThailandIDUsSharing Needles/SyringesY30.6a19.7b27.7ab0 IDUsC use w. casual partnerY62.3a78.9b83.4b0 IDUsC use w. other types of partnerN ChinaIDUsSharing Needles/SyringesN 0 IDUsConsistent condom use w all partnersY Field detected impact, not done in DC as "# of partner by type" not collected Pending RussiaMSMsNumber of partnersN 0 MSMsC use at last sex w commercialY54.6a72a97.2b In progress MSMsC use at last sex w other types of partnerN 0

14. 14 How can YOU estimate the number of BCC DALYs averted from an intervention? Example: BCC model to Prevent Heterosexual Transmission of HIV  Use the BCC model worksheets on PSI website

15. 15 The excel sheet will help you get a preliminary number of BCC DALYs for proposals, MBOs,.. The excel sheet will help you get a preliminary number of BCC DALYs for proposals, MBOs,.. The excel sheets will not give you the conclusive number of BCC DALYs. The excel sheets will not give you the conclusive number of BCC DALYs. Only monitoring and evaluation analysis done by Metrics will yield the conclusive number of BCC DALYs. Only monitoring and evaluation analysis done by Metrics will yield the conclusive number of BCC DALYs. How can YOU estimate the number of BCC DALYs averted from an intervention? (cont’d)

16. 16 Some FAQs “How does the BCC DALY differ from the product DALY?” “How does the BCC DALY differ from the product DALY?” “How do I avoid double counting from condom sales?” “How do I avoid double counting from condom sales?” “My BCC program has been ongoing for years. Can I retroactively calculate BCC DALYs?” “My BCC program has been ongoing for years. Can I retroactively calculate BCC DALYs?” “My BCC program has been ongoing for years but I have not collected the required data. How will this affect my BCC DALYs?” “My BCC program has been ongoing for years but I have not collected the required data. How will this affect my BCC DALYs?” “ Do I get BCC DALYs for behavior maintenance?” “ Do I get BCC DALYs for behavior maintenance?” “My program gained 10,000 DALYs during a2-year period. What do the 10,000 DALYs gained mean?” “My program gained 10,000 DALYs during a2-year period. What do the 10,000 DALYs gained mean?” “If I have BCC activities with a high risk group, but am conducting TRaC surveys with the general population, how do I get BCC DALYs for the high risk group activities?” “If I have BCC activities with a high risk group, but am conducting TRaC surveys with the general population, how do I get BCC DALYs for the high risk group activities?”

17. 17 FAQ “How does the BCC DALY differ from the product DALY?” Product DALY Models Produce coefficients (i.e., number of DALYs gained per PSI product sold) Produce coefficients (i.e., number of DALYs gained per PSI product sold) A set of sexual behavior data applied to all PSI platform A set of sexual behavior data applied to all PSI platform PSI branded condoms are counted only PSI branded condoms are counted only BCC DALY Models Produce no coefficients Produce no coefficients Accrue DALYs based on the pre- & post-intervention TRaC studies Accrue DALYs based on the pre- & post-intervention TRaC studies If the intervention does not change behavior of interest, no DALYs will be gained If the intervention does not change behavior of interest, no DALYs will be gained All condoms (not only PSI condoms) are taken into account because the BCC intervention aims at increasing condom use in general, not use of PSI condoms only. All condoms (not only PSI condoms) are taken into account because the BCC intervention aims at increasing condom use in general, not use of PSI condoms only.

18. 18 FAQ “How do I avoid double counting from condom sales?” When a country has both BCC and condom social marketing programs, there is a risk of double counting DALYs from condom sales and from BCC interventions aimed at increasing condom use. When a country has both BCC and condom social marketing programs, there is a risk of double counting DALYs from condom sales and from BCC interventions aimed at increasing condom use. To avoid double counting (for BCC DALYs): To avoid double counting (for BCC DALYs): Take into account increase in use of non-PSI branded condoms only Take into account increase in use of non-PSI branded condoms only Data on condom brand Data on condom brand Market share data when condom brand data is not available Market share data when condom brand data is not available

19. 19 FAQ “My BCC program has been ongoing for years. Can I retroactively calculate BCC DALYs?” Yes, if you have collected the behavior of interest of the intervention in at least two rounds of survey and included the suggested questions in at least one survey. Yes, if you have collected the behavior of interest of the intervention in at least two rounds of survey and included the suggested questions in at least one survey.

20. 20 FAQ “My BCC program has been ongoing for years! If I can’t retroactively calculate BCC DALYs, then won’t my current DALY measure be low since I can’t compare existing levels of behavior to the true baseline, which was conducted before my intervention began?” Probably. For an ongoing multi-year BCC, if the true baseline data is not available, we are not able to compare the most recent round of data to the true baseline. In this case, the earliest available round of data will serve as a ‘baseline’. Probably. For an ongoing multi-year BCC, if the true baseline data is not available, we are not able to compare the most recent round of data to the true baseline. In this case, the earliest available round of data will serve as a ‘baseline’.

21. 21 FAQ Time Behavior of interest T0T1T2   Yes. Your program has maintained the behavior above the level of T0 during T1 ~ T2, therefore, DALYs can be claimed due to the maintenance.   DALYs gained for any period would be the DALYs above the baseline. “ Do I get BCC DALYs for behavior maintenance?”

22. 22FAQ Time Behavior of interest Jan, 06Jan, 07Jan, 08   We assume changes in behavior occur steadily over the intervention period. DALYs gained follow the same pattern.   In this example, 5,000 DALYs are gained in 2006 and 10,000 DALYs are gained in 2007compared to baseline. “Baseline was conducted in Jan 2006 and follow-up in Jan 2008. The program gained 10,000 DALYs during the 2-year period. What do the 10,000 DALYs gained mean?” 5000 DALYs gained 5000 DALYs gained

23. 23 FAQ “If I have BCC activities with a high risk group, but am conducting TRaC surveys with the general population, how do I get BCC DALYs for the high risk group activities?” In order to generate BCC DALYs for a specific population, you must have a TRaC survey for that population. In order to generate BCC DALYs for a specific population, you must have a TRaC survey for that population. You can only generate BCC DALYs for general population activities from a TRaC survey among the general population. You can only generate BCC DALYs for general population activities from a TRaC survey among the general population.

24. 24 FAQ “What is the best way to measure the impact of a behavior change communication (BCC) intervention?” The best way is to conduct both a baseline and follow-up survey that include indicators to measure change in incidence of relevant diseases. PSI programs - as appropriate given funding, capacity, and other factors - attempt to push measurement of health impact as far "up" the log frame as possible, including in some cases measuring actual incidence and/or prevalence of Malaria, TB, STI, and other diseases or causes of morbidity and mortality. The best way is to conduct both a baseline and follow-up survey that include indicators to measure change in incidence of relevant diseases. PSI programs - as appropriate given funding, capacity, and other factors - attempt to push measurement of health impact as far "up" the log frame as possible, including in some cases measuring actual incidence and/or prevalence of Malaria, TB, STI, and other diseases or causes of morbidity and mortality. Many of the diseases that PSI is working on can be prevented through behavior change. Measuring changes in risk behaviors therefore can help indicate that our activities decrease the number of new infections. Many of the diseases that PSI is working on can be prevented through behavior change. Measuring changes in risk behaviors therefore can help indicate that our activities decrease the number of new infections. In addition to measuring changes in behavior of interest and relevant determinants, PSI has developed and is developing DALY models for each BCC intervention so that the health impact can be measured using one single indicator (DALY averted) for interventions across different health areas and variant target population. In addition to measuring changes in behavior of interest and relevant determinants, PSI has developed and is developing DALY models for each BCC intervention so that the health impact can be measured using one single indicator (DALY averted) for interventions across different health areas and variant target population.

25. 25 Toolkit Chapter: TRaC, Communications, and the DALY Toolkit Chapter: TRaC, Communications, and the DALY Provides instructions on how to collect necessary data to enable Research & Metrics to determine and attribute DALYs averted for the health impact of communications activities. Provides instructions on how to collect necessary data to enable Research & Metrics to determine and attribute DALYs averted for the health impact of communications activities. http://www.psi.org/research/toolkits/trac_communications_dalycalc_july_2008.pdf Toolkit Chapter: TRaC, Condom sales and the DALY Calculator Toolkit Chapter: TRaC, Condom sales and the DALY Calculator Provides step-by-step instructions to PSI social marketers and researchers on how to use TRaC surveys to generate the HIV risk profile of PSI condom users. Provides step-by-step instructions to PSI social marketers and researchers on how to use TRaC surveys to generate the HIV risk profile of PSI condom users. http://www.psi.org/research/toolkits/trac_condom_sales_dalycalc_july_2008.doc PSI website PSI website http://www.psi.org/research/http://www.psi.org/research/ (BCC DALY tab) http://www.psi.org/research/ HIV Department for HIV BCC interventions HIV Department for HIV BCC interventions BCC Resources