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[The following is a guest blog by Mary DeCoster, Former Program Specialist with Curamericas on their Care Group project in Guatemala. If you are interested in blogging on your Care Group projects results, please contact firstname.lastname@example.org.]
I was really impressed with the evaluation data showing how well Care Groups perform in closing indicator gaps – well above other high performing approaches. Tom Davis has summarized it beautifully here (narrated presentation –under 3 minutes). www.caregroupinfo.org/vids/CGGapClosure/CareGroupGapClosure.html
And I was surprised to learn that our Care Group project in Guatemala performed relatively low compared to other Care Group projects. The project had achieved 20 of its 24 indicators. It reduced child death by 14%, which is about average for Child Survival projects overall (depending on the year the average is assessed), but the average reduction in the child death rate in Care Group projects is well above our 14% reduction at 30%. (See table below.)
You can find the Curamericas Guatemala 2002-2007 Final Evaluation using this link:
I started reflecting on the project in order to see what may have caused those results. I think it comes down to three main factors: (1) a very challenging project area with very low social capital, (2) staffing issues, and (3) less than optimal use of behavior change strategies.
Challenging project area: The project area in Northwestern Huehuetenango was a very challenging area for NGO’s to work in. Community members were so traumatized by the 30 + years of violence and the displacement – as returning refugees – that they didn’t trust their own neighbors, much less outsiders coming in to do a project. Four hundred and forty villages were completely annihilated and close to 200,000 Mayans were either massacred outright or thrown from helicopters into the Pacific Ocean. The area was so difficult that several other NGO’s had given up and left the project area. This lack of trust made it hard to recruit volunteer mothers for Care Groups. Projections were to recruit 400 volunteer mothers, but there was resistance from families and husbands even when the women themselves began to express interest. As time went by, trust increased and there were over 300 active Health Communicators (CG Volunteers). The project director took care to hire staff who spoke the local Mayan languages, and when possible to hire from within the project area, which helped tremendously in gaining trust, but it was still a slow process. There were geographic and transportation challenges in the project area, as well – long walks over mountainous terrain to get to Care Group meetings, dangerous roads, and lack of transportation. (The population density was about 195 inhabitants per square kilometer, much higher than in some other successful CG projects.) Despite the relatively high population density, the mountainous terrain meant that one to two hours walk to meetings was not unusual. (Reading the 2010 FH Mozambique final evaluation, I thought it must have been so helpful that the promoters and Care Group Volunteers had only had about a 15 minute walk to their meetings.)
Staffing issues: There was a lack of staff in district MOH clinics. It was very difficult for the MOH to recruit and retain staff willing to work in this remote area, especially physicians and nurses. That meant that project staff felt compelled to spend too much of their time on curative care rather than training and supervision. The project did not get the level of collaboration from district MOH that had been expected, and it was difficult to recruit and retain project staff. Working on the project meant being away from home and families for two weeks at a time, going home for a long week-end, and back at it again, working incredibly long days — many on the team frequently worked from 5 a.m. to 11 p.m.
Less than optimal use of behavior change strategies: Supervision and quality improvement checklists needed greater emphasis. It seems that the project staff didn’t wholeheartedly take it up. More consistent use of the supportive supervision methods that they were all taught, and the Quality Improvement & Verification Checklists (QIVC’s) with staff and volunteers would have served to reinforce the most important elements of the Care Group model, would have prevented problems like inconsistent use of participatory methods, and would help staff and volunteers have a greater sense of accomplishment.
Project staff members were slow to be persuaded of the importance of using participatory methods with the Care Groups, as well. The tendency was to default to reciting health messages in a didactic way. It was difficult to convince staff to take the time to use the songs, role plays, games and stories that we had developed. It seemed that a lot of the staff felt that it was more professional to deliver health messages in lecture style, so they unfortunately failed to consistently model use of the participatory methods to community facilitators and volunteers.
After the midterm evaluation – when lack of use of participatory methods was cited as the greatest area of concern – we were finally able to get the staff and promoters (CF’s) fully on-board about the importance of active participatory education for the Care Groups and mothers beneficiary groups (with which the CG Volunteers meet), which was an important turning point for the success of the project. Most of the team felt that there was so much to do that they could not take the time for the “fun stuff”.
Given the MTE suggestions, the staff improved their consistency in using active learning methods and Care Group Volunteers increased their use of these methods with mothers’ groups. In addition, CGVs asked beneficiary mothers to commit to trying the new behaviors at home. As a result of these improvements, the staff began to clearly see that this is a powerful approach to providing memorable messages and more importantly, promoting behavior change.
Exclusive breastfeeding got a big boost when a community facilitator and then a nurse on the team exclusively breastfed their newborns – word spread like wildfire that this really worked! It was a big topic of conversation at team meetings and Care Groups – people were amazed how healthy and beautiful those 100% breastfed babies were.
It’s also important to use the local epidemiology to decide the level of effort assigned to each intervention. Recognition and management of pneumonia improved during the project, but the percentage effort should have been bumped up from 15%. The midterm evaluation (looking at the vital events tracking) showed that pneumonia deaths were higher than expected. The project did respond to those results, but we could have given it even greater emphasis. Recognition of danger signs for pneumonia could have been given increased emphasis in the Care Groups, and it would have been even better (I can now say with 20/20 hindsight) to have developed an entire module on pneumonia. The final evaluation showed that most of the child deaths in the project area were from pneumonia.
Curamericas Guatemala would be well positioned to show more dramatic results from a second Care Group project in or near the original project area. The previous Care Group project did a lot to build up more social capital – now people know and trust their neighbors and project staff more, and there are active village health committees. (And that’s one thing to keep in mind when interpreting these results – not just the mortality reduction, but the fact that Care Groups appeared to be very successful in rebuilding the social capital lost in this area. This effect on social capital needs to be measured and studied in the future.) Training materials and educational materials for the Care Groups are ready to use, or would be easily adapted. And the need continues to be great in the project area and has been exacerbated by the global financial downturn and climate change, especially droughts and floods.
For more on the project area, see this short video clip from a flooding disaster in San Miguel Acatan, one of the three municipalities in the project area: http://www.youtube.com/watch?v=0yWmV3Q5jOk&NR=1
There are some great photos at this site of the project area and community members; http://curamericasguatemala.blogspot.com (from Mario Valdez, director of Curamericas Guatemala).
Mary DeCoster, MPH
Consultant & Former Program Specialist, Curamericas
I think the evidence we are seeing on Care Groups is proof that there’s a large role for community-level volunteers in bringing about the sort of changes that we want to see and that are necessary for ending child deaths. But it goes beyond that. It’s not just that volunteers are the best way to stretch a rupee or dollar. Not paying people can lead to better performance on some tasks than paying them. There’s recent evidence that for simple, straightforward tasks that only require mechanical skills, monetary rewards work great: Higher pay = better performance. But when a task gets more complicated, when it requires even rudimentary cognitive skills, larger monetary rewards lead to poorer performance. This is not a hunch. This is based on research by economists at MIT, Univ of Chicago, and Carnegie Mellon (funded by the Federal Reserve), and has been replicated in developing country settings. And in my opinion, the persuasive, thinking on your feet, working-around-barriers work that we need people to do to promote behavior change is far from a mechanical skill. This health promotion work – when it’s kept light and not burdensome – also has a high non-monetary pay-off for the volunteer in terms of some of the things which do motivate people: achieving mastery, having autonomy, and gaining purpose through what they do.
Another lesson that I take away from this work is that paying “a little something” can often hurt productivity and results. Imagine if you had a neighbor who asks you for a ride to the store, but then insists that they pay you $1 for it. Are you more likely to take them? Many times, these small offers of monetary incentives actually turn us off, and they can make us process the request differently, looking at cost-benefit rather than drawing on our other (higher?) motivations. With Care Groups, no monetary incentives are given to the Care Group volunteers (who do 80% or more of the actual work) and we have seen that even the non-monetary (but tangible) incentive of a $5 wrap-around skirt each year (with health messages on them) often cause more problems than they resolve, and programs can be entirely successful without them. (Now we should be thinking creatively about how we can help volunteers to offset the time they spend on this work, like giving them time-saving things [e.g., pressure cookers?] that decrease their time burdens at home.) In short, we were never just Homo Economicus, completely rational and narrowly self-interested, economically-driven actors. We are so much better than that, and I have always found that those old models that look at people that way are dehumanizing, quite incomplete, and need to be jettisoned.
But don’t take my word for it: Watch this entertaining video presentation by Daniel Pink (author of Drive) on this new line of research. Think about what this means for you, your organization and how you do your projects, and add a comment below. Warning: If you are 50 or older (like me), you might want to move your screen away from you about two feet. It move very quickly, and otherwise you might get nauseas. : ) Click the arrows in the bottom-right corner to see if full-screen.
And by the way, if you are asking yourself where I get the motivation to maintain this site and write these blogs, I’ll give you a hint — no one’s paying me. : ) Something deeper is going on.
— Tom Davis
Senior Specialist for Social & Behavioral Change, TOPS Project
Senior Program Director, Program Quality Improvement, Food for the Hungry
I wanted to share some of the findings with you from our latest evaluation of a Care Group project, Food for the Hungry’s USAID-funded child survival project in Mozambique. If we could prevent all child deaths today in the whole world for a full 7 hours, we would save 6,472 lives. That’s the equivalent of what this Care Group project in Mozambique achieved using 80% volunteer labor. And we estimate that about 90% of FH’s input into the system through this project was through behavior change — promoting changes at the household and community levels, but also using community mobilization to increase health system utilization. Now we need to scale up this remarkable approach so that more countries can meet Millennium Development Goal #4.
The project was evaluated by Dr. Henry Perry of Johns Hopkins University. (I highly recommend Henry if you are looking for an experienced child survival consultant.) We will eventually post the final evaluation document to this website, but in the meantime, here are some of the highlights from that evaluation:
- The project saved an estimated 6,522 lives of preschool children. We estimated lives saved using the LIST. It was heartening to see how many parents were saved from this grief. To see the coverage changes that brought about these lives saved, click here.
- We measured time input by everyone involved in the project and found that 80% of the work was done by community volunteers, and 97% of the work was done by community-level staff and volunteers. Communities are helping themselves out of their poverty using Care Groups.
- Largely due to the fact that people were mobilized to help their neighbors voluntarily, the cost per life saved was only $464 – less than a third of the average cost per life saved in CSHGP child survival projects (and that average is very cost effective). The total cost per beneficiary per year was only $2.75.
- We are growing more and more interested in measuring the effects of the Care Group model on gender-based violence. In this project, respect between husbands and wives, and for woman as leaders, increased: 61% of Leader Mothers (Care Group Volunteers) who served as the main volunteers in the project said that their husbands respected them more now (at final evaluation). 64% said their community leaders respected them more, 25% said health staff at the clinics respected them more, and 100% said other women and mothers respected them more now. This may be a part of the reason that spousal abuse appears to be much lower now among these Leader Mothers (3%) as compared with other women in their communities (34%). And spousal abuse of all mothers of young children appears to have decreased during the project (from 69% in 2004 [when it was measured as part of a LDM study] to 34% in 2010) … but more needs to be done. Leader Mothers also said that they respected their husbands more now, so mutual respect is growing. (In Mozambique as a whole, about 55% of women said that they thought it was okay for a man to hit a woman.)
- Malnutrition (underweight) decreased by 34% in communities where FH worked for only 15 months. In the other project area, malnutrition dropped 22%. The final KPC showed statistically-significant, positive changes in consumption of many different food groups.
- Insecticide treated net use increased from 35% to 80% in the first project area, and from 16% to 89% (in only 15 months) the other project area. While these have been available to mothers who show up for prenatal care, community mobilization is what got the mothers to the health facility.
On Monday of this week, I had a good talk with Dan Heath, the author of Switch, the #1 organizational and behavioral change book on Amazon.com right now. (I highly recommend it!) He saw the narrated presentation on Care Groups on this site and said that he was “blown away” by the results. We are too, and hope that you will tell your colleagues about the approach. As Dan said, “You know you have a winning horse … and you need to let that horse run.”
Tom Davis, MPH
Senior Director of Program Quality Improvement
Food for the Hungry
I’ve been reading a host of exciting books on social networks and social network theory lately: Linked, Connected, etc. We are not talking about Facebook here, but the networks that we find in all communities and countries, regardless of their internet connectivity. Findings presented in Connected show that we have a measurable influence out to three degrees — our friends’ friends’ friends — in our social network. There are more and more studies showing how behaviors and outcomes spread through networks including cigarette smoking/cessation, obesity, and even happiness. New findings in social network theory are driving changes in many domains including genetics, behaviorism, health promotion.
As I’ve read these books, I’ve become increasingly convinced that one reason we are seeing such amazing results in behavior change using Care Groups is that we are utilizing the power of scale-free social networks. By having beneficiary mothers choose “their” Leader Mother (who does health promotion with them), they are more likely to be choosing one of the “hubs” in their social network — someone who is in a much better position to convince them to make healthy changes. Also, with the structure put in place by Care Groups, there are fewer links to traverse between any two given mothers, so communication and persuasion is enhanced. The mothers who serve as connectors between mothers are also more likely to be practicing healthy behaviors, and so healthy behaviors are more likely to be spread. If a Leader Mother — who is more often than not a hub — hears about a positive story of a mother using ORS, for example, she is more likely to transmit that information to other mothers with which she is connected (since it is in tune with her beliefs and experience) than she is to transmit a story about ORS “not working.” Certain types of information (e.g., pro-exclusive breastfeeeding info) is preferentially transmitted through the social network, and that’s important when you are going against the prevailing cultural practice.
I am convinced, however, that we could be doing a lot more to harness the power of social networks for child survival and community health if more of us understood the latest findings and developed the tools needed to better understand the networks that we are dealing with and our effect on those networks. Findings from modeling on immunization strategies, for example, show that we could dramatically decrease the number of people who we need to immunize to stop an epidemic if we focused on people’s acquaintances (who are more likely to be hubs) in a given community. Given that behaviors also flow through these social networks, it would make sense that focusing more on those hubs (and using them to influence others) should make behavior change happen more quickly and at lower cost. Doing some social network analysis can also help us to know who in the broader community to target and who has the most influence on mothers and their child survival behaviors. (See this article on breastfeeding and social networks in Bolivia, for example.)
If you are new to social networks, I recommend these videos on social network theory and acquaintance immunization.
Tom Davis, MPH
Chairman, CORE Group Board of Directors
Director of Health Programs, Food for the Hungry
Welcome to Care Group Info! I’m Tom Davis, Chairman of the Board, CORE Group, and Director of Health Programs for Food for the Hungry. The CORE Group is THE network for people who work in community health, and the CORE Group has been instrumental in documenting this approach and getting the word out to others. If you are looking to learn more about methods to reach the poor with lifesaving information at low cost, you’re in the right place. Care Groups have been around now for 12 years, but recently they have been gaining a lot more attention by international NGOs and multilateral organizations. If you are new to Care Groups, I recommend you watch the narrated presentation we have posted. If you are more of a reader, download the manual.
I learned about Care Groups 12 years ago from one of the original developers of the approach, Dr. Pieter Ernst in Mozambique. (The other main collaborator on the methodology is Dr. Muriel Elmer, formerly with World Relief.) In Food for the Hungry, we began using them at that point and have used them in many settings in the world (most in Africa) since then. When — with World Relief — we started to gather information on the results of Care Groups and compared them to other child survival projects, we realized that this was a very special approach that deserved a lot more attention — hence the website.
For example, in our Care Group project using Care Groups in Mozambique (sponsored by USAID), we have seen a 42% drop in malnutrition (underweight) in only 2.5 years. The cost per beneficiary there is a mere $3.60 per beneficiary per year. By doing Lives Saved Analysis (using the Bellagio Lives Saved Calculator — the same one used in the Lancet Child Survival Series), we found that for only $305, we could save the life of one child. This is about 1/4 of the cost to save life for a typical (and very cost-effective) USAID funded child survival program.
As I have read more of the literature on networks, persuasion, community-based social marketing and other disciplines, I have more and more hypotheses about the power of Care Groups and why they are successful. But these are mostly hunches at this point. What we do know is that they work. What we need to do now is to better explore why they work, under what conditions they work, and how to convince policy makers to scale up the approach where it has been effective..
In future posts, we can discuss some of the possible reasons for Care Groups’ success.
Chairman of the Board, CORE Group
Dir. of Health Programs, Food for the Hungry