This document describes the Care Group Trio model used in Bangladesh to promote behavior change around maternal and child health. The model involves forming groups of mothers, fathers, and grandmothers as leaders to influence their peers. Research showed these individuals most strongly influence health behaviors. Groups meet separately with a promoter then jointly to discuss challenges and solutions. An evaluation found increased rates of behaviors like exclusive breastfeeding and antenatal care. Lessons include practicing counseling skills, recognizing high performers, and meeting barrier identification with problem-solving and accountability across the trios.

1. April 23, 2013
Carolyn Kruger, Ph.D.
Senior Advisor MNCH, PCI
CARE GROUP TRIOS:
AN INNOVATIVE HOUSEHOLD
BEHAVIOR CHANGE MODEL
CORE
Group
Spring
Meeting
2013

2.  USAID/FFP: PROSHAR – “Program for Strengthening Household
Access to Resources”, June 2010 to May 2015
 ½ million beneficiaries (direct and indirect) in 23 unions of three
Upazilas
 Implementing partners include : ACDI/ VOCA; PCI; GOB; and
three partner NGOs
PROSHAR OVERVIEW

3. SO1: Income and access to
food of poor and ultra poor
households increased
SO2: “Health of pregnant & lactating women and children under 5
(with particular attention to children under 2) improved”
SO3: Institutions and households
prepared to respond effectively to
shocks
IR. 2.1. Malnutrition prevented
and treated
IR. 2.2. Improved effectiveness
of health clinic services
Goal of PROSHAR:
Reduced Food Insecurity
Among Vulnerable Rural
Populations in Selected
Upazilas in Khulna Division
IR. 1.2. Market linkages
developed and
strengthened
IR. 1.1. Agricultural
productivity
increased and
diversified
IR. 1.3. Non-agriculture
opportunities expanded and
diversified
IR. 3.1. Disaster Risk
Reduction Plans
(DRRPs) functional
IR. 3.2. Early
warning system
functional
IR. 3.3 Increase
knowledge and
skills
INTEGRATED PROGRAM DESIGN

4.  PCI’s research showed mothers are often the least
influential in decisions about nutrition & health care
 Fathers & mothers-in-law have strongest influence on
behavior change; fathers dictate care seeking behaviors
& mothers-in-law set child rearing practices
 PCI thus developed “CG trios” that involve fathers &
mothers-in-law in order to sustainably change behaviors
DEVELOPMENT OF TRIO CONCEPT

5. WHO INFLUENCES BEHAVIORS?
8%
6%
2%
24%
41%
10%
22%
12%
28%
40%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Husband Mother-in-law* Sister-in-law Neighbors No one
Disapproval of pregnant women consuming extra food during pregnancy
NonDoers
Doers
Targeting influential people

6. 55%
20%
33%
12%
0%
12%
61%
57%
31%
14%
10%
4%
0%
10%
20%
30%
40%
50%
60%
70%
Sufficient
breastmilk
Family Support* Don't need extra
food
Less work load No expense* Baby doesn't cry
Perceived self-efficacy:
What made it easier for you to exclusively breastfeed?
NonDoers
Doers
Improving the knowledge and
responsibility of family members on the
importance of EBF and their support of the
mother
WHAT INFLUENCES NUTRITION PRACTICES
(E.G. EBF)?

7. TRADITIONAL CARE GROUP MODEL

8. Each Care Group Trio consists of 12 leaders each. Mother CGs meet
monthly. Grandmothers & Father CGs will meet every three months with the
mother CGs.
(162 Care Group Trios total)
Each paid promoter
oversees
approximately 10
Care Group Trios
(12 promoters total)
Each supervisor
oversees
approximately three
paid promoters
(4 supervisors total)
Supervisor
Promoter
Grand
mothers
Mothers Fathers
Promoter
Promoter
PROSHAR TRIO CARE GROUP APPROACH
Each leader will meet with approximately 14 peers regularly
(monthly/mothers & quarterly/fathers & grandmothers) reaching
81,648 HH decision-makers

9. CG TRIOS MEETING
Care Group
(Mother
Leaders)
• Mother leaders (ML) meet 2x/month
• Health promoter (HP) meets with MLs 2x/month; MLs organize meeting with their
groups the following week
• Flipchart with specific health & nutrition messages used
Care Group
(Grand Mother
Leaders)
• Grandmother leaders (GmLs) meet 1x/month
• HP meets with GmLs in the first month of the quarter; GmLs meet with their groups in the
following two months
• Flash card set is used with specific health & nutrition messages
Care Group
(Father
Leaders)
• Father leaders (FLs) meet 1x every two months
• HP meets with the FL 1x/month; FLs meets with their groups in the following two months
• Flash card set is used with specific messages
Care Group
(Trios
meeting)
• Every quarter HP meets with the three leader groups together
• Objectives are to discuss: CG activity status; challenges; success stories; lessons learned and
plans for addressing challenges

10.  Flipcharts
 Flash Cards
BCC MATERIALS DEVELOPED
 Puzzles
 Posters
 Stickers

11. 31.4
38.2
32.3 34.6
29.2
56
88.7
53
73
40.9
0
10
20
30
40
50
60
70
80
90
100
Exclusive Breast
Feeding
Early Initiation
of BF
3+ ANC Visits Post Partum Vit-
A
3 Correct IYCF
Behaviors
Baseline Sept 2012 Results
BEHAVIOR CHANGE TRENDS

12.  Building capacity of MLs to counsel CG participants
using ASPIRE
(ask, show, probe, inform, request, examine) – need
practice!
 ML uses specific CG monitoring tools – picture
checklist, registration
 Weak MLs are targeted for intensive one-on-one
counseling by HPs
 High performing CGs & families are recognized to
encourage optimal behaviors at household level
 Fathers need flexible meeting times that don’t interfere
with work schedule
TRIO IMPLEMENTATION

13. 1. The Trio Care Group approach is a “promising practice” that makes a
difference in changing behaviors among pregnant women.
2. CG Trios overall have had a high level of participation (even for fathers
and grandmothers who have greater participation challenges).
3. Focus on household and community behavior change, not just
communication messages.
4. The three groups have different roles in the family and community –
discuss and demonstrate how their roles can influence change.
5. Promote the Trio groups as change agents, not just messengers.
6. Provide pictures of desired mother, father, grandmother desired
behaviors and focus on “why the behavior is healthy”.
7. Promote home visits to promote healthy behavior change and focus on
“why the behavior is healthy”.
8. Groups should meet together to identify barriers to change, to problem
solve for solutions and to be accountable for change in their families
and communities.
LESSONS LEARNED TO DATE

14. Thank You!