Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
EFFECTIVENESS
OF CARE GROUPS
AND
INTERPERSONAL
APPROACHES:
EVIDENCE AND A
RESOURCE
Tom Davis, Feed the Children
Jim Ricca,...
PRESENTATIONS
 Overview and introduction of presenters (5 mins)
 Presentation on the findings and analysis from Jim Ricc...
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 pa...
MAJOR PROGRAMMATIC INPUTS
 One paid Promoter (~10th grade educ.) per 700-1,200 beneficiary
households, and one Supervisor...
FH/Mozambique Care Group Model
Promoter #6
Promoter #3
Promoter #7
12 Leader Mothers
12 families
12 families
12 families
1...
CSHGP Programming Can Help
Countries Significantly Accelerate
Progress Toward MDG4
May 8, 2014
Jim Ricca
Senior Learning A...
Presentation Overview
Analysis of typical set of pre-OR CSHGP projects:
• What are coverage increases for child health
int...
Acknowledgements
 Co-authors: Nazo Kureshy, Karen LeBan,
Debra Prosnitz, Leo Ryan
 Also Michel Pacque, Claire Boswell, K...
Methods
 Inclusion criteria:
 Final evaluation within 12 months of when
analysis of done (30 projects)
 Had complete ba...
Logic model: Project documentation (top), implementation (middle),
and analyses done in the publication (bottom)
INPUTS AC...
Coverage increases for all interventions
significantly better than trend
12
-10
0
10
20
30
40
50
60
70
80
90
100
ANC4
TT2
...
Estimated Impact (annual ARR for U5MR)
13
Implementation Strategies
Looked at six general strategies: facility
improvement, governance groups,
interpersonal BC, out...
Conclusions – CSHGP ahead of its time
11 of 12 better than trend (p = 0.003)
How much better?
On average, U5MR decrease = ...
Conclusions (2)
 Grantee strategies operationalized Alma
Ata in a way that no set of projects before
& very few since hav...
Implications
Very few countries will make MDG4 targets.
Many are calling for equity-focused strategies.
These approaches (...
Thank you to all who have been
involved with CSHGP for a
generation, to grantees for
phenomenal passion, dedication,
and e...
Lives Saved Tool (LiST) Analysis of
Care Group versus Non-Care Group
Child Survival Projects
Christine Marie George, PhD, ...
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 t...
Care Group Model
Rationale
• There is widespread experience with Care Group project
implementation and enthusiasm is growing among
program ...
Edward et al. 2007
Examining the evidence of the under-five mortality reduction in a
community-based programme in Gaza, Mo...
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 e...
Research Questions
• Do Care Group CSHGP projects achieve greater
improvement in high-impact child survival coverage
indic...
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
A...
Lives Saved Tool (LiST) version 4.68
High-impact coverage indicators
modelled in LiST
Coverage of 4 antenatal care
visits
Multiple micronutrient
consumption ...
Validation of LiST
• Several reports now have validated LiST as a
measurement tool for estimating mortality impact
• Ricca...
Care Group Eligibility Criteria
 Selection criteria: Care Groups
• Care Group projects found at:
http://www.caregroupinfo...
Non Care Group Eligibility Criteria
 Selection criteria: Non-Care Group projects
• There must be a DHS or MICS survey ava...
Eligible Child Survival Programs
• Nine care group and 12 non-care group child survival
projects met these study eligibili...
Excluded Child Survival Programs
 Care Group projects in three countries were
excluded
• Liberia (MTI), no matching non-C...
Projects included in the analysis
Country Region Organization Type Project Period
Target area
children 0-59
months
Cambodi...
Projects included in the analysis
Country Region Organization Type Project Period
Target area
children 0-59
months
Kenya W...
Projects included in the analysis
Country Region Organization Type Project Period
Target area
children 0-59
months
Kenya W...
Projects included in the analysis
Country Region Organization Type Project Period
Target area
children 0-59
months
Rwanda ...
Model Assumptions
• Beginning under-5 mortality rate for the project is
assumed to be the same as that for the region of t...
-20
0
20
40
60
80
100
ANC4 TT2 IFA IPTp SBA EBF Comp
Feed
PPV Vit A ITN Meas Full
Vacc
Hand
Wash
ORT Abx
Pneum
Mal
Treat
M...
Coverage Results
• For all 15 high-impact indicators for which change in
coverage was calculated for Care Group and non-Ca...
Coverage Results
• The difference in coverage was significantly greater for
Care Group projects (p=0.014) (ignoring cluste...
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...
Mean Annual Percent Reduction in
Under Age 5 Mortality (U5MR)
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
Cambodia Kenya Malaw...
Summary findings
• Care Group projects have an estimated average annual
under-5 mortality decline that is 1.49 greater tha...
Discussion
• Care Group projects achieve greater changes in
coverage of key child survival interventions than non-
Care Gr...
Discussion
 Is the effect due to the Care Group methodology?
• Not clear that any specific interventions achieve
higher c...
Alternative explanations
• The organizations that implement Care Groups
are more effective than organizations
implementing...
Limitations
• Small number of projects included in the analysis
• Direct measures of mortality would be preferable, but
th...
Next steps
• Since there are increasing numbers of Care Group
projects with data for baseline and endline coverage, a
furt...
Acknowledgments
We are grateful for the support of the LiST Team
• Yvonne Tam, MPH
• Neff Walker, PhD
• Ingrid Friberg, P...
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 ...
What’s new/different in this version?
• Reflects experiences and examples from multiple
NGO’S
• Emphasis on Peer Support h...
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/...
The TOPS Program was made
possible by the generous support of
the American people through the
United States Agency for
Int...
ATTN: COST EFFECTIVENESS
Cost per DALY averted in
FH/Mozambique CG Project: $15 (cost
per beneficiary/yr: $2.78)
Cost pe...
KEY RESULTS OF CONCERN WORLDWIDE’S
OR ON THE INTEGRATED CARE GROUP
MODEL
 Tested traditional CG model with NGO workers as...
HOW DOES PEER EDUCATION WORK?
What are your theories on why CGs
work?
Theories of health behavior, learning and social
inf...
WHY PEER EDUCATORS WORK:
CHANGING SOCIAL NORMS
 Prominent Theorists: Albert Bandura, Robert
O’Connor
 What those around ...
EXAMPLES OF CHANGING PERCEPTIONS
OF SOCIAL NORMS TO CHANGE
BEHAVIOR
 EX: School-based antismoking program.
 EX: Video fo...
Which line is closer in length to the line on the left:
Line A, Line B, or Line C?
Click for Asch conformity experiment vi...
WRAP-UP AND NEXT STEPS
Additional questions on the model/
findings?
Are their models that you have seen that
are more ef...
Upcoming SlideShare
Loading in …5
×

Effectiveness of Care Groups and Interpersonal Approaches_Henry Perry, Jim Ricca, Mary DeCoster, Tom Davis_5.8.14

635 views

Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Effectiveness of Care Groups and Interpersonal Approaches_Henry Perry, Jim Ricca, Mary DeCoster, Tom Davis_5.8.14

  1. 1. 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
  2. 2. 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)
  3. 3. RAPID INTRODUCTIONS Name, Organization
  4. 4. 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.
  5. 5. 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.
  6. 6. FH/Mozambique Care Group Model Promoter #6 Promoter #3 Promoter #7 12 Leader Mothers 12 families 12 families 12 families 12 families 12 families 12 families 12 families 12 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 families 12 families Promoter #2 Promoter #1 12 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
  7. 7. CSHGP Programming Can Help Countries Significantly Accelerate Progress Toward MDG4 May 8, 2014 Jim Ricca Senior Learning Advisor MCHIP Washington
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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., peripheralizatio n of services, bicycle ambulances, etc. Improved determinants of mother / caretaker behavior (i.e., knowledge, attitu des), resulting in increased demand for services Increased demand for utilization of health services (e.g. immunization, antibiotic s 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
  12. 12. Coverage increases for all interventions significantly better than trend 12 -10 0 10 20 30 40 50 60 70 80 90 100 ANC4 TT2 IFA IPTp SBA EBF CF PPV VitA ITNM easles DPT3Handwash Latrine ORT Abxpneum oniaM alTreat Project DHS
  13. 13. Estimated Impact (annual ARR for U5MR) 13
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. Overview • What are Care Groups? • Rationale • Methods • Findings • Discussion • Conclusion and next steps
  21. 21. 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
  22. 22. Care Group Model
  23. 23. 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
  24. 24. Edward et al. 2007 Examining the evidence of the under-five mortality reduction in a community-based programme in Gaza, Mozambique
  25. 25. Perry et al., 2011 Source: Chapter in Essentials of Global Community Health, 2011
  26. 26. Davis et al., 2013 Source: Journal of Global Health: Science and Practice, 2013
  27. 27. 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)
  28. 28. 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?
  29. 29. Participatory Learning and Action Groups Prost et al., Lancet 2013
  30. 30. Women’s Groups Practicing Participatory Learning and Action (PLA)
  31. 31. 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
  32. 32. Lives Saved Tool (LiST) version 4.68
  33. 33. 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
  34. 34. Validation of LiST • Several reports now have validated LiST as a measurement tool for estimating mortality impact • Ricca et al., BMC Public Health 2011
  35. 35. 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.
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. -20 0 20 40 60 80 100 ANC4 TT2 IFA IPTp SBA EBF Comp Feed PPV Vit A ITN Meas Full Vacc Hand Wash ORT Abx Pneum Mal Treat MeanChangeinCoverage Coverage Indicators Care Group Projects Non-Care Group Projects 1 6 4 9 3 2 3 5 7 8 9 7 3 2 4 8 5 8 9 8 5 9 5 9 3 8 2 6 3 3 1 0 High Impact Child Survival Indicator Coverage Changes
  45. 45. 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)
  46. 46. 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.
  47. 47. 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
  48. 48. Mean Annual Percent Reduction in Under Age 5 Mortality (U5MR) 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 Cambodia Kenya Malawi Mozambique Rwanda Meanannualpercentreductionin U5MR Care Group Projects Non-Care Group Projects
  49. 49. 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”
  50. 50. 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
  51. 51. 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?)
  52. 52. 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)
  53. 53. Limitations • Small number of projects included in the analysis • Direct measures of mortality would be preferable, but this is not feasible
  54. 54. 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)
  55. 55. Acknowledgments We are grateful for the support of the LiST Team • Yvonne Tam, MPH • Neff Walker, PhD • Ingrid Friberg, PhD
  56. 56. Questions and Answers (up to 5:00 pm)
  57. 57. Care Groups: A Training Manual for Program Design and Implementation
  58. 58. Manual developed by FH in 2012
  59. 59. 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
  60. 60. 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
  61. 61. What Happens at a Care Group Meeting? Facilitation Cues
  62. 62. Facilitation Cues: 1. Objectives
  63. 63. 2. Game or Song
  64. 64. 3. Attendance and troubleshooting
  65. 65. 4. Behavior change promotion (story) using pictures
  66. 66. 5. Activity
  67. 67. 6. Discuss barriers and solutions
  68. 68. 7. Practice and Coach
  69. 69. 8. Ask for a commitment
  70. 70. Interactive presentation on facilitation cues Developed by Mitzi Hanold, Food for the Hungry http://www.caregroupinfo.org/vids/CGFacilitation/story.html
  71. 71. 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.
  72. 72. 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)
  73. 73. 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.
  74. 74. 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?
  75. 75. 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.
  76. 76. 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.
  77. 77. 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
  78. 78. 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?

×