Lives Saved Tool (LiST) Analysis of
Care Group versus Non-Care Group
Child Survival Projects
Christine Marie George, PhD, ...
Presenter’s Name
Date
Overview
• What are Care Groups?
• Rationale
• Methods
• Findings
• Discussion
• Conclusion and next...
Presenter’s Name
Date
What are Care Groups?
“A Care Group is a group of 10-15 volunteer,
community-based health educators ...
Presenter’s Name
Date
Care Group Model
Presenter’s Name
Date
Rationale
• There is widespread experience with Care Group
project implementation and enthusiasm is ...
Presenter’s Name
Date
Edward et al. 2007
Examining the evidence of the under-five mortality reduction in a
community-based...
Presenter’s Name
Date
Perry et al., 2011
Source: Chapter in Essentials of Global Community Health, 2011
Presenter’s Name
Date
Davis et al., 2013
Source: Journal of Global Health: Science and Practice, 2013
Presenter’s Name
Date
Study Rationale
• Many evaluations of Care Group projects exist, but
no systematic assessment of the...
Presenter’s Name
Date
Research Questions
• Do Care Group CSHGP projects achieve greater
improvement in high-impact child s...
Presenter’s Name
Date
Participatory Learning and Action
Groups
Prost et al., Lancet 2013
Presenter’s Name
Date
Women’s Groups Practicing
Participatory Learning and Action (PLA)
Presenter’s Name
Date
Differences in Participatory Learning and
Action (PLA) Groups and Care Groups
Care Groups PLA Groups...
Presenter’s Name
Date
Lives Saved Tool (LiST) version 4.68
Presenter’s Name
Date
High-impact coverage indicators
modelled in LiST
Coverage of 4 antenatal care
visits
Multiple micron...
Presenter’s Name
Date
Validation of LiST
• Several reports now have validated LiST as a
measurement tool for estimating mo...
Presenter’s Name
Date
Care Group Eligibility Criteria
Selection criteria: Care Groups
• Care Group projects found at:
http...
Presenter’s Name
Date
Non Care Group Eligibility Criteria
Selection criteria: Non-Care Group projects
• There must be a DH...
Presenter’s Name
Date
Eligible Child Survival Programs
• Nine care group and 12 non-care group child survival
projects met...
Presenter’s Name
Date
Excluded Child Survival Programs
Care Group projects in three countries were
excluded
• Liberia (MTI...
Presenter’s Name
Date
Projects included in the analysis
Country Region Organization Type Project Period
Target area
childr...
Presenter’s Name
Date
Projects included in the analysis
Country Region Organization Type Project Period
Target area
childr...
Presenter’s Name
Date
Projects included in the analysis
Country Region Organization Type Project Period
Target area
childr...
Presenter’s Name
Date
Projects included in the analysis
Country Region Organization Type Project Period
Target area
childr...
Presenter’s Name
Date
Model Assumptions
• Beginning under-5 mortality rate for the project is
assumed to be the same as th...
Presenter’s Name
Date
High Impact Child Survival Indicator Coverage Changes
Presenter’s Name
Date
Coverage Results
• For all 15 high-impact indicators for which change
in coverage was calculated for...
Presenter’s Name
Date
Coverage Results
• The difference in coverage was significantly greater
for Care Group projects (p=0...
Presenter’s Name
Date
Under Age 5 Mortality Rates (U5MR)
Country Care (N) Non-Care (N)
Cambodia -5.52% (3) -4.23% (3)
Keny...
Presenter’s Name
Date
Mean Annual Percent Reduction in
Under Age 5 Mortality (U5MR)
Presenter’s Name
Date
Summary findings
• Care Group projects have an estimated average
annual under-5 mortality decline th...
Presenter’s Name
Date
Discussion
• Care Group projects achieve greater changes in
coverage of key child survival intervent...
Presenter’s Name
Date
Discussion
Is the effect due to the Care Group methodology?
• Not clear that any specific interventi...
Presenter’s Name
Date
Alternative explanations
• The organizations that implement Care Groups are
more effective than orga...
Presenter’s Name
Date
Limitations
• Small number of projects included in the analysis
• Direct measures of mortality would...
Presenter’s Name
Date
Next steps
• Since there are increasing numbers of Care Group
projects with data for baseline and en...
Presenter’s Name
Date
Acknowledgments
We are grateful for the support of the LiST Team
•Yvonne Tam, MPH
•Neff Walker, PhD
...
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Effectiveness of Care Groups and Interpersonal Approaches: Evidence and a Resource

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  • (chapter in Essentials of Global Community Health, 2011)
  • (http://www.jhsph.edu/departments/international-health/centers-and-institutes/institute-for-international-programs/list/)
  • 2 projects that qualified were later excluded (1 was national in scope without adequate data and 1 had evaluation data that was not representative of the project area)
    2 Care Group projects implemented the activities in a staged fashion (expanding to a major portion of the project area after 2-3 years)
  • The number of projects implementing each intervention is displayed above the bars.
  • Effectiveness of Care Groups and Interpersonal Approaches: Evidence and a Resource

    1. 1. 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
    2. 2. Presenter’s Name Date Overview • What are Care Groups? • Rationale • Methods • Findings • Discussion • Conclusion and next steps
    3. 3. Presenter’s Name Date 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
    4. 4. Presenter’s Name Date Care Group Model
    5. 5. Presenter’s Name Date 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
    6. 6. Presenter’s Name Date Edward et al. 2007 Examining the evidence of the under-five mortality reduction in a community-based programme in Gaza, Mozambique
    7. 7. Presenter’s Name Date Perry et al., 2011 Source: Chapter in Essentials of Global Community Health, 2011
    8. 8. Presenter’s Name Date Davis et al., 2013 Source: Journal of Global Health: Science and Practice, 2013
    9. 9. Presenter’s Name Date 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)
    10. 10. Presenter’s Name Date 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?
    11. 11. Presenter’s Name Date Participatory Learning and Action Groups Prost et al., Lancet 2013
    12. 12. Presenter’s Name Date Women’s Groups Practicing Participatory Learning and Action (PLA)
    13. 13. Presenter’s Name Date 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
    14. 14. Presenter’s Name Date Lives Saved Tool (LiST) version 4.68
    15. 15. Presenter’s Name Date 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 diarrhea Insecticide-treated bed net coverage; malaria treatment; IPTp coverage Measles, tetanus and full immunization coverage Vitamin A supplementation
    16. 16. Presenter’s Name Date Validation of LiST • Several reports now have validated LiST as a measurement tool for estimating mortality impact • Ricca et al., BMC Public Health 2011
    17. 17. Presenter’s Name Date 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.
    18. 18. Presenter’s Name Date 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
    19. 19. Presenter’s Name Date Eligible Child Survival Programs • Nine care group and 12 non-care group child survival projects met these study eligibility criteria.   Care Group  projects Non-Care Group  projects Cambodia 3 3 Kenya 1 2 Malawi 2 1 Mozambique 3 1 Rwanda 1 2
    20. 20. Presenter’s Name Date 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
    21. 21. Presenter’s Name Date 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
    22. 22. Presenter’s Name Date Projects included in the analysis Country Region Organization Type Project Period Target area children 0-59 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 Region International 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 Sofala Food for the Hungry Care Group 2006-2010 60,666 Mozambique Sofala Food for the Hungry Care Group 2009-2010 83,778 Mozambique Manica and Sofala Provinces Health Alliance International Non-Care Group 2002-2007 97,200 Mozambique Gaza Province World Relief Care Group 2004-2009 33,451
    23. 23. Presenter’s Name Date Projects included in the analysis Country Region Organization Type Project Period Target area children 0-59 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 Region International 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 Sofala Food for the Hungry Care Group 2006-2010 60,666 Mozambique Sofala Food for the Hungry Care Group 2009-2010 83,778 Mozambique Manica and Sofala Provinces Health Alliance International Non-Care Group 2002-2007 97,200 Mozambique Gaza Province World Relief Care Group 2004-2009 33,451
    24. 24. Presenter’s Name Date 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 Kibungo International Rescue Committee Non-Care Group 2001-2005 109,700 Rwanda Cyangugu World Relief Care Group 2001-2006 24,021
    25. 25. Presenter’s Name Date 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
    26. 26. Presenter’s Name Date High Impact Child Survival Indicator Coverage Changes
    27. 27. Presenter’s Name Date 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)
    28. 28. Presenter’s Name Date 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.
    29. 29. Presenter’s Name Date 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
    30. 30. Presenter’s Name Date Mean Annual Percent Reduction in Under Age 5 Mortality (U5MR)
    31. 31. Presenter’s Name Date 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”
    32. 32. Presenter’s Name Date 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
    33. 33. Presenter’s Name Date 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?)
    34. 34. Presenter’s Name Date 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)
    35. 35. Presenter’s Name Date Limitations • Small number of projects included in the analysis • Direct measures of mortality would be preferable, but this is not feasible
    36. 36. Presenter’s Name Date 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)
    37. 37. Presenter’s Name Date Acknowledgments We are grateful for the support of the LiST Team •Yvonne Tam, MPH •Neff Walker, PhD •Ingrid Friberg, PhD

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