The Care Group Strategy: A Strategy for Rapid, Equitable and Lasting Impact for Maternal and Child H

1
The Care Group StrategyA Strategy for Rapid,
Equitable and Lasting Impact for Maternal and
Child Health Programs in Mozambique
Presentation at the Sofala Child Survival
Start-up Workshop By Thomas P. Davis Jr., MPH Di
rector of Health Programs , Food for the Hungry
2
The main idea Care Groups improve behavior
change, bring down costs per beneficiary, and
build a sustainable community-level structure for
health promotion.
3
What are Care Groups?

• A community-based strategy for improving coverage
  and behavior change
  
• Developed by Dr. Pieter Ernst with World Relief/
  Mozambique, used subsequently by World Relief in
  Cambodia, and Food for the Hungry, International
  in Mozambique
• Focuses on building teams of volunteer women who
  represent, serve, and do health promotion with
  blocks of ten to fifteen households each
  

4
Other Characteristics of Care Groups

• Groups of 14 households with mothers of children
  0-23m and pregnant women are formed through an
  initial census.
  
• One woman (volunteer Leader Mother) is elected to
  represent each group of 14 HH.
  
• Turnover of Leader Mothers (Care Group members)
  in Mozambique has been quite low (Mozambique
  5.3 dropout, 2.7 left area, 2.2 died).
  
• Groups meet biweekly or monthly.
• Training of CG members is done in the community
  (at low cost).
  
• Groups are facilitated by paid Promoters or other
  health staff.
  

5
Mozambique Care Group Model
Each Health Promoter educates and motivates 10
Care Groups. Each Care Group has 12 Leader
Mothers.
Each Leader Mother educates and motivates
pregnant women and mothers with children 0-23m
of age in 14 households every two weeks then
monthly. Children in households with children
24-59m are visited every six months.
Promoters
Care Groups
Promoter 2
Promoter 3
Promoter 1
14 families
12 Leader Mothers
14 families
12 Leader Mothers
14 families
Promoter 6
Promoter 5
Promoter 4
12 Leader Mothers
14 families
12 Leader Mothers
14 families
14 families
12 Leader Mothers
Promoter 7
14 families
12 Leader Mothers
14 families
12 Leader Mothers
14 families
12 Leader Mothers
14 families
14 families
12 Leader Mothers
14 families
12 Leader Mothers
With this model, one Health Promoter can cover
1,680 beneficiaries.
6
Topics Covered During FH/Mozambiques Care Group
Meetings

• Breastfeeding practices
• Introduction and preparation of complementary
  foods
  
• Maternal nutrition
• Hygiene practices deworming
• Home management and care seeking for diarrhea
• Recognition of pneumonia, care seeking, and other
  IMCI
  
• HIV/AIDS messages

7
What Happens during Biweekly Care Group Meetings?

• Reporting of vital events and illnesses
• Reporting on progress in health promotion,
  troubleshooting
  
• Demonstration with flipchart of this periods
  health messages
  
• Group reflection on the messages then practicing
  the periods education task in pairs
  
• Other social activities (e.g,. songs, dramas,
  games)
  
• Meetings generally last two hours

8
What happens after Care Group Meetings?

• Each Leader Mother (LM) visits her 10-15
  households during the following two weeks
  
• Each LM educates her mothers on the key messages
  for the month using a small BW flipchart
  
• Key messages of the month are almost always
  discussed, but CG members can work on mothers
  current concern, as well
  
• Sometimes LMs pair up to do education
• The Promoter supervises these home visits by LMs
  and coaches them.
  

9
What have the results of Care Groups shown?

• Dramatic, rapid changes in

• knowledge and
• practice

Such as.
10
ORT
11
Exclusive breastfeeding...
12
Persistent Breastfeeding...
13

• And dramatic, rapid changes in

• coverage

Such as.
14
Vitamin A coverage...
15
Immunization coverage...
16
Deworming...
17

• Each woman visits her 10-15 households during
  the following two weeks
  
• CG women educate their mothers on the key
  messages for the month using a small BW
  flipchart
  
• Key messages of the week are almost always
  discussed, but CG members can work on mothers
  current concern, as well
  
• Sometimes CG members pair up to do education

• Each woman visits her 10-15 households during
  the following two weeks
  
• CG women educate their mothers on the key
  messages for the month using a small BW
  flipchart
  
• Key messages of the week are almost always
  discussed, but CG members can work on mothers
  current concern, as well
  
• Sometimes CG members pair up to do education

• Each woman visits her 10-15 households during
  the following two weeks
  
• CG women educate their mothers on the key
  messages for the month using a small BW
  flipchart
  
• Key messages of the week are almost always
  discussed, but CG members can work on mothers
  current concern, as well
  
• Sometimes CG members pair up to do education

• And decreases in disease prevalence

Such as.
18
Diarrheal prevalence...
19
Moderate/Severe Stunting in children 6-23m of age
Decreased by 40 from 50.4 to 30.3 (pn2,337) during the 1998 to 2001 period.
Severe Stunting in children 6-23m of age
Decreased by 48 from 25 to 13 (pn2,337) during the same period.
20
Decrease in Child Mortality
A study by Johns Hopkins University (conducted in
conjunction with World Relief and Food for the
Hungry) found that child deaths decreased by 62
in areas where Care Groups were used.
21
(No Transcript)
22
Results Infant Mortality Rate Decrease of 42
42 decrease in IMR
23
Results Child Mortality Rate Decrease of 94
24
What other factors may have contributed to the
Mozambique Care Group results?

• Mothers trained to start or expand kitchen
  gardens where they grow vitamin A rich
  vegetables
  
• Agricultural production program interventions
  were conducted in the same communities as the
  health and nutrition program.

25
What about sustainability??

• The plan Interventions phased in then
  responsibilities slowly shifted from project-paid
  Promoters to Care Group leaders.
  
• FH still in the four original districts (cited
  earlier), but World Relief also uses Care Groups
  in Mozambique. From their studies
  
• 93 of the 1,457 volunteers active at the end of
  WRs Care Group project (in Gaza Province) were
  active 20 months after end of project.
  
• 92 LMs left their post or moved out 44 died.
• Out of these 132 vacant roles, communities
  selected 40 replacements and trained them on
  their own.
  
• Changes brought about in the original program
  were maintained A full 30 months after the end
  of the project, final program goals on eight key
  indicators continued to be exceeded.

26
Sustainability of Final Indicator Levels
Four-Years Post-Project in the WR-Mozambique Care
Group Project Home Care of Sick Children
(Note End of Project was September 1999. Black
line is project goal. Red line is actual
indicator levels.)
27
Sustainability of Final Indicator Levels
Four-Years Post-Project (WR-Mozambique Care Group
Project) Preventive Services
28
Why are Care Groups so successful?
Possibly 1) The unit is a neighborhood or part o
f a neighborhood instead of an entire community,
building on small groups of 8-14 members (similar
to churches use of fast-growing cell groups and
base communities).
29
Why are Care Groups so successful?
2) Social support is increased so fewer incentiv
es are needed, drop-out is lower, less retraining
is necessary, and more happens outside of
meetings. (Community/social support for CHWs
1-2 trained/community is often low.) Meetings
have a social as well as health purpose.
30
Why are Care Groups so successful?
3) Tasks for community-level volunteers are
light (i.e., one home visit per day on average).
Doing less more often is a useful strategy for
populations where literacy is low.
4) Leader Mothers (Care Group members) really
know their households and are more invested in
them. Behavior change, and identification and
follow-up of defaulters is easier.
5) More highly-trained health workers
are used more efficiently in a multiplier
model.

31
Some Benefits of Using Care Groups
1) Care Groups can dramatically boost coverage
levels and program effectiveness.
2) Using Care Groups can systematize your
approach to assuring equitable access at the
community level.
3) Using Care Groups can improve program
measurability by allowing for more systematic and
thorough vital events reporting and quarterly
monitoring of K,P, and C changes.
32
4) Using Care Groups can improve sustainability
by creating better self-sustaining structures at
the community levels, and better ties among
communiy leaders, health facilities, and CHWs.
5) Care Groups provide an ideal structure for
implementing the Hearth Nutritional
Rehabilitation model and other positive deviance
approaches.
6) Through use of Care Groups, you may be able to
decrease cost-per-beneficiary through a more
efficient use of paid staff, and more use of
community volunteers The cost-per-benificiary in
this Care Group project was 4.50/beneficiary/year
.
Food for the Hungry plans to use Care Groups in
this Expanded Impact child survival project.
33
Increasing Equity and Impact of Child Health
Programs in Developing Countries through Care
Groups

• A Strategy for Rapid, Equitable, and Lasting
  Results

Presentation for 2004 APHA Annual Meeting
By Thomas P. Davis Jr., MPH Director of Health Pr
ograms , Food for the Hungry
Dr. Adugna Kebede, Health Nutrition Program
Manager, Beira, Mozambique