[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: Curamericas Guatemala 2002-2007 Final Evaluation
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:
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