Care Groups:
Experience and Evidence
Henry Perry, MD, PhD, MPH
Department of International Health
Johns Hopkins Bloomberg ...
Presenter’s Name
Date
Overview
• History and definition
• Current implementation
• Current evidence
• The evidence for PLA...
Presenter’s Name
Date
Beginnings: World Relief/
Mozambique
Pieter Ernst, Muriel Elmer,
Anbrasi Edward, Melanie
Morrow, War...
Presenter’s Name
Date
Early Lessons
Need a census – sometimes communities
neglected some villagers or households
Need crit...
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
Early Champions: Anbrasi Edward, Melanie
Morrow, Tom Davis, and Carl Taylor
Presenter’s Name
Date
Early Expansion
Tom Davis, then working for Food for the
Hungry and Curamericas Global, recognized
t...
Presenter’s Name
Date
Critical Support
Small grant from the Core Group for
preparation of the Care Group manual (The
Care ...
Presenter’s Name
Date
Current Implementation
27 organizations
Across a total of 23 countries
106,000 Care Group volunteers...
Presenter’s Name
Date
Attempts at Scale and Integration
with MOH
Food for the Hungry/Mozambique Extended
Impact Project – ...
Presenter’s Name
Date
Implementing Organizations (27)
ACDI/VOCA
ADRA
Africare
American Red Cross
CARE
Concern Worldwide
Ca...
Presenter’s Name
Date
Countries Where Care Group Projects
Have Been Implemented (23)
Bangladesh
Bolivia
Burkina Faso
Burun...
Presenter’s Name
Date
Implementors and Donors
Virtually all projects implemented by
international NGOs
Major and early don...
Presenter’s Name
Date
Other Donors
CIDA (Canada)
DfID (UK)
ECHO (European Commission: Humanitarian
Assistance and Civil Pr...
Presenter’s Name
Date
Content Area
All projects so far focused on community-
based maternal and child health, including
nu...
Presenter’s Name
Date
Extensions of the Model
Formation of peer-support groups of CHWs
implementing iCCM in Rwanda (as par...
Presenter’s Name
Date
Potential Areas of Expansion
Early child development
Maternal depression
Promotion of good education...
Presenter’s Name
Date
What Is Evidence?
• Field experience (non-systematic)
• Project evaluations
• KPC surveys (before-af...
Presenter’s Name
Date
What Is Evidence?
Source? Who collects? Methodology? What happens
to the data?
Household
surveys (KP...
Presenter’s Name
Date
Criteria by Which to Judge
Effectiveness
Change in population coverage of key maternal
and child hea...
Presenter’s Name
Date
Criteria by Which to Judge
Effectiveness (cont.)
Robustness (the degree to which the
approach’s effe...
Presenter’s Name
Date
Process Measurement (OR,
Implementation Research)
Is model being implemented as planned?
What is the...
Presenter’s Name
Date
Process Measurement (OR,
Implementation Research)
What is the age, gender and educational level of
C...
Presenter’s Name
Date
Unpublished Evidence
Available evidence not systematically assessed
•Widespread experience with Care...
Presenter’s Name
Date
Unpublished Evidence (cont.)
• I have conducted or participated in 7 Care Group
mid-term or final pr...
Presenter’s Name
Date
Handwashing Practices, World Relief/
Cambodia Child Survival Project (based on
mini-KPC data)
Percen...
Presenter’s Name
Date
Unpublished Evidence
(Tom Davis – 2008)
Care Group Performance: Perc. Reduction in Child Death Rate ...
Presenter’s Name
Date
Unpublished Evidence (cont.)
Conclusions
• Care Groups are effective in empowering
Care Group volunt...
Presenter’s Name
Date
Unpublished Evidence (cont.)
Conclusions (cont.)
• Rapid uptake and maintenance of expanded
coverage...
Presenter’s Name
Date
Published, But Not in Peer-
Reviewed Journal
Presenter’s Name
Date
From Book Chapter (based on vital
events registration by volunteers)
Presenter’s Name
Date
Peer-reviewed Journal
Publications
Transactions of
the Royal
Society of
Tropical
Medicine and
Hygien...
Presenter’s Name
Date
Presenter’s Name
Date
Source: Journal of Global Health: Science and Practice, 2013
Presenter’s Name
Date
REDUCTION IN CHILDHOOD DIARRHEAL PREVALENCE USING
HOLLOW-FIBER WATER FILTERS WITH AND WITHOUT BEHAVI...
Presenter’s Name
Date
Write Ups in Progress
LiST analysis comparing estimated mortality
impact of Care Group with non-Care...
Presenter’s Name
Date
Participatory Women’s Groups:
“Kissing Cousins”?
Presenter’s Name
Date
Women’s Groups Practicing
Participatory Learning and Action (PLA)
Presenter’s Name
Date
Participatory Learning and Action
Groups
Prost et al., Lancet 2013
Presenter’s Name
Date
Differences in Participatory Learning and
Action (PLA) Groups and Care Groups
Care Groups PLA Groups...
Presenter’s Name
Date
Differences in Participatory Learning and
Action (PLA) Groups and Care Groups (cont.)
Care Groups PL...
Presenter’s Name
Date
Comparing Strength of Evidence
Criteria Care
Groups
PLA
Groups
Comment
Number of published
reports i...
Presenter’s Name
Date
Comparing Funding Support for
Operations Research
PLA – millions of dollars (from the Gates
Foundati...
Presenter’s Name
Date
Next Steps:
Integration with MOH for long-term
sustainability and scaling up
Continued refinement of...
Presenter’s Name
Date
Next Steps:
More rigorous analysis and summary of
existing evaluations (and more LiST
analyses)
RCTs...
Presenter’s Name
Date
Acknowledgments
I am grateful for assistance from the Care Group
experts:
•Melanie Morrow
•Tom Davis...
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  • TOPS - the Technical and Operational Performance Support Program
  • Care group presentation 29 may2014-final

    1. 1. Care Groups: Experience and Evidence Henry Perry, MD, PhD, MPH Department of International Health Johns Hopkins Bloomberg School of Public Health Care Group Technical Advisory Group Meeting, 29 May 2014
    2. 2. Presenter’s Name Date Overview • History and definition • Current implementation • Current evidence • The evidence for PLA groups • Conclusions
    3. 3. Presenter’s Name Date Beginnings: World Relief/ Mozambique Pieter Ernst, Muriel Elmer, Anbrasi Edward, Melanie Morrow, Warren and Gretchen Berggren Care Groups for trachoma in S. Africa in the 1970s Grew out of interest in a more effective form of health education and the government’s division of 10 families into a block First Care Group Project: 1995-1999 (supported by USAID CSHGP)
    4. 4. Presenter’s Name Date Early Lessons Need a census – sometimes communities neglected some villagers or households Need criteria for selecting volunteers – sometimes village leaders selected alcoholics or older people
    5. 5. 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
    6. 6. Presenter’s Name Date Care Group Model
    7. 7. Presenter’s Name Date Early Champions: Anbrasi Edward, Melanie Morrow, Tom Davis, and Carl Taylor
    8. 8. Presenter’s Name Date Early Expansion Tom Davis, then working for Food for the Hungry and Curamericas Global, recognized the power of Care Groups after learning about World Relief’s first Care Group project in Gaza Province, in southern Mozambique Under Tom’s leadership, Food for the Hungry first tried out this model in Mozambique (Sofala Province) in 1997 and Curamericas in Guatemala (Huehuetenango Department) in 2001
    9. 9. Presenter’s Name Date Critical Support Small grant from the Core Group for preparation of the Care Group manual (The Care Group Difference: A Guide to Mobilizing Community-Based Volunteer Educators) and for independent verification of mortality impact in the second World Relief/ Mozambique project, 1999-2003 (leading to the Edwards peer-reviewed article in 2007)
    10. 10. Presenter’s Name Date Current Implementation 27 organizations Across a total of 23 countries 106,000 Care Group volunteers trained 1.3 million households reached In 2010, 14 NGOs in 16 countries were implementing Care Group projects New manual almost ready for dissemination: Care Groups, A Training Manual for Program Design and Implementation
    11. 11. Presenter’s Name Date Attempts at Scale and Integration with MOH Food for the Hungry/Mozambique Extended Impact Project – covered an area with 1.1 million Concern Worldwide has carried out a randomized controlled trial comparing the effectiveness of the model with a MOH CHW as Care Group facilitator compared to an NGO facilitator Malawi MOH planning to scale up Care Groups
    12. 12. Presenter’s Name Date Implementing Organizations (27) ACDI/VOCA ADRA Africare American Red Cross CARE Concern Worldwide Catholic Relief Services Curamericas Emmanuel International Feed the Children Food for the Hungry Future Generations GOAL International Aid International Medical Corps International Rescue Committee Living Water International Medair Medical Teams International Pathfinder PLAN Project Concern International Salvation Army World Service Save the Children World Renew World Relief World Vision
    13. 13. Presenter’s Name Date Countries Where Care Group Projects Have Been Implemented (23) Bangladesh Bolivia Burkina Faso Burundi Cambodia DRC Ethiopia Guatemala Haiti Indonesia Kenya Liberia Malawi Mozambique Nicaragua Niger Peru Philippines Rwanda Senegal Sierra Leone Somalia Zambia
    14. 14. Presenter’s Name Date Implementors and Donors Virtually all projects implemented by international NGOs Major and early donors: • USAID Child Survival and Health Grants Program – 10 projects • USAID nutrition funds: Title II MYAP, TOPS – 15 projects • USAID OFDA (Office of Foreign Disaster Assistance) – 3 projects
    15. 15. Presenter’s Name Date Other Donors CIDA (Canada) DfID (UK) ECHO (European Commission: Humanitarian Assistance and Civil Protection) UNICEF World Bank (for nutrition programs in Mozambique) World Bank (for linking Care Groups with PLA in project by Concern Worldwide and Mai Mwana, a local NGO) Private funds of NGOs (especially child sponsorship funds)
    16. 16. Presenter’s Name Date Content Area All projects so far focused on community- based maternal and child health, including nutrition 1 project (the first Care Group program in Mozambique) has now expanded to tuberculosis
    17. 17. Presenter’s Name Date Extensions of the Model Formation of peer-support groups of CHWs implementing iCCM in Rwanda (as part of a scaling up project led by IRC, World Relief, and Concern Worldwide Incorporation of a savings program into Care Groups (Food for the Hungry) Development of Care Groups for fathers and mothers-in- law as well as for mothers (Trios Project in Bangladesh) “Care Groups” of farmers’ groups, called agricultural cascade education (Food for the Hungry in DR Congo)
    18. 18. Presenter’s Name Date Potential Areas of Expansion Early child development Maternal depression Promotion of good education behaviors for young children Gender-based violence Promotion of “resiliency beliefs”
    19. 19. Presenter’s Name Date What Is Evidence? • Field experience (non-systematic) • Project evaluations • KPC surveys (before-after uncontrolled program evaluations) • Qualitative assessments • Cost • “Seeing is believing”/ word of mouth • Non-randomized controlled studies • Peer-reviewed journal publications • Randomized controlled trials (?)
    20. 20. Presenter’s Name Date What Is Evidence? Source? Who collects? Methodology? What happens to the data? Household surveys (KPC, birth history) Project staff vs. independent data collectors Comparison/ control area(s) Project evaluation report (publicly available or not) Focus group and key informant interviews (formal vs. informal) Formal versus informal Randomized vs. non-randomized, random sample versus purposive sample Published in peer-reviewed journal Project monitoring data
    21. 21. Presenter’s Name Date Criteria by Which to Judge Effectiveness Change in population coverage of key maternal and child health indicators Improvement in child nutrition Reduction in under-5 mortality and maternal mortality Cost per beneficiary Cost-effectiveness (cost per life saved or DALY averted) Sustainability Scalability
    22. 22. Presenter’s Name Date Criteria by Which to Judge Effectiveness (cont.) Robustness (the degree to which the approach’s effectiveness is maintained when implemented by different organizations in different contexts)
    23. 23. Presenter’s Name Date Process Measurement (OR, Implementation Research) Is model being implemented as planned? What is the actual Care Group size? How much time do Care Group Volunteers spend in Care Group meetings and with beneficiary mothers? How long does it take them to travel to carry out their work? What percentage of mothers were visited in previous 2 weeks?
    24. 24. Presenter’s Name Date Process Measurement (OR, Implementation Research) What is the age, gender and educational level of Care Group Volunteers? What is their turnover? What is their longevity after the NGO project ends. What are the most effective ways of teaching messages to Care Group Volunteers and beneficiary mothers? How important are audio- visual aids, teaching in groups vs. one-on-one? What other people participate in educational sessions besides mothers?
    25. 25. Presenter’s Name Date Unpublished Evidence Available evidence not systematically assessed •Widespread experience with Care Group project implementation •Enthusiasm is growing among program managers •Approximately 20 completed project evaluations that used the Care Group methodology
    26. 26. Presenter’s Name Date Unpublished Evidence (cont.) • I have conducted or participated in 7 Care Group mid-term or final project evaluations • World Relief/Rwanda – MTE (2004) • Curamericas Global/Guatemala – MTE (2005) and FE (2007) • World Relief/Cambodia – FE (2005) • World Relief/Mozambique – FE (2009) • Food for the Hungry/Mozambique – FE (2010) • SAWSO/Zambia – FE (2010) • I have personally led probably 100 different focus group discussions or interviews with key informants about Care Group projects
    27. 27. Presenter’s Name Date Handwashing Practices, World Relief/ Cambodia Child Survival Project (based on mini-KPC data) Percentage of mothers who wash their hands before food preparation, before feeding their children before eating, or after defecation OA: Original Project Area EA: Extension Project Area
    28. 28. Presenter’s Name Date Unpublished Evidence (Tom Davis – 2008) 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% AR C /C am bodiaW R /V urIW R /V urII W R /V urIVFH /M oz W R /C am bodia W R /M alaw i W R /M alaw iII W R /R w anda C uram ./G uat Plan/Kenya SA W SO /Zam bia M TI/Liberia Avg.C are G rp P roj. Avg C S P roj. CSHGP Project %Red.U5MR U5MR Red. Based on LiST analysis by Ricca of 13 CSHGP projects that finished in 2005-6
    29. 29. Presenter’s Name Date Unpublished Evidence (cont.) Conclusions • Care Groups are effective in empowering Care Group volunteers • The effect builds up slowly over the life of the project • As Care Group volunteers become more experienced, they become more effective • As the community and the Care Group volunteers begin to achieve success in reducing deaths, enthusiasm (and empowerment) build
    30. 30. Presenter’s Name Date Unpublished Evidence (cont.) Conclusions (cont.) • Rapid uptake and maintenance of expanded coverage of key interventions • Coverages achieved are greater than for non-Care Group CSHGP
    31. 31. Presenter’s Name Date Published, But Not in Peer- Reviewed Journal
    32. 32. Presenter’s Name Date From Book Chapter (based on vital events registration by volunteers)
    33. 33. Presenter’s Name Date Peer-reviewed Journal Publications Transactions of the Royal Society of Tropical Medicine and Hygiene, 2007 BMC Public Health, 2011 Global Health: Science and Practice, 2013
    34. 34. Presenter’s Name Date
    35. 35. Presenter’s Name Date Source: Journal of Global Health: Science and Practice, 2013
    36. 36. Presenter’s Name Date REDUCTION IN CHILDHOOD DIARRHEAL PREVALENCE USING HOLLOW-FIBER WATER FILTERS WITH AND WITHOUT BEHAVIORAL CHANGE Erik D. Lindquist, Christine M. George, Thomas P. Davis Jr., Karen J. Neiswender, W. Ray Norman, Rodolfo Calani, G. José Sanchez Montecinos, and Henry Perry (AJTMH, in press) Figure 2. Diarrheal Prevalence for Control and Intervention Groups for the 2010 study. The mean diarrheal prevalence is depicted for the pre- and post- intervention (bars) and monthly intervention (lines) phase surveys. Legend: Control group, white bars and dotted line; Filter Only group, gray bars and dashed line; Filter and BCC black bars and solid line
    37. 37. Presenter’s Name Date Write Ups in Progress LiST analysis comparing estimated mortality impact of Care Group with non-Care Group child survival projects Results of cluster-randomized trial comparing MOH CWHs as Care Group facilitators with NGO facilitators in Burundi Results of effectiveness of CHWs participating in a “Care Group-like” process for iCCM (with home visits)
    38. 38. Presenter’s Name Date Participatory Women’s Groups: “Kissing Cousins”?
    39. 39. Presenter’s Name Date Women’s Groups Practicing Participatory Learning and Action (PLA)
    40. 40. Presenter’s Name Date Participatory Learning and Action Groups Prost et al., Lancet 2013
    41. 41. 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) usually every 2 weeks, ensuring all pregnant women or mothers of young children are reached At monthly 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, nutrition Maternal and neonatal health, maternal depression
    42. 42. Presenter’s Name Date Differences in Participatory Learning and Action (PLA) Groups and Care Groups (cont.) Care Groups PLA Groups 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). Reflection and action encouraged Facilitator shares health messages gradually while at the same time facilitating process for enabling women to reflect on how to take action Process for ensuring equity All eligible women are identified and are reached by a Care Group volunteer (thereby ensuring that the most vulnerable are included) None. No process to ensure that all eligible women are included in the program or reached with key messages
    43. 43. Presenter’s Name Date Comparing Strength of Evidence Criteria Care Groups PLA Groups Comment Number of published reports in peer-reviewed journals assessing effectiveness 2 >12 Most of PLA studies reported in the Lancet Rigor of impact assessment Fairly good Highest possible Process documentation (and measurement of coverage outcomes) Strong Weak Number of projects/studies >30 10 (?) Number of different implementing entities >30 1 All PLA trials so far led by University of London research group (T. Costello) Different settings of implementation 23 countries 4 countries
    44. 44. Presenter’s Name Date Comparing Funding Support for Operations Research PLA – millions of dollars (from the Gates Foundation) Care Groups – almost none (except $50,000 CORE Group grant to fund mortality independent assessment of initial Care Group project) until two recent small operations research grants from USAID
    45. 45. Presenter’s Name Date Next Steps: Integration with MOH for long-term sustainability and scaling up Continued refinement of the Care Group model for increased effectiveness or for the same effectiveness at lower cost Promotion of the model among donors More funds for M&E and continuing to build the evidence base
    46. 46. Presenter’s Name Date Next Steps: More rigorous analysis and summary of existing evaluations (and more LiST analyses) RCTs of Care Groups? “Head-to-head” with PLA or in combination? Studies of scaling up and integration with MOH programs (and paid CHWs as facilitators)
    47. 47. Presenter’s Name Date Acknowledgments I am grateful for assistance from the Care Group experts: •Melanie Morrow •Tom Davis •Sarah Borger •Mary DeCoster •Jennifer Weiss

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