Care Group InnovationsCarolyn Kruger

Senior Advisor, Maternal, Newborn and Child Health, PCI

Jennifer WeissHealth Advisor, Concern Worldwide

Mary DeCosterCoordinator for SBC Programs, FH/TOPS

Melanie MorrowDirector of MCH Programs, World Relief

Tom DavisChief Program Officer, FH &

Senior Specialist for SBC, TOPS Project

Objectives

• Hear several presentations on ways in which the Care Group model is being modified and tested by multiple PVOs.

• Hear an update on multi-sectoral peer education models which are similar to Care Groups.

• Generate operations research questions that can be used to further advance the model.

What are Care Groups?

• Developed by Dr. Pieter Ernst with World Relief/ Mozambique, and championed by FH and WR for the past decade.

• Care Group Criteria document is available here: www.caregroupinfo.org/blog/criteria

• 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.

Short video (edited) on Care

Group Structure

Time Contribution (in hours) of CG Volunteers and Other Project Staff

October 2005 – September 2010

Hours Dedicated to FH/Mozambique Care Group Project

Sofala Province, Mozambique (Oct '05 - Sept '10)

7,067, 0.2%

61,659, 2%

401,824, 14%

2,453,726, 84%

Volunteers

Promoters

FH/Moz Local Manag.

FH/US staff

Community driven …

84% of the work was done by Care Group Volunteers, and

98% by community members (CGVs + paid local CHWs).

Total value of volunteer time (@$2.98/8hrs) = $904,811

Promoters (CHWs)

International Aid

International Medical Corps

International Rescue Committee

Medical Teams International

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

Bangladesh

Bolivia

Burkina Faso

Burundi

Cambodia

DRC

Ethiopia

Guatemala

Haiti

Indonesia

Kenya

Liberia

Malawi

Mozambique

Niger

Peru

Philippines

Rwanda

Sierra Leone

Zambia

Who is using Care Groups and where are they being used?

TOPS Survey on Care Groups Usage

• Recent TOPS survey (95% response rate): 65% of Food Security project implementers are aware of the CG model or with some of the resources associated with it.

• Most common ways that people learn about the model are by working with someone who has used them (67%), training events (50%), the CareGroupInfo.org website (42%) using the manual on their own (42%), or a combination of methods.

• 100% of respondents who knew of the CG model said that they had used the model; 64% said they were very effective and 27% said they were somewhat effective.

• Becoming the “default model” for some organizations: Having CHWs work with volunteer peer educators through the CG structure … still a role for CHWs!

GHI: National Scale-up in Burundi

• Burundi Global Health Initiative Strategy: One goal is to “expand the USAID MCH program currently implementing Care Group activities, which focuses on providing high-quality nutritional support to pregnant and lactating women.”

• “USG aims for national adoption of this strategy by GOB.”

Summary of Results

• CGs have on average double the estimated U5MR reduction as compared to non-CG projects.

• Better than average behavior change (54% higher performance on RapidCATCHindicators)

• Recent publication: 38% decrease in moderate/severe underweight in SofalaProvince, Mozambique at $0.55 per capita.

Care Group Performance: Perc. Reduction in Child Death Rate (0-59m)

in Thirteen CSHGP Care Group Projects in Eight Countries

through Seven PVOs

23%

33%

48%

36%42%

32%28% 29%

14%

26%

12%

35%30%

14%

33%

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

ARC/C

ambo

dia

WR/V

ur I

WR/V

ur II

WR/V

ur IV

FH/M

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WR/C

ambo

dia

WR/M

alaw

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WR/M

alaw

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WR/R

wan

da

Curam

./Gua

t

Plan/Ken

ya

SAWSO/Zam

bia

MTI/Liberia

Avg

. Care Grp Proj.

Avg

CS P

roj.

CSHGP Project

% R

ed

. U

5M

R

U5MR Red.

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

vs. CSHGP Average

32

41

35

52

71

59

39

53 51

77

49

63

37

53

0

10

20

30

40

50

60

70

80

90

Und

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Birt

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SBA

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RapidCATCH Indicator

Indicator Gap Closure on Rapid Catch Indicators:

Care Groups CSHGP Projects vs. All CSHGP Projects

All CSHGPs, 2003-2009 (n=58)

CSHGP using Care Groups (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%)

WHY/HOW CGs Work

Purpose of Innovations

• Purpose of good innovation in child survival: (1) Increase cost-effectiveness … decrease dollars per life saved; and (2) increase sustainability.

• Ideally, use randomization to compare area with traditional CG model vs. modified model, and measure each area separately.

• Usual first step: See if change is feasible, look for apparent effectiveness. Later test head-to-head.

FH CG Innovations

• Given results in health/nutrition, FH will be using Cascade Groups in many of our multisectoral programs worldwide. Difference between Cascade and Care Groups:

Care Groups often (but not always) reach only parents of children 0-23m/0-59m and pregnant women. Cascade Groups will reach parents of children 0-18 years of age.

Care Groups (per the CG Criteria document) mainly focus on promoting MCHN behaviors. Cascade Groups are multi-sectoral, and focus on promoting health/nutrition, livelihoods (including Ag/NRM), education, and disaster risk reduction behaviors.

• FH is now using a model in Ag/NRM in the DRC called Agricultural Cascade Education (ACE) which is based on CGs but reaches farmers and mainly focuses on ANR topics.

Food for the Hungry CG Innovations

Can we address maternal depression

through Care Groups?

Maternal Depression is Highly Linked

with Stunting in Children

• Surkan et al1 found a strong association between maternal depression and underweight and stunting in children.

• Incidence of depression in developing countries is between 15-57%.

• Women suffer twice as much depression as men; mothers are at even greater risk.

• Elimination of maternal depression could result in a reduction in stunting of 29-34% (based on the PAR).

1 Pamela J Surkan, Caitlin E Kennedy, Kristen M Hurley & Maureen M Black. Maternal depression and early childhood growth in developing countries: Systematic review and meta-analysis. Bulletin of the World Health Organization 2011;89:608-615 http://www.who.int/bulletin/volumes/89/8/11-088187/en/

We can Decrease Maternal

Depression in Developing Countries

• World Vision and researchers (Bolton, Verdeli, et al) did RCTs of Interpersonal Therapy in Groups (IPT-G) including:

depressed adults in South Uganda,

depressed adolescents in refugee camps in North Uganda (many were child soldiers)

• IPT-G is used to address grief, devastating life changes, issues of respect in family life

• Community workers – trained for 2 weeks to deliver the intervention over 4 months

• After 16 weeks, depression decreased: 86% to 6.5% in the IPT-G intervention group – 92% reduction 94% to 55% in the control group. (Note: Some depression does resolve on

its own.)

Method Description: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1525093/

Study: http://jama.jamanetwork.com/data/Journals/JAMA/4884/JOC30288.pdf

FH’s CG Innovation for Maternal Depression

Given the link with stunting -- FH plans to test ways to prevent/treat depression through Care Groups

• We’ve used DBC/BA with Care Group projects to find out how to motivate change in specific behaviors.

• Sometimes more generalized motivation is the problem –low motivation due to depression, hopelessness, etc.

OR Question: Will addressing depression make a difference in behavior change and outcomes in CG projects?

We welcome others to study this too, and encourage you to share your results!

Ideas for testing IPT-G with Care Groups

A) Option #1: Run IPT-G process through regular Care Group structure, separate process for depressed and non-depressed.

B) Option #2: Run IPT-G groups simultaneously with Care Groups for prev/tx of depression (separate staff running separate groups, with CGVs helping to identify women who could benefit). Separate process for depressed and non-depressed.

• Compare to controls.• 2nd Comparison Group: Standard CGs.• Outcome: Reduction in stunting and underweight,

depression in mothers, and others.

Measuring Changes

TOPS/ FSN Network Care Groups Implementation Manual (and Trainings): See.. http://fsnnetwork.org/event/care-groups-implementation-training

The manual includes a Care Group OR annex – here are the areas that can be explored with that:

Process vs. plan

Care Group Volunteer motivation

Changes in depression and generalized self-efficacy in volunteers and beneficiaries

Changes in Intimate Partner Violence

Changes in respect for women (volunteers and beneficiaries)

Innovations Presentations

• PCI / WR: Care Groups + Savings Groups innovation

• PCI’s "Trios" Care Group innovation

• Concern Worldwide’s “Integrated” Care Group innovation

• Q&A, 2-3 mins after each presentation

• Generating operations research questions (20-30 mins)

Operations Research Questions

• Split into three groups

• Generate a list of the most interesting and important questions that need to be answered regarding Care Groups.

• Consider questions about:

Effectiveness for specific purposes (e.g., reducing newborn deaths, lowering IPV/GBV, increasing social capital, improving disaster response) vs. other models

How they work (mechanisms –more trusted source of info? Problem-solving / removing barriers? Decreasing depression/improving generalized self-efficacy? Reducing fear (re: HFs)?)

Effect of combining CGs w/something (e.g., w/savings groups; w/empowerment groups).

Effect on CG Volunteers (e.g., in leadership skills/role; advocacy; relationship with spouse)

• Report out

Acknowledgment

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 Food for the Hungry and do not necessarily reflect the views of USAID or the United States Government.