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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
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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)
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RAPID INTRODUCTIONS
Name, Organization
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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.
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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.
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FH/Mozambique Care Group Model
Promoter #6
Promoter #3
Promoter #7
12 Leader Mothers
12 families12 families
12 families12 families12 families12 families12 families12 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 families12 families
Promoter #2
Promoter #112 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
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CSHGP Programming Can Help Countries Significantly Accelerate Progress Toward
MDG4 May 8, 2014
Jim RiccaSenior Learning Advisor
MCHIP Washington
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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
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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
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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
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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., peripheralization of services, bicycle ambulances, etc.
Improved determinants of mother / caretaker behavior (i.e., knowledge, attitudes), resulting in increased demand for services
Increased demand for utilization of health services (e.g. immunization, antibiotics 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
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Coverage increases for all interventions significantly better than trend
12
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Estimated Impact (annual ARR for U5MR)
13
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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
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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
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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
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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
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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
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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
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Overview
• What are Care Groups?• Rationale• Methods• Findings• Discussion• Conclusion and next steps
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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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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
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Edward et al. 2007
Examining the evidence of the under-five mortality reduction in a community-based programme in Gaza, Mozambique
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Perry et al., 2011
Source: Chapter in Essentials of Global Community Health, 2011
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Davis et al., 2013
Source: Journal of Global Health: Science and Practice, 2013
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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)
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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?
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Participatory Learning and Action Groups
Prost et al., Lancet 2013
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Women’s Groups Practicing Participatory Learning and Action (PLA)
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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), 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
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Lives Saved Tool (LiST) version 4.68
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High-impact coverage indicators modelled in LiST
Coverage of 4 antenatal care visitsMultiple micronutrient consumption during pregnancySkilled birth attendancePostnatal preventive careExclusive breastfeeding Appropriate complementary feeding Handwashing
Presence of a latrineAntibiotic treatment of pneumoniaOral rehydration therapy for diarrheaInsecticide-treated bed net coverage; malaria treatment; IPTp coverageMeasles, tetanus and full immunization coverageVitamin A supplementation
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Validation of LiST
• Several reports now have validated LiST as a measurement tool for estimating mortality impact
• Ricca et al., BMC Public Health 2011
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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.
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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
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Eligible Child Survival Programs
• Nine care group and 12 non-care group child survival projects met these study eligibility criteria.
Care Group
projectsNon-Care Group
projectsCambodia 3 3
Kenya 1 2Malawi 2 1
Mozambique 3 1Rwanda 1 2
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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
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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
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Projects included in the analysis
Country Region Organization Type Project Period
Target area children 0-59 months
KenyaWestern 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 RegionInternational
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 SofalaFood for the
Hungry Care Group 2006-2010 60,666
Mozambique SofalaFood for the
Hungry Care Group 2009-2010 83,778
MozambiqueManica and
Sofala ProvincesHealth Alliance International Non-Care Group 2002-2007 97,200
Mozambique Gaza Province World Relief Care Group 2004-2009 33,451
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Projects included in the analysis
Country Region Organization Type Project Period
Target area children 0-59 months
KenyaWestern 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 RegionInternational
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 SofalaFood for the
Hungry Care Group 2006-2010 60,666
Mozambique SofalaFood for the
Hungry Care Group 2009-2010 83,778
MozambiqueManica and
Sofala ProvincesHealth Alliance International Non-Care Group 2002-2007 97,200
Mozambique Gaza Province World Relief Care Group 2004-2009 33,451
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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 KibungoInternational
Rescue Committee Non-Care Group 2001-2005 109,700
Rwanda Cyangugu World Relief Care Group 2001-2006 24,021
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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
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ANC4 TT2 IFA IPTp SBA EBF Comp Feed
PPV Vit A ITN Meas Full Vacc
Hand Wash
ORT Abx Pneum
Mal Treat
-20
0
20
40
60
80
100
Care Group ProjectsNon-Care Group Projects
Coverage Indicators
Me
an
Ch
an
ge
in C
ov
era
ge
1
64
9
3
2 3 5
78
9 7
3
2
4
8 5
8
9 8
5
9 5
9
3
8
26
3
3
1
0
High Impact Child Survival Indicator Coverage Changes
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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)
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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.
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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
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Mean Annual Percent Reduction in Under Age 5 Mortality (U5MR)
Cambodia Kenya Malawi Mozambique Rwanda0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00Care Group Projects
Non-Care Group Projects
Me
an
an
nu
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pe
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nt
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uc
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U5
MR
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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”
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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
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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?)
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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)
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Limitations
• Small number of projects included in the analysis• Direct measures of mortality would be
preferable, but this is not feasible
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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)
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Acknowledgments
We are grateful for the support of the LiST Team• Yvonne Tam, MPH• Neff Walker, PhD• Ingrid Friberg, PhD
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Questions and Answers (up to 5:00 pm)
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Care Groups: A Training Manual for
Program Design and Implementation
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Manual developed by FH in 2012
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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
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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
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What Happens at a Care Group Meeting? Facilitation Cues
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Facilitation Cues:1. Objectives
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2. Game or Song
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3. Attendance and troubleshooting
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4. Behavior change promotion (story) using pictures
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5. Activity
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6. Discuss barriers and solutions
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7. Practice and Coach
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8. Ask for a commitment
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Interactive presentation on facilitation cues
Developed by Mitzi Hanold, Food for the Hungry
http://www.caregroupinfo.org/vids/CGFacilitation/story.html
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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.
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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)
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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.
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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?
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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.
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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.
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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
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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?