1. Care Groups:
Experience and Evidence
Henry Perry, MD, PhD, MPH
Department of International Health
Johns Hopkins Bloomberg School of Public Health
Care Group Technical Advisory Group Meeting, 29 May 2014

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Overview
• History and definition
• Current implementation
• Current evidence
• The evidence for PLA groups
• Conclusions

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Beginnings: World Relief/
Mozambique
Pieter Ernst, Muriel Elmer,
Anbrasi Edward, Melanie
Morrow, Warren and Gretchen
Berggren
Care Groups for trachoma in
S. Africa in the 1970s
Grew out of interest in a more
effective form of health
education and the
government’s division of 10
families into a block
First Care Group Project:
1995-1999 (supported by
USAID CSHGP)

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Early Lessons
Need a census – sometimes communities
neglected some villagers or households
Need criteria for selecting volunteers –
sometimes village leaders selected
alcoholics or older people

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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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Early Champions: Anbrasi Edward, Melanie
Morrow, Tom Davis, and Carl Taylor

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Early Expansion
Tom Davis, then working for Food for the
Hungry and Curamericas Global, recognized
the power of Care Groups after learning
about World Relief’s first Care Group project
in Gaza Province, in southern Mozambique
Under Tom’s leadership, Food for the Hungry
first tried out this model in Mozambique
(Sofala Province) in 1997 and Curamericas
in Guatemala (Huehuetenango Department)
in 2001

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Critical Support
Small grant from the Core Group for
preparation of the Care Group manual (The
Care Group Difference: A Guide to
Mobilizing Community-Based Volunteer
Educators) and for independent verification
of mortality impact in the second World
Relief/ Mozambique project, 1999-2003
(leading to the Edwards peer-reviewed
article in 2007)

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Current Implementation
27 organizations
Across a total of 23 countries
106,000 Care Group volunteers trained
1.3 million households reached
In 2010, 14 NGOs in 16 countries were
implementing Care Group projects
New manual almost ready for dissemination: Care
Groups, A Training Manual for Program Design
and Implementation

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Attempts at Scale and Integration
with MOH
Food for the Hungry/Mozambique Extended
Impact Project – covered an area with 1.1
million
Concern Worldwide has carried out a
randomized controlled trial comparing the
effectiveness of the model with a MOH CHW
as Care Group facilitator compared to an
NGO facilitator
Malawi MOH planning to scale up Care Groups

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Implementing Organizations (27)
ACDI/VOCA
ADRA
Africare
American Red Cross
CARE
Concern Worldwide
Catholic Relief Services
Curamericas
Emmanuel International
Feed the Children
Food for the Hungry
Future Generations
GOAL
International Aid
International Medical Corps
International Rescue Committee
Living Water International
Medair
Medical Teams International
Pathfinder
PLAN
Project Concern International
Salvation Army World Service
Save the Children
World Renew
World Relief
World Vision

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Countries Where Care Group Projects
Have Been Implemented (23)
Bangladesh
Bolivia
Burkina Faso
Burundi
Cambodia
DRC
Ethiopia
Guatemala
Haiti
Indonesia
Kenya
Liberia
Malawi
Mozambique
Nicaragua
Niger
Peru
Philippines
Rwanda
Senegal
Sierra Leone
Somalia
Zambia

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Implementors and Donors
Virtually all projects implemented by
international NGOs
Major and early donors:
• USAID Child Survival and Health Grants
Program – 10 projects
• USAID nutrition funds: Title II MYAP, TOPS
– 15 projects
• USAID OFDA (Office of Foreign Disaster
Assistance) – 3 projects

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Other Donors
CIDA (Canada)
DfID (UK)
ECHO (European Commission: Humanitarian
Assistance and Civil Protection)
UNICEF
World Bank (for nutrition programs in Mozambique)
World Bank (for linking Care Groups with PLA in
project by Concern Worldwide and Mai Mwana, a
local NGO)
Private funds of NGOs (especially child sponsorship
funds)

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Content Area
All projects so far focused on community-
based maternal and child health, including
nutrition
1 project (the first Care Group program in
Mozambique) has now expanded to
tuberculosis

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Extensions of the Model
Formation of peer-support groups of CHWs
implementing iCCM in Rwanda (as part of a scaling up
project led by IRC, World Relief, and Concern
Worldwide
Incorporation of a savings program into Care Groups
(Food for the Hungry)
Development of Care Groups for fathers and mothers-in-
law as well as for mothers (Trios Project in
Bangladesh)
“Care Groups” of farmers’ groups, called agricultural
cascade education (Food for the Hungry in DR Congo)

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Potential Areas of Expansion
Early child development
Maternal depression
Promotion of good education behaviors for
young children
Gender-based violence
Promotion of “resiliency beliefs”

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What Is Evidence?
• Field experience (non-systematic)
• Project evaluations
• KPC surveys (before-after uncontrolled
program evaluations)
• Qualitative assessments
• Cost
• “Seeing is believing”/ word of mouth
• Non-randomized controlled studies
• Peer-reviewed journal publications
• Randomized controlled trials (?)

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What Is Evidence?
Source? Who collects? Methodology? What happens
to the data?
Household
surveys (KPC,
birth history)
Project staff vs.
independent
data collectors
Comparison/
control area(s)
Project
evaluation report
(publicly
available or not)
Focus group and
key informant
interviews
(formal vs.
informal)
Formal versus
informal
Randomized vs.
non-randomized,
random sample
versus purposive
sample
Published in
peer-reviewed
journal
Project
monitoring data

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Criteria by Which to Judge
Effectiveness
Change in population coverage of key maternal
and child health indicators
Improvement in child nutrition
Reduction in under-5 mortality and maternal
mortality
Cost per beneficiary
Cost-effectiveness (cost per life saved or DALY
averted)
Sustainability
Scalability

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Criteria by Which to Judge
Effectiveness (cont.)
Robustness (the degree to which the
approach’s effectiveness is maintained when
implemented by different organizations in
different contexts)

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Process Measurement (OR,
Implementation Research)
Is model being implemented as planned?
What is the actual Care Group size? How
much time do Care Group Volunteers spend
in Care Group meetings and with beneficiary
mothers? How long does it take them to
travel to carry out their work? What
percentage of mothers were visited in
previous 2 weeks?

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Process Measurement (OR,
Implementation Research)
What is the age, gender and educational level of
Care Group Volunteers? What is their turnover?
What is their longevity after the NGO project
ends.
What are the most effective ways of teaching
messages to Care Group Volunteers and
beneficiary mothers? How important are audio-
visual aids, teaching in groups vs. one-on-one?
What other people participate in educational
sessions besides mothers?

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Unpublished Evidence
Available evidence not systematically assessed
•Widespread experience with Care Group project
implementation
•Enthusiasm is growing among program managers
•Approximately 20 completed project evaluations that
used the Care Group methodology

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Unpublished Evidence (cont.)
• I have conducted or participated in 7 Care Group
mid-term or final project evaluations
• World Relief/Rwanda – MTE (2004)
• Curamericas Global/Guatemala – MTE (2005) and FE
(2007)
• World Relief/Cambodia – FE (2005)
• World Relief/Mozambique – FE (2009)
• Food for the Hungry/Mozambique – FE (2010)
• SAWSO/Zambia – FE (2010)
• I have personally led probably 100 different
focus group discussions or interviews with
key informants about Care Group projects

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Handwashing Practices, World Relief/
Cambodia Child Survival Project (based on
mini-KPC data)
Percentage of mothers who wash their hands before food preparation, before feeding their children
before eating, or after defecation
OA: Original Project Area
EA: Extension Project Area

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Unpublished Evidence
(Tom Davis – 2008)
Care Group Performance: Perc. Reduction in Child Death Rate (0-59m)
in Thirteen CSHGP Care Group Projects in Eight Countries
through Seven PVOs
23%
33%
48%
36%
42%
32% 28% 29%
14%
26%
12%
35%
30%
14%
33%
0%
10%
20%
30%
40%
50%
60%
AR
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Avg.C
are
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Avg
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P
roj.
CSHGP Project
%Red.U5MR
U5MR Red.
Based on LiST analysis
by Ricca of 13 CSHGP
projects that finished in
2005-6

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Unpublished Evidence (cont.)
Conclusions
• Care Groups are effective in empowering
Care Group volunteers
• The effect builds up slowly over the life of
the project
• As Care Group volunteers become more
experienced, they become more effective
• As the community and the Care Group
volunteers begin to achieve success in
reducing deaths, enthusiasm (and
empowerment) build

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Unpublished Evidence (cont.)
Conclusions (cont.)
• Rapid uptake and maintenance of expanded
coverage of key interventions
• Coverages achieved are greater than for
non-Care Group CSHGP

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Published, But Not in Peer-
Reviewed Journal

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From Book Chapter (based on vital
events registration by volunteers)

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Peer-reviewed Journal
Publications
Transactions of
the Royal
Society of
Tropical
Medicine and
Hygiene, 2007
BMC Public Health,
2011
Global Health:
Science and
Practice, 2013

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Source: Journal of Global Health: Science and Practice, 2013

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REDUCTION IN CHILDHOOD DIARRHEAL PREVALENCE USING
HOLLOW-FIBER WATER FILTERS WITH AND WITHOUT BEHAVIORAL CHANGE
Erik D. Lindquist, Christine M. George, Thomas P. Davis Jr., Karen J. Neiswender, W. Ray
Norman, Rodolfo Calani, G. José Sanchez Montecinos, and Henry Perry (AJTMH, in
press)
Figure 2. Diarrheal Prevalence for Control and Intervention Groups for the 2010
study. The mean diarrheal prevalence is depicted for the pre- and post-
intervention (bars) and monthly intervention (lines) phase surveys. Legend:
Control group, white bars and dotted line; Filter Only group, gray bars and
dashed line; Filter and BCC black bars and solid line

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Write Ups in Progress
LiST analysis comparing estimated mortality
impact of Care Group with non-Care Group
child survival projects
Results of cluster-randomized trial comparing
MOH CWHs as Care Group facilitators with
NGO facilitators in Burundi
Results of effectiveness of CHWs participating
in a “Care Group-like” process for iCCM
(with home visits)

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Participatory Women’s Groups:
“Kissing Cousins”?

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Women’s Groups Practicing
Participatory Learning and Action (PLA)

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Participatory Learning and Action
Groups
Prost et al., Lancet 2013

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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) usually every 2 weeks,
ensuring all pregnant women or
mothers of young children are
reached
At monthly 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,
nutrition
Maternal and neonatal
health, maternal depression

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Differences in Participatory Learning and
Action (PLA) Groups and Care Groups (cont.)
Care Groups PLA Groups
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).
Reflection and action encouraged
Facilitator shares health
messages gradually while at
the same time facilitating
process for enabling women
to reflect on how to take
action
Process for
ensuring equity
All eligible women are identified and
are reached by a Care Group
volunteer (thereby ensuring that the
most vulnerable are included)
None. No process to ensure
that all eligible women are
included in the program or
reached with key messages

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Comparing Strength of Evidence
Criteria Care
Groups
PLA
Groups
Comment
Number of published
reports in peer-reviewed
journals assessing
effectiveness
2 >12 Most of PLA studies reported in
the Lancet
Rigor of impact
assessment
Fairly
good
Highest
possible
Process documentation
(and measurement of
coverage outcomes)
Strong Weak
Number of
projects/studies
>30 10 (?)
Number of different
implementing entities
>30 1 All PLA trials so far led by
University of London research
group (T. Costello)
Different settings of
implementation
23
countries
4
countries

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Comparing Funding Support for
Operations Research
PLA – millions of dollars (from the Gates
Foundation)
Care Groups – almost none (except $50,000
CORE Group grant to fund mortality
independent assessment of initial Care
Group project) until two recent small
operations research grants from USAID

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Next Steps:
Integration with MOH for long-term
sustainability and scaling up
Continued refinement of the Care Group model
for increased effectiveness or for the same
effectiveness at lower cost
Promotion of the model among donors
More funds for M&E and continuing to build the
evidence base

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Next Steps:
More rigorous analysis and summary of
existing evaluations (and more LiST
analyses)
RCTs of Care Groups? “Head-to-head” with
PLA or in combination?
Studies of scaling up and integration with MOH
programs (and paid CHWs as facilitators)

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Acknowledgments
I am grateful for assistance from the Care Group
experts:
•Melanie Morrow
•Tom Davis
•Sarah Borger
•Mary DeCoster
•Jennifer Weiss