Reducing Malnutrition and Child Deaths Using Care Groups

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1 Reducing Malnutrition and Child Deaths Using Care Groups Thomas P. Davis Jr., MPH Chief Program Officer Feed the Children November 2014

3 FH Care Group Project October 1, 2005 September 30, Interventions: Nutrition, Diarrhea/WASH, integration w/imci No food supplementation Funding: $2.5 million from USAID CSHGP, $0.5 million match from FH. Scale: Total population reached = 1.1 million people. 148K children 0-59 months of age, 71K WRA = 220K total beneficiaries in seven districts. Equity: >90% of mothers had contact with the CGV every two weeks.

4 Results and Impact

5 Area B Results Dondo Gorongosa Nhamatanda

6 Area B Project Indicators FH/Moz CS Final Evaluation: Area B Project Indicators (Pt. 1) 100% 90% 80% 70% 60% 50% 40% Baseline, Area B Final, Area B 30% 20% 10% 0% Underweight Exc. BF Ate 3+ meals Oil added to meal Vit. A supp. p<0.001 p <0.01 p<0.001 p<0.001 p<0.001

7 Area B Project Indicators FH/Moz CS Final Evaluation: Area B Project Indicators (Pt. 2) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Vit. A foods Dewormed Weighed last p<0.001 p< m p<0.001 ORS/RHF p<0.002 Same/more food during diarrhea p<0.001 Correctly prepare ORS p<0.001 Knows 3+ danger signs p< Baseline, Area B Final, Area B

8 Consults per Preg. Woman Consults / Infant Coverage Coverage Weighings per Child Institutional Deliveries (Coverage) 160% 140% % % 80% 60% 40% Caia, Chemba, Mar. (Project Districts) Buzi, Chib, Dondo (Control Districts) Caia, Chemba, Maring (Project Districts) Buzi, Chib, Dondo (Control Districts) 20% 0.1 0% 1s s s 2008 Period 0 1s s s 2008 Period Differences in Health Service Utilization: Care Group vs. Non-Care Group Districts (Sofala, Mozambique) Initial Prenatal Consults Infant Health Facility Consults (Care Seeking) Caia, Chemba, Maring (Project Districts) Buzi, Chib, Dondo (Control Districts) Caia, Chemba, Mar (Project Districts) Buzi, Chib, Dondo (Control Districts) 0 1s s s 2008 Period 0 1s s s 2008 Period

9 % Underweight (WAZ<-2) FH/Moz CS Final Evaluation: Area B Districts Change in Underweight 35.0% 30.0% 25.0% 20.0% Overall reduction: 34% (p<0.0001) 15.0% 10.0% 5.0% 0.0% Feb 2009 June 2010 Dondo 28.7% 19.1% Gorongosa 32.0% 19.0% Nhamatanda 27.5% 18.7% All Phase II 29.4% 18.9% Measurement month/year

11 Brief Description of the Care Group Model

12 Theoretical/Conceptual Frameworks that Guide the Design/Analysis Social Network Science (Christakis & Fowler) and Persuasion Literature (Cialdini) Positive Deviance The PD Principle is seeing the glass halffull. Health Belief Model and Theory of Reasoned Action

13 What are Care Groups? Community-based strategy for improving coverage and behavior change Developed by Dr. Pieter Ernst Used subsequently in 27 organizations in 23 countries. Focuses on building teams of volunteer women who serve households each Pure volunteers no monetary incentives, just job aids

14 Major Programmatic Inputs FH/Mozambique Care Group Model One paid Promoter Groups. (7 th grade Each Care education Group has or higher) per 1,680 Promoters 12 Care Group Volunteers beneficiary households, (a.k.a., Leader and Mothers) one Supervisor (nurse) per 7-10 (Paid CHWs) Promoters. Promoter #2 Some projects use MOH Groups six months. staff as Promoters, others work with 12 Leader Mothers the MOH Promoter in other #3 ways. 12 families Promoter #1 4-5 day training on each of eight behavior promotion Promoter #5 12 Leader Mothers modules, 3-4 trainings/year for first two years. Promoter #4 Promoter #6 Educational materials (e.g. flipcharts) for Promoters and Care 12 Leader Mothers 12 families Group Volunteers, bicycles for Promoters, vitamin A, deworming meds, other supplies. Promoter #7 Each Health Promoter educates and motivates 5 Care Care 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 12 families 12 families 12 families 12 families 12 families 12 families 12 families One Child Survival or Nutrition Program Manager, 0.33 FTE 12 families M&E staff, 0.65 FTE HQ backstop. 12 families 12 families With this model, one Health Promoter can cover 720 beneficiary households.

15 What happens during Care Group meetings? Short walk to the meeting site: 15 mins Reporting of vital events and illnesses and progress in health promotion Demonstration with flipchart of this week s 2-3 health messages Group reflection on the messages then practice in pairs Other social/teaching activities Meetings are hours every two weeks

16 What happens after Care Group Meetings? Each Care Group Volunteer visits her 12 HHs. Promoter directly supervises one CGVs every 2 wks Deworming/vitamin A distributed to all preschoolers; EPI coordination with MOH Mostly HH/community-level health/nutrition promotion; some focus on health facility. Cycle of modules repeated after months.

18 General intervention area/topic and Behavior Change Objectives Intervention Area: Community Mobilization and interpersonal communication (based on formative research) to improve child nutritional status and decrease child deaths

19 General intervention area/topic and Behavior Change Objectives The main objectives of the program were to decrease malnutrition (underweight) in children 0-23m through: Increased uptake of nutrition behaviors; and Increasing uptake of WASH and illness-related behaviors.

20 Formative Research Design, Methods, Insights, and Design Decisions Audience: Mothers of children 0-23m and pregnant women (principally) and their influencers Formative research methods: Local Determinants of Malnutrition Study Barrier Analysis Studies FGDs on feeding practices

21 Formative Research Results Local Determinants of Malnutrition (LDM) Study identified several key behaviors, including: encouraging non-hungry child to eat; emptying one breast before switching to another; iron supplements during breastfeeding; POU water treatment

22 Formative Research Results Barrier Analysis focused on several key behaviors: Treatment of drinking water [with Certeza] Hand washing with soap Use of ORS/Zinc Exclusive breastfeeding See also

23 BARRIER ANALYSIS RESULTS What are the advantages to exclusive breastfeeding? % of Respondents 50% 40% 30% 20% 10% 0% 18% 4% Less expensive (OR = 0.22; p<0.05) Barriers 0% 42% No advantage at all Doers NonDoers Also, child grows well (p=0.06; OR=0.44) Emphasized during discussion about advantages of EBF

24 Communication Channels Principally biweekly interpersonal communication during the first 1,000 days and quarterly with mothers of children 2-5yo. Half of mothers: daughters usually attended the home visit. Men reached primarily through quarterly Community Leaders meetings. No mass media.

25 Systems Analysis or Engagement Health Facility Assessments Verbal Autopsies with feedback to MOH Vitals Events Registry

26 Monitoring Quality: Quality Improvement and Verification Checklists FH St af f or ML Av e r age Scor e on QIVC Checklist 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% OCT NOV DEC FEB MAR APRIL MAY JUNE JULY AUG SEPT Education Provided to Care Group Education Provided to an Individual C-IMCI Care Checklist Promoter Supervision QIVC

27 Care Groups Outperform in Behavior Change: Indicator Gap Closure: Care Group vs. non-cg Projects Behavior change was double in Care Group projects % more reduction in the U5MR rate

28 Integration with MOH

29 Applicability to SBCC for Nutrition During the First 1,000 Days Very applicable for First 1,000 Days: Low cost, effective across (27+) organizations and (23) countries. Leverages thousands of pure community volunteers. ~24 contacts a year with mother/influencers. Can integrate with national programs by putting volunteer structure under CHWs. CG integrated model assures data flow Ministry HIS. National scale up through integration with iccm and other means.

30 Support Mechanisms for Further Scale-up Hundreds trained on Care Group model. Website has many resources: Materials and discussions also posted on Has been used for more narrowly-focused programs (e.g., TB) Promote use of volunteer peer educators and formative research at 2 nd International Conference on Nutrition??

Enhancing Community Level Health System through the Care Group Approach

Enhancing Community Level Health System through the Care Group Approach USAID-funded Title II Food for Peace Development Food Assistance Program Knowledge Sharing from FH /ORDA s Health and Nutrition Interventions