This is the study that showed a 38% reduction in underweight. Several lessons learned about how and why Care Groups work were mentioned in this recently published article on the project in Sofala. I won’t go through those here, because I want you to read the paper. This journal is a great place for you to consider publishing your papers on your projects.
So I wanted to establish first that we are looking at innovations with a model that is already outperforming many of our more standard approaches (such as having CHWs work directly with mothers rather than through peer educators). But just because the model is performing well doesn’t mean that we should not continue to push the envelope. As we discuss innovations, you should be asking several questions: (1) Does the innovation lead to more cost-effective results in terms of lives saved? Usually that will mean that you will see better behavior change happening, as well, but there are other ways that they may be saving lives. (2) Secondly, does the innovation lead to better sustainability? That may be sustainability by having the MOH adopt the model, it may be sustainability by having CGVs continuing to do health promotion for years afterwards, or for the system to become part of some private system. We should not get stuck on one view of what sustainability will look like. There may be other things that you will measure, such as satisfaction with the model, but in the end, if you are having worse results in terms of cost-effectiveness or sustainability, it’s probably not something that we should be promoting.Also, as we innovate, we should be trying to do so with randomization and measurement. At the very least, I think we need to be trying out changes in the model in one set of districts and comparing it with the standard model used in another set of districts (i.e., a quasi-experimental design). And we need to measure our work in such a way that we can detect differences in results in those different areas, and also assure that we follow the protocols we have set out for how the work should differ in the two areas … for example, tracking attendance at Care Group meetings, tracking contact between CGVs and mothers (and/or fathers, grandmothers), and tracking quality of health promotion.Now not everything you will hear about today will meet these criteria. Often a first step is just to see if a change is feasible – such as working with mothers, spouses, and grandmothers – and to see if it appears to be at least as effective as the standard model in terms of results and sustainability. Later on, implementers can and should test it head-to-head with the standard model before promoting the change widely. I think we should be doing the same thing with testing Care Groups against more traditional CHW models where funding allows, as well, but from the data I have presented, I don’t know that that work is the most pressing.Mary DeCoster is the Coordinator of SBC Programs for FH and the TOPS Project, and she and I will now talk to you about some of FH’s plans to tweak the Care Group model, and other things we are doing in Food for the Hungry concerning Care Groups.
Other studies show compromised parenting behaviors linked with depression. “Our findings indicate that a reduction in the incidence of maternal depressive symptoms in developing countries would not only have a beneficial effect on mothers, but would also improve child growth substantially…”
IPT-G is short term therapy, focuses on improving symptoms and interpersonal functioning, and based on Interpersonal Psychotherapy (IPT) is a time-limited treatment that encourages the patient to regain control of mood and functioning typically lasting only 12–16 weeks. IPT is based on the common factors of psychotherapy: a "treatment alliance in which the therapist empathically engages the patient, helps the patient to feel understood, arouses affect, presents a clear rationale and treatment ritual, and yields success experiences."
Sometimes in Care Groups we see uptakes in new behaviors that haven’t been promoted yet – after a few successes, mothers feel an increase in hopefulness and “agency”. So sometimes we can see increases in adoption of family planning, antenatal care, or care seeking… before you even get to the point in the project where you are teaching that module. This is most likely due to this increase in generalized self-efficacy, decrease in depression, or some effect on overall motivation and will.
Option #1: Run IPT-G process through regular Care Group structure. Select depressed women reached by CGs in a couple of communities and use IPT-G with them over 4 months, replacing the CG teaching normally done with them during that period with this IPT-G intervention. Teach non-depressed mothers in same groups other coping and “learned optimism” skills. This would be similar to how FH has integrated PD/Hearth with Care Groups. Option #2: Run IPT-G groups simultaneously with Care Groups for prevention and treatment of depression(separate staff running separate groups, with CGVs helping to identify women who could benefit). Do a prevention of depression module with non-depressed mothers at the same time through the CGVs. With both options, we would identify mothers in control communities and measure changes in depression. Second comparison group could be all mothers in standard CGs.Expected Outcome: Reduction in stunting and underweight, depression in mothers, and others.
We’re working on a Care Groups implementation manual, with many of you from the FSN Network Care Groups Forward Interest Group, based on the manual developed by FH last year, in collaboration with World Relief. There’s an OR annex in there to help/encourage Care Groups implementers to do operations research
We will now hear about a range of other innovations to the Care Group model being tried out. First up, Carolyn Kruger from PCI and Melanie Morrow from World Relief will talk about combining savings groups with Care Groups.
Care Group Innovations
Care Group InnovationsCarolyn KrugerSenior Advisor, Maternal, Newborn and Child Health, PCIJennifer WeissHealth Advisor, Concern WorldwideMary DeCosterCoordinator for SBC Programs, FH/TOPSMelanie MorrowDirector of MCH Programs, World ReliefTom DavisChief Program Officer, FH &Senior Specialist for SBC, TOPS Project
Objectives• Hear several presentations on ways in whichthe Care Group model is being modified andtested by multiple PVOs.• Hear an update on multi-sectoral peereducation models which are similar to CareGroups.• Generate operations research questions thatcan be used to further advance the model.
What are Care Groups?• Developed by Dr. Pieter Ernst withWorld Relief/ Mozambique, andchampioned by FH and WR for thepast decade.• Care Group Criteria document isavailable here:www.caregroupinfo.org/blog/criteria• A community-based strategy forimproving coverage and behaviorchange• Different from typical mothers groups:Each volunteer is chosen by her peers,and is responsible for regularly visiting10-15 of her neighbors.
Time Contribution (in hours) ofCG Volunteers and Other Project StaffOctober 2005 – September 2010Hours Dedicated to FH/Mozambique Care Group ProjectSofala Province, Mozambique (Oct 05 - Sept 10)7,067, 0.2%61,659, 2%401,824, 14%2,453,726, 84%VolunteersPromotersFH/Moz Local Manag.FH/US staffCommunity driven …84% of the work was done by Care Group Volunteers, and98% by community members (CGVs + paid local CHWs).Total value of volunteer time (@$2.98/8hrs) = $904,811Promoters(CHWs)
International Aid International MedicalCorps International RescueCommittee Medical TeamsInternational Pathfinder PLAN Salvation Army WorldService Save the Children World Relief World Vision ACDI/VOCA ADRA Africare American Red Cross CARE Concern Worldwide Catholic ReliefServices Curamericas EmmanuelInternational 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 ZambiaWho is using Care Groups and whereare they being used?
TOPS Survey onCare Groups Usage• Recent TOPS survey (95% response rate): 65% of FoodSecurity project implementers are aware of the CG model orwith some of the resources associated with it.• Most common ways that people learn about the model areby 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 ofmethods.• 100% of respondents who knew of the CG model said thatthey had used the model; 64% said they were very effectiveand 27% said they were somewhat effective.• Becoming the “default model” for some organizations:Having CHWs work with volunteer peer educators throughthe CG structure … still a role for CHWs!
GHI: National Scale-up inBurundi• Burundi Global Health Initiative Strategy: Onegoal is to “expand the USAID MCH programcurrently implementing Care Group activities,which focuses on providing high-qualitynutritional support to pregnant and lactatingwomen.”• “USG aims for national adoption of thisstrategy by GOB.”
Summary of Results• CGs have on average double the estimatedU5MR reduction as compared to non-CGprojects.• Better than average behavior change (54%higher performance on RapidCATCHindicators)• Recent publication: 38% decrease inmoderate/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 Countriesthrough Seven PVOs23%33%48%36%42%32%28% 29%14%26%12%35%30%14%33%0%10%20%30%40%50%60%ARC/CambodiaWR/VurIWR/VurIIWR/VurIVFH/MozWR/CambodiaWR/MalawiWR/MalawiIIWR/RwandaCuram./GuatPlan/KenyaSAWSO/ZambiaMTI/LiberiaAvg.CareGrpProj.AvgCSProj.CSHGP Project%Red.U5MRU5MR Red.
Care Groups Outperform in Behavior Change:Indicator Gap Closure: Care Group Projectsvs. CSHGP Average32413552715939535177496337530102030405060708090UnderwtBirthSpacSBATT2EBFCompFeedAllVacsMeaslesITNDangerSignsIncFluidsAIDSKnowHWWSAllRapidPercentRapidCATCH IndicatorIndicator Gap Closure on Rapid Catch Indicators:Care Groups CSHGP Projects vs. All CSHGP ProjectsAll CSHGPs,2003-2009 (n=58)CSHGP using CareGroups (2003-2010,n=9)Gap closurerange for CareGroup projects:~35 – 70%(Avg = 57%)Gap closurerange in non-CGprojects ~25 –45%(Avg. = 37%)
Purpose of Innovations• Purpose of good innovation in child survival: (1)Increase cost-effectiveness … decrease dollarsper life saved; and (2) increase sustainability.• Ideally, use randomization to compare area withtraditional CG model vs. modified model, andmeasure each area separately.• Usual first step: See if change is feasible, look forapparent effectiveness. Later test head-to-head.
FH CG Innovations• Given results in health/nutrition, FH will be using CascadeGroups in many of our multisectoral programs worldwide.Difference between Cascade and Care Groups: Care Groups often (but not always) reach only parents ofchildren 0-23m/0-59m and pregnant women. CascadeGroups will reach parents of children 0-18 years of age. Care Groups (per the CG Criteria document) mainly focuson promoting MCHN behaviors. Cascade Groups aremulti-sectoral, and focus on promoting health/nutrition,livelihoods (including Ag/NRM), education, and disasterrisk reduction behaviors.• FH is now using a model in Ag/NRM in the DRC calledAgricultural Cascade Education (ACE) which is based onCGs but reaches farmers and mainly focuses on ANR topics.
Food for the HungryCG InnovationsCan we addressmaternal depressionthrough CareGroups?
Maternal Depression is Highly Linkedwith Stunting in Children• Surkan et al1 found a strong association betweenmaternal depression and underweight and stuntingin children.• Incidence of depression in developing countries isbetween 15-57%.• Women suffer twice as much depression as men;mothers are at even greater risk.• Elimination of maternal depression could result in areduction 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 earlychildhood growth in developing countries: Systematic review and meta-analysis. Bulletin of the WorldHealth Organization 2011;89:608-615 http://www.who.int/bulletin/volumes/89/8/11-088187/en/
We can Decrease MaternalDepression in Developing Countries• World Vision and researchers (Bolton, Verdeli, et al) did RCTs ofInterpersonal Therapy in Groups (IPT-G) including: depressed adults in South Uganda, depressed adolescents in refugee camps in North Uganda (manywere child soldiers)• IPT-G is used to address grief, devastating life changes, issues of respectin family life• Community workers – trained for 2 weeks to deliver the interventionover 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 onits 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 forMaternal DepressionGiven the link with stunting -- FH plans to test ways toprevent/treat depression through Care Groups• We’ve used DBC/BA with Care Group projects to find outhow 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 differencein behavior change and outcomes in CG projects?We welcome others to study this too, and encourage you toshare your results!
Ideas for testing IPT-Gwith Care GroupsA) Option #1: Run IPT-G process through regularCare Group structure, separate process fordepressed and non-depressed.B) Option #2: Run IPT-G groups simultaneously withCare Groups for prev/tx of depression (separatestaff running separate groups, with CGVs helpingto identify women who could benefit). Separateprocess 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 ChangesTOPS/ FSN Network Care Groups Implementation Manual (andTrainings): See.. http://fsnnetwork.org/event/care-groups-implementation-trainingThe manual includes a Care Group OR annex – here are the areasthat can be explored with that: Process vs. plan Care Group Volunteer motivation Changes in depression and generalized self-efficacy involunteers and beneficiaries Changes in Intimate Partner Violence Changes in respect for women (volunteers andbeneficiaries)
InnovationsPresentations• PCI / WR: Care Groups + Savings Groupsinnovation• PCI’s "Trios" Care Group innovation• Concern Worldwide’s “Integrated” Care Groupinnovation• Q&A, 2-3 mins after each presentation• Generating operations research questions (20-30mins)
Operations ResearchQuestions• Split into three groups• Generate a list of the most interesting and important questions thatneed to be answered regarding Care Groups.• Consider questions about: Effectiveness for specific purposes (e.g., reducing newborndeaths, lowering IPV/GBV, increasing social capital, improvingdisaster response) vs. other models How they work (mechanisms –more trusted source of info?Problem-solving / removing barriers? Decreasingdepression/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
AcknowledgmentThis presentation was made possible by thegenerous support of the American peoplethrough the United States Agency forInternational Development (USAID). Thecontents are the responsibility of Food for theHungry and do not necessarily reflect the viewsof USAID or the United States Government.