Effectiveness of Care Groups and Interpersonal Approaches: Evidence and a Resource

Lives Saved Tool (LiST) Analysis of Care Group versus Non-Care Group

Child Survival Projects

Christine Marie George, PhD, International Health, JHSPH

Emilia Vignola, MSPH Candidate, International Health, JHSPH

Jim Ricca, MD, MPH, ICF Macro

Jamie Perin, PhD, International Health, JHSPH

Henry Perry, MD, PhD, MPH, International Health, JHSPH

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Overview

• What are Care Groups?• Rationale• Methods• Findings• Discussion• Conclusion and next steps

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What are Care Groups?

“A Care Group is a group of 10-15 volunteer, community-based health educators who regularly meet together with project staff for training and supervision. They are different from typical mother’s groups in that each volunteer is responsible for regularly visiting 10-15 of her neighbors, sharing what she has learned and facilitating behavior change at the household level. Care Groups create a multiplying effect to equitably reach every beneficiary household with interpersonal behavior change communication.

http://www.caregroupinfo.org/blog/criteria

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Care Group Model

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Rationale

• There is widespread experience with Care Group project implementation and enthusiasm is growing among program managers

• 23 organizations implementing Care Group projects in 20 countries

• Published articles documenting the effectiveness of Care Groups

• Edward et al. 2007• Perry et al., 2011• Davis et al., 2013

Christine Marie George

Can you show a map of where all the countries are located where Care Groups have been implemented?

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Edward et al. 2007

Examining the evidence of the under-five mortality reduction in a community-based programme in Gaza, Mozambique

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Perry et al., 2011

Source: Chapter in Essentials of Global Community Health, 2011

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Davis et al., 2013

Source: Journal of Global Health: Science and Practice, 2013

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Study Rationale

• Many evaluations of Care Group projects exist, but no systematic assessment of them

• More evidence of effectiveness of Care Groups is needed

• Participatory Learning and Action (PLA) Groups have substantial evidence of effectiveness from multiple randomized controlled trials and a meta-analysis of these results (and almost all of these results have been generated by the same research group)

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Research Questions

• Do Care Group CSHGP projects achieve greater improvement in high-impact child survival coverage indicators than non-Care Group projects?

• Do Care Group projects achieve greater reductions in the under-five mortality rate than non-Care Group projects?

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Participatory Learning and Action Groups

Prost et al., Lancet 2013

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Women’s Groups Practicing Participatory Learning and Action (PLA)

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Differences in Participatory Learning and Action (PLA) Groups and Care Groups

Care Groups PLA Groups

Type of empowerment

At Care Group level among Care Group volunteers (mostly)

At village level among pregnant women

Method of contact

One on one through home visits (mostly), ensuring all pregnant women or mothers of young children are included

At group meetings where all pregnant women are invited to come (with no strategy for recruiting all eligible women)

Type of interventions

Maternal, neonatal and child health Maternal and neonatal health

Process for education and behavior change

“Cascade” dissemination of one key message per round, ensuring that the complete repertoire of messages is covered (and with iteration presumably the conveyance of messages becomes more effective)

Facilitator shares health messages gradually while at the same time facilitating process for enabling women to reflect on how to take action

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Lives Saved Tool (LiST) version 4.68


Emma, Can you make a couple of screen shots for Henry.

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High-impact coverage indicators modelled in LiST

Coverage of 4 antenatal care visits

Multiple micronutrient consumption during pregnancy

Skilled birth attendance

Postnatal preventive care

Exclusive breastfeeding

Appropriate complementary feeding

Handwashing

Presence of a latrine

Antibiotic treatment of pneumonia

Oral rehydration therapy for diarrheaInsecticide-treated bed net coverage; malaria treatment; IPTp coverageMeasles, tetanus and full immunization coverage

Vitamin A supplementation

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Validation of LiST

• Several reports now have validated LiST as a measurement tool for estimating mortality impact

• Ricca et al., BMC Public Health 2011

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Care Group Eligibility Criteria

Selection criteria: Care Groups• Care Group projects found at: http://

www.caregroupinfo.org/blog/implementors• Project evaluations downloaded from the MCHIP website• DHS or MICS available for the country where the Care

Group project was conducted within 3 years of both the project baseline and endline

• A non-Care Group child survival project conducted in the same country within 3 years of the Care Group project where there was also a DHS and MICS survey available within 3 years of baseline and endline.


I would explain some of the LiST indicators. I think this was in our Table 2. I attached these figures and the methods section we drafted

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Non Care Group Eligibility Criteria

Selection criteria: Non-Care Group projects• There must be a DHS or MICS survey available

within 3 years of their baseline and endline survey• A Care Group project in the same country meeting

the criteria for inclusion


I would explain some of the LiST indicators. I think this was in our Table 2. I attached these figures and the methods section we drafted


Christine Marie George5/7/2014I would explain some of the LiST indicators. I think this was in our Table 2. I attached these figures and the methods section we drafted

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Eligible Child Survival Programs

• Nine care group and 12 non-care group child survival projects met these study eligibility criteria.

Care Group

projectsNon-Care Group

projectsCambodia 3 3

Kenya 1 2Malawi 2 1

Mozambique 3 1Rwanda 1 2

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Excluded Child Survival Programs

Care Group projects in three countries were excluded

• Liberia (MTI), no matching non-Care Group project• Guatemala (Curamericas), no recent DHS survey

available• Zambia (SAWSO), no recent DHS survey available

Non-Care Group projects excluded in one country• Malawi (PSI) – only nationally implemented• Malawi (STC) – no true baseline or endline surveys

available

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Projects included in the analysis

Country Region Organization Type Project Period

Target area children 0-59

months

Cambodia Kampong Thum

Adventist Development Relief

Agency Non-Care Group 2001-2006 17,477

Cambodia Battambang Catholic Relief

Services Non-Care Group 2001-2006 24,896

Cambodia Kampong Chhnang International Relief and Development Non-Care Group 2006-2010 6,217

Cambodia Siem Reap Red Cross Care Group 2005-2008 43,610

Cambodia Kompong Cham World Relief Care Group 1998-2002 12,167a

Cambodia Kompong Cham World Relief Care Group 2003-2007 12,875


Include headings here


Maybe it would be easier to break these down into two table grouped by country.It be also nice to see a summary table showing the number of care groups and non care groups in each country.

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months

Kenya Western Province

African Medical and Research

Foundation Non-Care Group 2005-2010 31,644

Kenya Rift Valley HealthRight Non-Care Group 2006-2010 48,844

Kenya Coast Plan Care Group 2004-2009 46,354

Malawi Southern RegionInternational Eye

Foundation Non-Care Group 2002-2006 42,500

Malawi Northern Region World Relief Care Group 2000-2004 36,732

Malawi Northern Region World Relief Care Group 2005-2009 32,025

Mozambique SofalaFood for the

Hungry Care Group 2006-2010 60,666

Mozambique SofalaFood for the

Hungry Care Group 2009-2010 83,778

MozambiqueManica and Sofala

ProvincesHealth Alliance

International Non-Care Group 2002-2007 97,200

Mozambique Gaza Province World Relief Care Group 2004-2009 33,451





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months

Rwanda Butare Province Concern Non-Care Group 2001-2006 24,494

Rwanda KibungoInternational

Rescue Committee Non-Care Group 2001-2005 109,700

Rwanda Cyangugu World Relief Care Group 2001-2006 24,021





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Model Assumptions

• Beginning under-5 mortality rate for the project is assumed to be the same as that for the region of the project (based on DHS data)

• LiST estimates the under-5 mortality rate at the end of the project according to changes in coverage of key child survival indicators

• The average annual change in under-5 mortality is calculated taking into account the length of the project

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High Impact Child Survival Indicator Coverage Changes


This table needs to be reformated, and the abbreviation should be listed in a small key next to the table

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Coverage Results

• For all 15 high-impact indicators for which change in coverage was calculated for Care Group and non-Care Group projects, the mean change in coverage was greater in the Care Group projects

• However, after controlling for country, the results are of marginal statistical significance, p=0.07 (using the Wilcoxon signed-ranked test)

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Coverage Results

• The difference in coverage was significantly greater for Care Group projects (p=0.014) (ignoring clustering effects by country)

• The probability of this result occurring by chance (assuming no clustering effects are present) is 0.0007.


I would check this with Jamie

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Under Age 5 Mortality Rates (U5MR)

Country Care (N) Non-Care (N)

Cambodia -5.52% (3) -4.23% (3)

Kenya -3.78% (1) -3.21% (2)

Malawi -3.23% (2) -3.64% (1)

Mozambique -5.18% (3) -3.66% (1)

Rwanda -5.70% (1) -0.94% (2)

Average -4.68 -3.14

Estimated mean annual percent change in U5MR


Henry I think some countries are missing here!

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Mean Annual Percent Reduction in Under Age 5 Mortality (U5MR)

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Summary findings

• Care Group projects have an estimated average annual under-5 mortality decline that is 1.49 greater than the non-Care Group projects

• The rate of decline of the estimate under-5 mortality rate for Care Group projects is 49% greater than for Care Group projects

• Malawi is an “outlier”

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Discussion

• Care Group projects achieve greater changes in coverage of key child survival interventions than non-Care Group CSHGP projects after controlling for the country in which the projects were implemented

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Discussion

Is the effect due to the Care Group methodology?• Not clear that any specific interventions achieve higher

coverage levels using Care Groups compared to those using other approaches

• Not clear what specifically it is about the Care Group methodology that makes it effective (or is it the net combination of characteristics of the methodology?)

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Alternative explanations

• The organizations that implement Care Groups are more effective than organizations implementing non-Care Group projects

• The contexts in which Care Group projects are implemented are more conducing to achieving higher coverage levels (even after controlling for the country of intervention)

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Limitations

• Small number of projects included in the analysis• Direct measures of mortality would be preferable,

but this is not feasible

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Next steps

• Since there are increasing numbers of Care Group projects with data for baseline and endline coverage, a further similar analysis with larger number of projects would be useful

• The growing evidence that Care Groups are effective suggests that there is now a need for randomized controlled trials involving Care Groups as one arm of an intervention (perhaps head-to-head with PLA groups)

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Acknowledgments

We are grateful for the support of the LiST Team•Yvonne Tam, MPH•Neff Walker, PhD•Ingrid Friberg, PhD

Effectiveness of Care Groups and Interpersonal Approaches: Evidence and a Resource

Health & Medicine

Transcript of Effectiveness of Care Groups and Interpersonal Approaches: Evidence and a Resource