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

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Overview

• History and definition• Current implementation• Current evidence• The evidence for PLA groups• Conclusions

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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)

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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

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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

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Care Group Model

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Early Champions: Anbrasi Edward, Melanie Morrow, Tom Davis, and Carl Taylor

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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

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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)

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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

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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

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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

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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

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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

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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)

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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

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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)

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Potential Areas of Expansion

Early child development

Maternal depression

Promotion of good education behaviors for young children

Gender-based violence

Promotion of “resiliency beliefs”

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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 (?)

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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

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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

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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)

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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?

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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?

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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

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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

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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 defecationOA: Original Project AreaEA: Extension Project Area

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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%

CSHGP Project

% R

ed

. U5

MR

U5MR Red.

Based on LiST analysis by Ricca of 13 CSHGP projects that finished in 2005-6

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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

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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

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Published, But Not in Peer-Reviewed Journal

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From Book Chapter (based on vital events registration by volunteers)

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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

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Source: Journal of Global Health: Science and Practice, 2013

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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

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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)

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Participatory Women’s Groups: “Kissing Cousins”?

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Women’s Groups Practicing Participatory Learning and Action (PLA)

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Participatory Learning and Action Groups

Prost et al., Lancet 2013

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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

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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

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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

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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

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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

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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)

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Acknowledgments

I am grateful for assistance from the Care Group experts:

•Melanie Morrow•Tom Davis•Sarah Borger•Mary DeCoster•Jennifer Weiss