Using Care Groups for Behavior Change in Nutrition and Health

Tom Davis, MPH

TOPS Senior Specialist for SBC

Session ObjectivesParticipants will be able to:1. Explain the impact of behavior change on child mortality. 2. Define Care Groups and name Care Group

characteristics.3. Explain the main result areas of Care Groups.4. Explain the rationale behind each of the Care Group criteria. 5. List the main processes and tools used with Care Groups

(Beneficiary Planning Sheet, major programmatic inputs, forming/working with CDCs, incentives, visual aids, lesson plans, worldview messages, stories, the ASPIRE method, formative research [BA and LDM Studies], Mini-KPCs, and other Care Group monitoring tools.)

Five-day trainings on Care Groups and other coverage strategies will be provided in 2012/2013 for FS implementers: Three Regional Trainings and Six Country-level Trainings.

The Care Group Strategy:A Strategy for Rapid, Equitable and

Lasting Impact for Maternal and Child Health Programs

By Carolyn Wetzel (FH Director of Health Programs ) andTom Davis Jr. (Senior Specialist for SBC, TOPS Project)

The Goal of Care Groups• Create a system whereby volunteer

Community Health Workers can sustainably do effective behavior change with pregnant women and mothers of children 0-23m

• Reduce U5MR, MMR, and malnutrition to contribute to the accomplishment of MDGs: 1:Eradice extreme hunger and poverty 3: Promoter Gender Equality & Empower Women 4: Reduce child mortality rates 5: Improve maternal health 6: Combat HIV/AIDS, malaria and other diseases

Household-level Behavior Change is Key

• A major key to successful and sustainable community health interventions is household-level behavior change. 

• Improvements in health facilities, the quality of care provided in health facilities and the availability of commodities are important to community health. However…

These factors will not lead to long-term impact on health outcomes unless there are innovative delivery strategies using evidence-based, community-informed solutions that lead to individual behavior change.

Do you agree?

A child death is a food security failure

Table 2: Under-5 deaths that could be prevented in the 42 countries with 90% of worldwide child deaths in 2000 through achievement of universal coverage with individual interventions

Estimated under-5 deaths prevented

Number of deaths (~103)

Proportion of all deaths

Preventive interventions Breastfeeding 1301 13% Insecticide-treated materials 691 7% Complementary feeding 587 6% Zinc 459 (351)* 5% (4%)* Clean delivery 411 4% Hib vaccine 403 4% Water, sanitation, hygiene 326 3% Antenatal steroids 264 3% Newborn temperature management 227 (0)* 2% (0%)* Vitamin A 225 (176)* 2% (2%)* Tetanus toxoid 161 2% Nevirapine and replacement feeding

150 2% Antibiotics for premature rupture of membranes 133 (0)* 1% (0%)* Measles vaccine 103 1% Antimalarial intermittent preventive treatment in pregnancy 22 <1% Treatment interventions Oral rehydration therapy 1477 15% Antibiotics for sepsis 583 6% Antibiotics for pneumonia 577 6% Antimalarials 467 5% Zinc 394 4% Newborn resuscitation 359 (0)* 4% (0%)* Antibiotics for dysentery 310 3% Vitamin A 8 <1%

Cumulative Impact of Household Behavior Change Interventions on Child Mortality Reduction:13%7%6%5%4%3%2%2%15%

57%Jones G, Steketee R, Bhutta Z, Morris S. and the Bellagio Child Survival Study Group. "How many child deaths can we prevent this year?" Lancet 2003; 362: 65-71.

What are Care Groups?

Developed by Dr. Pieter Ernst with World Relief/ Mozambique, and pioneered by FH and WR for the past decade. Now used by at least 22 organization in 20 countries.

Focuses on building teams of volunteer women who represent, serve, and do health promotion with blocks of <15 households each

A community-based strategy for improving coverage and behavior change

Small Group Activity:Care Group Criteria

• Divide into groups of about 5 people.• Go through the Care Group Criteria

Small Group Questions. Write your responses on newsprint.

• Small groups will report out responses when we come back to plenary.

• 30 mins for this small group work. You don’t have to finish all questions.

The Care Group Model

Promoter #6

Promoter #3

Promoter #7

12 Leader Mothers

14 families14 families

14 families14 families14 families14 families14 families14 families

Promoter #5

Promoter #4

Promoters (example, one district)

Each Promoter educates and motivates 5-9 Care Groups (9 in this example). Each Care Group has 6-16 CG Volunteers (12 in this example)

14 families14 families

Promoter #2

Promoter #114 families

14 families

12 Leader Mothers

12 Leader Mothers

12 Leader Mothers

12 Leader Mothers

12 Leader Mothers

12 Leader Mothers

Each Leader Mother educates and motivates pregnant women and mothers with children 0-23m of age in <15 households every two weeks. Children in households with children 24-59m are visited every six months.

Care Groups

With this model, one Health Promoter can cover up to 2,016 beneficiary households.

12 Leader Mothers

12 Leader Mothers

This example: “9x12x14 structure”

1Supervisor

CGV #10

CGV #1

CGV #7

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Care Group

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Prom

Who is Using Care Groups?

International Aid International Medical Corps International Rescue Committee Medical Teams Interenational Pathfinder PLAN Salvation Army World Service Save the Children World Relief World Vision

ACDI/VOCA ADRA Africare American Red Cross CARE Concern Worldwide Catholic Relief Services Curamericas Emmanuel International Food for the Hungry Future Generations GOAL

Where are Care Groups being Used? Banglades

h Bolivia Burkina

Faso Burundi Cambodia DRC Ethiopia Guatemala Haiti Indonesia

Kenya Liberia Malawi Mozambiq

ue Niger Peru Philippines Rwanda Sierra

Leone Zambia

What works in behavior change?Findings from Powerful to Change Studies

CORE SBCWG compared low and high performers for several behaviors (e.g., exclusive BF, hand washing with soap) – what works?

1. Using formative research (e.g., positive deviance studies, Barrier Analysis, Trials of Improved Practices) to find the determinants of behaviors and to choose the right messages/activities; and

2. Using a comprehensive coverage strategy: Using systematic home visitation or Care Groups to reach almost all beneficiaries very often (e.g., 95% every two weeks).

Care Groups Outperform in Behavior Change:Indicator Gap Closure: Care Group Projects

vs. CSHGP AverageIndicator Gap Closure on Rapid Catch Indicators:

Care Groups CSHGP Projects vs. All CSHGP Projects

32

4135

52

71

59

39

53 51

77

49

63

37

53

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90

RapidCATCH Indicator

Perc

ent

All CSHGPs, 2003-2009 (n=58)

CSHGP using CareGroups (2003-2010,n=9)

Gap closure range for Care Group projects: ~35 – 70%(Avg = 57%)

Gap closure range in non-CG projects ~25 – 45% (Avg. = 37%)

Care Group Performance: Perc. Reduction in Child Death Rate (0-59m)in Thirteen CSHGP Care Group Projects in Eight Countries

(Green line = average of USAID child survival programs)

23%

33%

48%41% 42%

32% 28% 29%

14%

26%

12%

34% 30%

14%

33%

0%10%20%30%40%50%60%

CSHGP Project

% R

ed. U

5MR

Series1

Care Groups and Estimated Reduction in Child Deaths

Target 60%

Care Groups Can Bring about Rapid and Significant Changes in BF Behavior

(22m)

Care Groups Can Bring about Rapid and Significant Changes in Health Service Coverage

Target 75%

Target 80%

Care Groups Can Bring about Rapid and Significant Changes in Feeding Behavior

Care Groups Can Bring about Significant Changes in Feeding Behavior

80% of these are statistically-significant changes

Institional Births in Project Districts and Comparison Districts

0

1000

2000

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6000

1s 2006 1s 2007 1s 2008 Oct09-Mar10

Time PeriodNum

ber o

f Birt

hs

Caia,Chemba, Marin(Proj Dists)

Buzi, Chib (CompDistricts)

Source: Moz MOH

Care Groups Can Bring about Rapid and Significant Changes in Health Service

Utilization (FH/Moz)

26.2%

20.5%

29.5%

19.6%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Area A Area B

FH/Moz CS Final Evaluation: Changes in Underweight (WAZ<-2)

Baseline

Final

Over a five year period

34% reduction

22% reduction

Over a 20 month period

Care Groups Can Bring about Rapid and Significant Changes in Impact(Underweight reduction, Feb ‘06-July ’10,

FH/Moz)

What about sustainability??• The plan: Interventions phased in then responsibilities slowly

shifted from project-paid Promoters to MOH staff or Care Group leaders. Actuality: CG Volunteers continue home visits on their own, and sometimes meet together.

• WR Data from Gaza Province, Mozambique: 93% of the 1,457 volunteers active at the end of WR’s Care Group project were active meeting with mothers or doing home visits with flipchart 20 months after end of project.

• Out of the vacant roles, communities replaced 1/3 of them and trained them on their own.

• Changes brought about in the original program were maintained: A full 45 months after the end of the project (all interventions and funding ceased), final program goals on eight key indicators continued to be exceeded.

Sustainability of Final Indicator Levels Four-Years Post-Project in the WR-Mozambique Care Group Project: Home Care of Sick Children(Note: Black line is project goal. Red line is actual indicator levels.)

Children with Diarrhea Treated with ORS

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End of Project

45m post-project

Sustainability of Final Indicator Levels Four-Years Post-Project (WR-Mozambique Care Group Project): Preventive Services

Children 12-23m Completely Vaccinated

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%End of Project

45m post-project

Small Group Brainstorm Divide into same small groups and

brainstorm a list of WHY you think Care Groups are outperforming other behavior change methods.

This list can include anything that we can/should apply to other behavior change approaches.

15 mins for this small group work.

Time Contribution (in hours) by Type of Project Staff

FH/Mozambique Care Group ProjectOctober 2005 – September 2010

80% of the work was done by Care Group Volunteers, and 97% by community members (CGVs + Promoters).

Community driven …

Other Care Group Best Practices

• Have the neighbors in the 5-14 households that the CGV will serve (visit and teach) elect the CGV.

• Contact with beneficiary mothers by the CGV can be through group meetings but also through individual home visits. (In FH/Moz CG Project, 70% of CGVs had contact with their mothers mostly or exclusively in group settings, and 30% had contact with beneficiary mothers mostly/exclusively through individual home visits.) Regardless, home visits are made to meeting defaulters.

• Groups should be facilitated by paid Promoters or other health/nutrition staff.

Other Care Group Best Practices

• Care Group Volunteers should not be paid, but only receive very infrequent small non-monetary incentives like wrap-around skirts every two years. Respect is probably the most important incentive. (See www.CareGroupInfo.org)

• Turnover of Care Group Promoters and Volunteers has generally been very low when incentives are used in this way.

• Training of Care Group members should be done in the community (at low cost).

A Care Group Promoter

Other Care Group Best Practices

• Messages – including gender messaging – should also be communicated to other family members, daughters in particular. Changes in relationships and gender-based violence are sometimes seen.

• Low Cost: By using this cascading structure, for the entire FH/Mozambique CG project, the cost per beneficiary per year was USD $2.78. (The cpb range for nine CG projects was $2.78 - $7.91; average was $5.77.)

A Beneficiary Mother

Selected Gender Indicators measured in the Care Group O.R. KPCMother Leader

% of CGVs who say they have gained more respect from.. since they began participating in the project… from health facility personnel 25%…from their extended family 41%… from their parents or husbands’ parents 48%… from their husbands 61%… from their community leaders 64%… from their mothers / other women / mother beneficiaries 100%% of CGVs who say that it is okay for a husband to hit his wife if he is not satisfied with her (final level shown; baseline was ~64%) 3%

Gender Equity Improvements: Respect

Wetzel, C, Davis Jr., T. Results of Care Group Operational Research conducted April to May 2010 as part of the project: Achieving Equity, Coverage, and Impact through a Care Group Network. Funded by USAID, Cooperative Agreement: GHS-A-00-05-00014-00.

How can your Organization Use

Care Groups?

Design and Implementation of

Care Groups Projects

By Carolyn Wetzel (FH Director of Health Programs ) and Tom Davis Jr. (Senior Specialist for SBC, TOPS Project)

“How To” Topics• Major Programmatic Inputs • Use of the Care Group Beneficiary Worksheet• Use of Community Development Committees• Use of visual aids• Use of worldview messages• Use of lesson plans• Use of stories• Use of the ASPIRE health promotion method• Use of formative research• Use of Mini-KPC surveys

NOTE: • The Care Group Difference manual is available at CORE Group website

and www.CareGroupInfo.org. • Three Coverage Strategies / Care Group Regional Trainings and six

country-level trainings to be offered by TOPS in the coming years (beginning FY13).

What you Need:Major Programmatic

Inputs• One paid Promoter minimum (7th grade education or

higher) per 2,016 beneficiary households, and one Supervisor (nurse) per 7-10 Promoters.

• 4-5 day training on each module (module taught in Care Groups in a 2-3m period), 3-4 trainings/year for first two years. Often 8-12 modules. C-IMCI training, optional.

• Color health promotion materials (e.g., flipcharts or cards) for Promoters and CGVs, bicycles for Promoters, Motorcycles for Supervisors, and some supplies for beneficiaries (e.g., vitamin A, deworming meds).

• One Program Manager, 0.5 FTE M&E staff, 1 FTE Trainer is helpful, 0.25-0.75 FTE HQ backstop is common.

• MOH involvement (coordination, joint supervision, etc.) is very helpful and may increase sustainability.

Planning Care Group Staffing/Volunteers

Click to Open

Forming or working with Community Development Committees• Formed in each area with a Care Group – comprised of men,

women, religious leaders, political leaders, etc. Try to include at least one CGV if not one from each CGV in the area.

• Leadership training provided, often includes Participatory Rural Appraisal and the development of a community workplan.

• Role:– Taking responsibility and ownership in planning and implementing

community development activities– Encouraging and supporting existing community groups (Care Groups,

Farmer Field School groups, others)– Advocacy for community needs to wider community and district

governance structures• May require additional staffing

Purpose of Visual Aids used in Care Groups

Purpose of the visual aids is NOT primarily to teach new facts, but to change BEHAVIOR and help GUIDE THE CGV in what they promote. To assure this happens, you should: – Teach Promoters and CGVs in the use of simple

non-formal education techniques, and – Conduct Formative Research to modify the

curricula according to (1) what is driving malnutrition and (2) what barriers exist to behavior change.

Use of Worldview Messages• Worldview messages relate to how one views life

including the environment, germs and people, and can block people from practicing healthy behaviors.

• Teaching people new prevention practices sometimes will not be enough – sometimes new perspectives on life are needed.

• Example: “I can change, and I can and should be an agent of change in my community.”

What is done in the CG Meeting? Example Lesson Plan Outline

• Game (e.g., Germ in the Circle; blindfolded tag game)• Take attendance and Troubleshooting• Share the story and ask about current practices: Hardship

(boy’s name) Has Diarrhea• Show pictures and share key messages on flipchart pages

6-11 about diarrhea transmission, care and treatment. • Activity: Dehydration Demonstration (with water in bag)• Probe about possible barriers and help them to find

solutions (inform) • Practice with flipchart and Coaching in a small group• Request a commitment• Examine previously promoted practices (e.g., going to a

GM/P post).

Use of Open-ended Stories• Open-ended stories are usually used in FH’s Care Groups. The

ending is provided by the participants.• Open-ended stories get people to imagine their response to a

situation, and to reflect on what they know and believe. • Open-ended stories help people to talk about difficult

situations without people taking the discussion personally.• Consider using a wise mother and a new mother in stories.• Lessons usually begin with a story: Usually Mother B

practicing an unhealthy behavior or having a problem and needing help.

• The discussion after the story gives participants a chance to discuss Mother B’s behavior and give her advice.

Non-formal education techniques: The ASPIRE Method

• A– Ask about mothers’ current practices based on a discussion about Mother B’s situation.

• S – Show/Share key messages from the flipchart pages.• P – Probe, asking the mothers and families what they think

about these practices and barriers to adoption. Is there anything that would prevent you from doing [these practices]?

• I – Inform them of ways to overcome the barriers mentioned; clarify misunderstandings.

• R – Request a verbal commitment to the new practices (however, they can say NO – it is their choice to decide; don’t’ ask unless they sound interested).

• E – Evaluate their past behaviors related to the last session – sees how they are doing keeping these commitments.

How ASPIRE is Integrated into the Lesson Plan

Section name Time needed for this section

Game Attendance and TroubleshootingAsk about current practices after Story (pic. 1)Show/share key msgs and Explain (picture 2) Show and Explain (pic.3) Show and Explain (picture 4) Activity (e.g., demonstration)Probe (about ideas on behavior and barriers)Inform (on ways to overcome barriers) Practice and CoachingRequest (a commitment)Examine (previously promoted practices)

10 minutes 15 minutes10 minutes 5 minutes 5 minutes5 minutes15 minutes10 minutes5 minutes20 minutes2 minutes5 minutes

1 hour, 50 minutes

Ask about mothers’ current practices

Show/Share key messages

Probe mother’s ideas and barriers

Request a verbal commitment

Pictures in Flipchart Remind CGV of ASPIRE Steps

Alternative to ASPIRE

1. Ask about Current Behaviors

2. Show/Share key messages

3. Prober for Barriers

4. Request Commitments

Using the Curricula• See Sample Care Group Lesson Plan List Handout –

Many lesson plans available on curricula page of www.CareGroupInfo.org.

• In most Care Group projects one lesson is covered every two weeks, so if you have six lessons in a module it will take three months to teach the module.

• In rural areas, seasons of rain or harvest may affect the ability of Care Groups to meet. It is recommended that your teaching schedule be adapted to allows for time periods of low CG activity.

Using Formative Research to adapt curricula to local context

• What sort of formative research studies do you think are the most helpful in developing behavior change curricula, whether you are using Care Groups or not?

• Positive Deviance Inquiries can be useful (e.g., Local Determinants of Malnutrition Studies) to identify the most important behaviors to change (those linked with malnutrition).

• Barrier Analysis or Doer/NonDoer Analysis to help staff to better understand how to successfully promote behavior change by identifying the most important barriers to change. (Also used Verbal Autopsy and HF Assessment in Moz.)

• Barrier Analysis will be discussed on Thursday, 2:00p, as part of the Designing for Behavior Change session.

• Narrated presentations on Care Groups, LDM Studies, and Barrier Analysis available at www.CareGroupInfo.org.

Important BF Results of a Local Determinants of Malnutrition Study

(Mozambique)45% of mothers of PD children said that they usually or always completely emptied their breasts when breastfeeding their PD child. Only 10% of mothers of malnourished children said that they did usually or always do so. (p=0.006) The odds ratio for this variable was 7.09 (1.36 < OR < 46.45) meaning that mothers of PD children were about seven times more likely to do this.

KEY Message: When breastfeeding a child, it is important to always completely empty each breast so that the child gets all of the calories and nutrients that they need.

KEY MESSAGE: The Milk Changes during Breastfeeding. The longer the child breastfeeds on one breast the

richer the milk becomes in protein and fat.

The FIRST milk

(watery milk)

The THIRD Milk

(creamy)

The SECOND

Milk (normal)

67% of mothers of PD children vs. 32% of mothers of malnourished children took at least one month of iron supplements during the months that they were breastfeeding.

The odds ratio for this variable was 4.05 (0.99<OR<18.83). Mothers of PD children were more than four times as likely to take iron supplements during breastfeeding as were mothers of malnourished children.

KEY Message: All mothers should take iron supplements during pregnancy and while lactating as a way to help their children grow.

Important BF Results of a Local Determinants of Malnutrition Study

(Mozambique)

Monitoring of Care Groups:Mini-KPCs

• Development projects typically measure impact and progress toward targets at midterm when only 40% of the project is left to be completed.

• Mini-KPCs can be used to to improve program effectiveness by targeting indicators that are not improving as expected.

• Mini-KPC’s are short surveys that are conducted every three to twelve months.

• Survey results can be easily analyzed by field offices and the results quickly obtained to inform program decisions.

Complete vs Mini KPCComplete KPC • Include many questions (+/-

60)• Require large amounts of

staff time for training, implementation, and analysis

• Attempts to provide information that allows for a program (or program area) to be completely assessed or evaluated.

Mini-KPC ► Includes 12-20 question (2-3

page questionnaire)► Is done frequently, so after

the initial training can be easily implemented and analyzed.

► Staff with little statistical training can do the analysis and quickly use the results. LQAS often used.

► Attempts to provide frequent feedback about specific aspects of a program.

Mini-KPC Example• The results of the December 2007 mini-KPC indicated

that children 6-23m receiving 3+ meals a day was below target in 2 of the 5 project districts.

Child ate solid or semi-solid foods 3+ times last 24h

13

8

19

15

7

0

5

10

15

20

Manga Caia Marromeu Chemba Maringue

Child ate solid or semi-solidfoods 3+ times last 24h

Decision Rule is 10 for proj. target of 65%

Mini-KPC Example

• Program management realized that unless feeding frequency was increased the project goal of decreasing malnutrition would not be reached.

• The team decided that more health promotion and skill building needed to be done in promoting snacks for children.

• Created snack recipes and shared them with mothers.

Decision Rule is 8 or 9Decision Rule is 10 for proj. target of 65%

Mini-KPC ExampleOne Year Later

• Main monitoring tool should be the Mini-KPC looking for behavior change.

• Promoter Monthly Report and Program Manager Monthly Report

• Quality Improvement and Verification Checklists: Full session on use of QIVCs on Thursday at 4:00p

Monitoring of Care Groups:Other Tools

Your Questions on…

• When to use and not use Care Groups?• Incentives?• Developing lesson plans and flipcharts?• Promoter’s, CGV’s, or Supervisor’s role?• Monitoring CGs?• Anything else?

Remember:Respond to the call for participants for the three regional and six country-level five-day skill-building trainings on Care Groups and other coverage strategies that will be provided in 2012/2013 for FS implementers

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Save the Children and do not necessarily reflect the views of USAID or the United States Government.