EFFECTIVENESS OF CARE GROUPS AND INTERPERSONAL APPROACHES: EVIDENCE AND A RESOURCE

Tom Davis, Feed the Children

Jim Ricca, MCHIP

Henry Perry, JHU SPH

Mary DeCoster, Food for the Hungry

PRESENTATIONS Overview and introduction of presenters (5 mins) Presentation on the findings and analysis from Jim

Ricca’s Health Policy and Planning paper” (15 mins) Presentation on the findings from Perry and George's

review and analysis of CSHGP Care Group projects and the evidence regarding the effectiveness of PLA groups (Perry, 25 mins)

Q&A (15 mins) Present on changes and features of Care Groups that

are in the newly released FSN Network Care Groups manual (DeCoster, 15 mins)

Discussion on mechanisms of CG effectiveness, wrap-up, and next steps (15 mins)

RAPID INTRODUCTIONS

Name, Organization

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

Different from typical mothers groups: Each volunteer is chosen by her peers, and is responsible for regularly visiting 10-15 of her neighbors.

MAJOR PROGRAMMATIC INPUTS One paid Promoter (~10th grade educ.) per 700-1,200

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

Initial 6 day training on the Care Group model. 4-5 day training on each module, 3-4 trainings/yr for first

2 years. Health promotion materials (e.g. flipcharts) for Promoters

and CGVs, bicycles or motorcycles for Supervisors and Promoters, vitamin A, deworming meds, other supplies.

One Program Manager, 0.33 FTE M&E staff, 0.25-0.5 FTE HQ. Sometimes integrated into MOH structure.

Usually no food supplements provided and few “give-aways” aside from deworming tablets and vitamin A.

See www.CareGroupInfo.org for more details.

FH/Mozambique Care Group Model

Promoter #6

Promoter #3

Promoter #7

12 Leader Mothers

12 families12 families

12 families12 families12 families12 families12 families12 families

Promoter #5

Promoter #4

Promoters

(Paid CHWs)

Each Health Promoter educates and motivates 5 Care Groups. Each Care Group has 12 Care Group Volunteers (a.k.a., Leader Mothers)

12 families12 families

Promoter #2

Promoter #112 families

12 families

12 Leader Mothers

12 Leader Mothers

Each Care Group Volunteer educates and motivates pregnant women and mothers with children 0-23m of age in 12 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 720 beneficiary households.

12 Leader Mothers

12 Leader Mothers

CSHGP Programming Can Help Countries Significantly Accelerate Progress Toward

MDG4 May 8, 2014

Jim RiccaSenior Learning Advisor

MCHIP Washington

Presentation Overview

Analysis of typical set of pre-OR CSHGP projects:• What are coverage increases for child

health interventions?• What is estimated additional impact on

U5MR?• What implementation strategies are

responsible?• What are implications for donor priorities?

8

Acknowledgements

Co-authors: Nazo Kureshy, Karen LeBan, Debra Prosnitz, Leo Ryan

Also Michel Pacque, Claire Boswell, Karen Fogg helped with key pieces of analysis

Analysis wouldn’t have been possible without well-done & well-documented projects

9

Methods

Inclusion criteria: Final evaluation within 12 months of

when analysis of done (30 projects) Had complete baseline & final KPC (3

excluded 27 projects) DHS data within 3 years of baseline AND

3 years of final (15 excluded 12 projects)

Confirmed all coverage data, reviewed all project documents, interviewed manager 10

Logic model: Project documentation (top), implementation (middle), and analyses done in the publication (bottom)

INPUTS ACTIVITIES OUTPUTS OUTCOMES IMPACT

USAID + NGO match funds

USAID technical assistance to NGO

NGO partners with health facilities & district health system

Underlying epidemiological situation

NGO partners with community / civil society organizations

Project strategies to increase service quality

Project strategies to increase access to services

Project strategies to improve health-related behaviors of mothers / caretakers

Non-project activities that increase quality, access, and healthy behaviors

Increased quality of services

Increased access to services (e.g., peripheralization of services, bicycle ambulances, etc.

Improved determinants of mother / caretaker behavior (i.e., knowledge, attitudes), resulting in increased demand for services

Increased demand for utilization of health services (e.g. immunization, antibiotics for pneumonia, etc.)

Improved health behaviors (e.g., EBF, ORS use, etc.)

Decreased child morbidity and mortality

Projects report population based outcomes through KPC surveys

Analyzed population-based outcomes

Analyzed through review of documents and interviews of NGO staff

Funded through established NGOs , with same material & technical resources

Analyzed project inputs &contextual factors like health system strength

Projects report annually on progress against plan

Projects design activities with standard strategies & receive expert technical review

Summary report compiled, using LiST to estimate U5MR drop

Estimated through LiST modeling

Coverage increases for all interventions significantly better than trend

12

Estimated Impact (annual ARR for U5MR)

13

Implementation Strategies

Looked at six general strategies: facility improvement, governance groups, interpersonal BC, outreach, CHW treatment, local media approaches

Frequent IPC (at least monthly with a majority of caretakers) in 10 of 12 projects through outreach, community meetings, or HH visits – associated with better outcomes

14

Conclusions – CSHGP ahead of its time

11 of 12 better than trend (p = 0.003)

How much better? On average, U5MR decrease = 5.8% annually vs. 2.5% in comparison areas.

15

Conclusions (2)

Grantee strategies operationalized Alma Ata in a way that no set of projects before & very few since have done

CSHGP doing Implementation Science before it was recognized as such

16

Implications

Very few countries will make MDG4 targets.Many are calling for equity-focused strategies.

These approaches (community-based, heavily focused on IPC) approximately doubled ARR for U5MR (which is exactly what’s needed to reach targets).

17

Thank you to all who have been involved with CSHGP

for a generation, to grantees for phenomenal passion, dedication, and

effective work, and to partners and beneficiaries

all over the globe!18

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

Overview

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

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

Care Group Model

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

Edward et al. 2007

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

Perry et al., 2011

Source: Chapter in Essentials of Global Community Health, 2011

Davis et al., 2013

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

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)

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?

Participatory Learning and Action Groups

Prost et al., Lancet 2013

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

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

Lives Saved Tool (LiST) version 4.68

High-impact coverage indicators modelled in LiST

Coverage of 4 antenatal care visitsMultiple micronutrient consumption during pregnancySkilled birth attendancePostnatal preventive careExclusive breastfeeding Appropriate complementary feeding Handwashing

Presence of a latrineAntibiotic treatment of pneumoniaOral rehydration therapy for diarrheaInsecticide-treated bed net coverage; malaria treatment; IPTp coverageMeasles, tetanus and full immunization coverageVitamin A supplementation

Validation of LiST

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

• Ricca et al., BMC Public Health 2011

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.

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

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

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

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

Projects included in the analysis

Country Region Organization Type Project Period

Target area children 0-59 months

KenyaWestern 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

Projects included in the analysis

Country Region Organization Type Project Period

Target area children 0-59 months

KenyaWestern 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

Projects included in the analysis

Country Region Organization Type Project Period

Target area children 0-59

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

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

ANC4 TT2 IFA IPTp SBA EBF Comp Feed

PPV Vit A ITN Meas Full Vacc

Hand Wash

ORT Abx Pneum

Mal Treat

-20

0

20

40

60

80

100

Care Group ProjectsNon-Care Group Projects

Coverage Indicators

Me

an

Ch

an

ge

in C

ov

era

ge

1

64

9

3

2 3 5

78

9 7

3

2

4

8 5

8

9 8

5

9 5

9

3

8

26

3

3

1

0

High Impact Child Survival Indicator Coverage Changes

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)

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.

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

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

Cambodia Kenya Malawi Mozambique Rwanda0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00Care Group Projects

Non-Care Group Projects

Me

an

an

nu

al

pe

rce

nt

red

uc

tio

n i

n

U5

MR

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”

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

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?)

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)

Limitations

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

preferable, but this is not feasible

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)

Acknowledgments

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

Questions and Answers (up to 5:00 pm)

Care Groups: A Training Manual for

Program Design and Implementation

Manual developed by FH in 2012

Adapted by TOPS & FSN Network• Final draft projected for end of May 2014• Members of Care Groups Forward Interest Group and FSN’s SBC

Task Force: Piloted sections with field staff, reviewed, edited, added examples and additional material

• Piloted by TOPS: • June 2013 in Arlington VA• Liberia in July 2013• January 2014 in Washington DC

• Uptake is promising • PCI• World Vision• Counterpart International• Oxfam• CRS

What’s new/different in this version?• Reflects experiences and examples from multiple

NGO’S• Emphasis on Peer Support has been made explicit /

clarified• New lessons:

• Using Formative Research to Strengthen Care Groups

• Behavior Change and Care Groups• What Happens in a Care Group Meeting?• Conducting a Home Visit• Planning for Sustainability

What Happens at a Care Group Meeting? Facilitation Cues

Facilitation Cues:1. Objectives

2. Game or Song

3. Attendance and troubleshooting

4. Behavior change promotion (story) using pictures

5. Activity

6. Discuss barriers and solutions

7. Practice and Coach

8. Ask for a commitment

Interactive presentation on facilitation cues

Developed by Mitzi Hanold, Food for the Hungry

http://www.caregroupinfo.org/vids/CGFacilitation/story.html

The TOPS Program was made possible by the generous support of the American people through the United States Agency for International Development (USAID) Office of Food for Peace. The contents of this presentation do not necessarily reflect the views of USAID or the United States Government.

ATTN: COST EFFECTIVENESS

Cost per DALY averted in FH/Mozambique CG Project: $15 (cost per beneficiary/yr: $2.78)

Cost per DALY averted in Bangladesh PLA Project: $220-$393 (Fottrell, 2013)

KEY RESULTS OF CONCERN WORLDWIDE’S OR ON THE INTEGRATED CARE GROUP MODEL

Tested traditional CG model with NGO workers as Promoters vs. an “integrated” model where Burundi MOH CHWs serve as Promoters. Clusters randomized to each model.

Both models were successful in indicator improvement. No significant differences between the integrated in traditional model. 36 of 40 indicators were similar in results.

Met or surpassed all five CG operational indicators (attendance, home visits reporting). Cost per beneficiary was lowered $0.90/beneficiary.

Somewhat better sustainability trend (last 6m, no Promoters) in the integrated model.

HOW DOES PEER EDUCATION WORK?

What are your theories on why CGs work?Theories of health behavior, learning and social influence explain how peer education approaches work. Three primary mechanisms: Diffusion of new ideas Changing social norms Increasing self-efficacy / empowerment

Decreasing depression?

Empowerment/ Decreased GBV / Increased respect?

WHY PEER EDUCATORS WORK:CHANGING SOCIAL NORMS Prominent Theorists: Albert Bandura, Robert

O’Connor What those around us think is true is

enormously important to us in deciding what we ourselves think is true.

One means we use to determine what is correct is to find out what other people think is correct, especially in terms of the way we decide what constitutes correct behavior.

We view a behavior as more correct in a given situation to the degree that we see others performing it.

EXAMPLES OF CHANGING PERCEPTIONS OF SOCIAL NORMS TO CHANGE BEHAVIOR

EX: School-based antismoking program.

EX: Video for children terrified of dogs. (Bandura, Grusec, Menlove, 1967)

EX: Video for severely withdrawn children. (Robert O’Connor, 1972)

Catherine Genovese murder: Bystander inaction

Sign up on conserving water in the shower (“Navy shower”) – 6% compliance. One modeler: 49% do it. Two modelers: 67% compliance.

Which line is closer in length to the line on the left: Line A, Line B, or Line C?

Click for Asch conformity experiment video

WRAP-UP AND NEXT STEPS

Additional questions on the model/ findings? Are their models that you have seen that

are more effective than this in behavior change in the same amount of time? Given these results, should this become our default health promotion model?

What steps do you think we should take in further diffusing the model, especially given that the CSHGP program has closed?