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Nurturing Care Group �Project Model��Tom Davis, MPH�Global Sector Lead, Health & Nutrition�March 2020

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Why a Multisectoral Nurturing Care focused Care Group Model?

The idea: Combining Group approach for household-level behavior change with the multisectoral nature of the Nurturing Care Framework – “Nurturing Care Group” project model.
Purpose: Promote basic parenting skills and adoption of key behaviors from more sectors.

Better address…

Violence Against Children
Adolescent Nutrition
Caregiver mental Health
Child Injuries
Early child stimulation/development

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So the project model we will be talking about today is a multisectoral version of the Care Group approach which we are calling Nurturing Care Groups. This particular model is a is used to promote most elements of the Nurturing Care Framework which was released by WHO and UNICEF in 2019.
The purpose is to promote basic parenting skills and adoption of key messages from most WV sectors: Not just Health, Nutrition and WaSH where CGs have traditionally been used, but also Child Protection and early child Education where it has been used less often.
The NC Framework promotes many things which all of us have already been promoting through Care Groups: Good Health and Adequate Nutrition in particular, but brings in more of the “thrive” agenda by focusing on opportunities for early learning, security and safety, and responsive caregiving.
This was important to us since we in WV have decided that we need to work further back in the chain of causation of child deaths and better address some neglected issues to improve child wellbeing. For example, we need to focus more on reducing violence against children (especially child marriage where a 10% reduction in child marriage can contribute to a 70% reduction in the MMR), improve adolescent nutrition (which of course affects LBW and prematurity, the leading cause of newborn deaths), reduce child injuries, increase early child stimulation and development, and improve caregiver mental health, . WV’s new Health & Nutrition Sector Approach gives more attention to all of these issues. We would like to present to this group on Food for the Hungry’s and WV’s C-RCT on caregiver mental health at some point, but the headline is that IPT-G plus CGs achieved a 95% reduction in depression, and non-depressed women had adoption rates of key health, nutrition and WASH behaviors that were almost 40 percentage points higher than that of depressed mothers.

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Frequency with which CHWs witnessed VAC, last 3 mons, by type

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Integration works: Increasing evidence that linking sectors improves outcomes.

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We also want to promote more sectoral messaging through Care Groups since we know that integration works: The research on combining Nutrition and Education is pretty strong, and there’s new evidence coming out on how linking these sectors improves outcomes. For example

[Click] In some cases, children who have access to adequate nutrition fail to eat and/or to grow properly because of the lack of stimulation and attention they experience at an early age. This is "failure to thrive" when children refuse to eat and, as a result, do not grow properly. Or it may be called "deprivation dwarfism" when children eat but still fail to grow because the emotional and stimulation deprivation they face depresses their endocrine system and inhibits the production of pituitary growth hormones, which is essential for the normal growth and development at the cellular level. In fact, as the graph on the top demonstrates, an evaluation of our CMAM work showed that integration of nutrition and responsive caregiving (through our Go Baby Go model) with CMAM led to faster and better recovery rates from wasting. These conditions occur everywhere, including in developed countries, but they may be particularly prevalent in conflict or post-conflict societies, in HIV/AIDS affected communities, or in extremely poor environments, where caregivers are so preoccupied with daily survival that they develop stress and depressive symptoms that interfere with their capacity to create the nurturing and stimulating environment needed for their children to thrive.
[Click] We know that the human brain cannot develop to its full potential through nutrition alone either. Early childhood stimulation plays a critical role in the process of brain formation and development, mainly by supporting the multiplication of synapses and the myelination process, all of which allows for more complex and faster neural transmissions. We can see this on brain scans. The brain on the left is from a healthy three year old, and the one on the right is from a three-year-old suffering from severe sensory-deprivation neglect.
[Click] In this graph on the right, children who received both stimulation and supplementation had higher development quotient scores than those who just received the one intervention.

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PCI ECG Outcomes and Objectives

Outcomes include:

Increased adoption of new ways of interacting with 0-5 year olds
Improved school readiness

Achieved:

Milestone assessments showed improvement in just 4 months from 31% to 63% advanced; 22% to 16% progressing well; and 47% to 22% not doing well

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10 Care Group and 9 non-CG projects in 5 African/Asian countries compared.
Care Groups had more than double the behavior change (p=0.0007), 53% better U5MR reductions (p=0.09).

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Main differences from traditional project models using the Care Group approach: Reach (often all HHs), using mostly home visits, and more holistically promoting Behaviours across five sectors. Staffing via CHWs or paid Promoters.

End of Project

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So that’s the “why.” Let’s talk about the “what.” What is different about this model?
The differences are not huge. It’s yet another incremental innovation on the approach. There are three main differences with this project model as compared to project models using a more traditional CG design: Reach, the focus on home visits rather than a combination of group meetings and home visits, and the behaviours promoted. Those are all degrees of course rather than absolute differences:

In terms of reach, we give some leeway in the training manual for a targeted approach (e.g., reaching children under 3 or 5 and their caregivers), but we plan for it mostly being used to reach every household in a given geographical area. This is actually a return to how the Care Group model was used by World Relief early on in Mozambique. As this graph demonstrates,, those early WR CG projects in Gaza had excellent sustainability. In addition to finding that 93% of CGVs were still reaching women with behavior promotion at 20 months post project, results were sustained – or improved upon – at 30m and 42m post-project. This is only one of about 17 graphs that showed the same trend. Maybe there’s something to that. Reaching every household also allows you to reach all the possible influencers and create a real buzz around a topic. We are testing the model this way in Ghana, which Ben will tell you about. The cost per beneficiary per year there is $3.21.
As I mentioned earlier, there will be more focus on Child Protection and Education. The model will be “plug and play,” so fields can better tailor the messages to the reality on the ground. Todd will be talking about the CP module.
For staffing, we are testing it in Ghana using both CHWs (like Concern did in Burundi), and with paid, low-level NCG Promoters. Most other elements of the model mirror that of models based on the traditional CG approach.

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Current Child Protection Lessons in the module:

1: Protecting Our Children
2: Understanding Parent Stress
3: Spending Quality Time Together
4: Disciplining with Dignity- Instructions, Praise and Consequences
5: Disciplining with Dignity- Ignoring Negative Behaviours and Time-Outs
6: Disciplining with Dignity- Establishing Household Rules and Routines

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Current WaSH Lessons in the module:

1: Collecting and Transporting Water

2: Our Family Drinks Safe Water

3: Our Family Has Clean Hands

4: Ending Open Defecation in Our Community

5: Building a Good Latrine

6: Cleaning and Maintaining Our Latrine

7: Proper Disposal of Child Faeces

8: Caring for Yourself During Menstruation

9: Breaking the Stigma of Menstruation

10: Keeping Food Safe and Clean

11: Providing a Safe Place for Our Children to Play

12: Our Household Compound is Clean and Safe

13: Safe Management of Animal Waste

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CHILD PROTECTION CURRICULUM

The main lessons in the Child protection curriculum center around:
Understanding and can recognizing different types of violence; and knowing how to report violence.

Indicator: % of parents who can name at least three types of violence that could take place in a household

Understanding Parental stress, using relaxation techniques, and seeking MH support

% of parents who can name at least two relaxation techniques
% of parents who know where to go to seek mental health support

Using positive parenting, praise, and non-violent discipline approaches

% of parents who consistently use non-violent forms of discipline.

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Theory of Change targets four main child well-being outcomes:

Children (and also adolescents, WRA and pregnant women) are well-nourished.
Children are protected from infection, disease, and injury
Children read, write and use numeracy skills [NCGs would focus on pre-numeracy and pre-literacy skills (e.g., print orientation, letter recognition).
Children are cared for in loving and safe families and communities

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10 Core Impact areas including…

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Why is (WASH) Behavior Change hard?

Need high-frequency contact to make behaviors stick
Often groups, not just individuals, must do the behaviors
Poor infrastructure can limit behavior change

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Care Group programs led to an average decline in under-5 mortality of 32% vs. 11% in non-Care Group Programs
Need to generate WASH-specific evidence, integrate into WV structure, and understand how to leverage the approach for greater impact

Evidence of Impact

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Testing in Ghana

Where: Sekyere & Savelugu APs
When: June 2019 to Sept 2020
What: Lessons delivered; Collecting and transporting water.
Quote by Akwele Kumebio :

…it is difficult to meet every woman for a community meeting, but with NCG we teach ourselves and others who don't turn up for meetings in their homes”

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Key Learning Questions

How does this approach complement community-led total sanitation?
What is the best way to achieve high rates of toilet use and handwashing with soap?
How much can we influence animal feces management?
Can we integrate with the government for better sustainability?

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Where to go from here

Learn what worked and what can be improved (esp. MHM & Animal Feces)
Test in other National Offices
Explore how high-quality sanitation and hygiene products can be integrated
Understand how to integrate with and strengthen government systems

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Questions & Answers

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Users welcome!

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CHWs’ actions to end violence against children (last 3m)

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Nehnwaa Care Group Project �(Curamericas / Liberia)

Liberia CG Project Indicator (all are s.s. changes)	Baseline	Final	Perc Pt Change	Gap Closure
Mortality reduction	3,053+ lives saved, $409/life saved (est.)
Impact: Underweight	67%	23%	-44	65%
Post-Natal Visit to Newborn	26%	99%	73	99%
DTP3	25%	99%	74	99%
Improved source for drinking water	63%	99.7%	36	99%
ITN Use (children)	46%	90%	4	97%
ITN Use (mothers during pregnancy)	38%	98%	61	97%
Maternal hand washing with soap before food prep.	5%	97%	92	97%
Proper disposal of child feces	4%	97%	93	97%
HIV Testing During Pregnancy	20%	97%	77	96%
IPT during pregnancy	19%	96%	77	95%
Appropriate Care Seeking, Pneumonia	43%	98%	55	94%
Improved toilet facility	25%	96%	71	94%

Here’s some data from another Care Group project in Liberia that had the best improvement in child nutritional status that I’ve EVER seen in any project – 65% reduction in underweight in 4 years. That is unheard of.
In Curamericas Global’s projects, they combined the Care Group strategy, community-based Impact-oriented approach, and some WASH inputs from the Hilton Foundation.
This is a lot of information, but look a the last column. The Indicator gap closure is a measure of what was achieved vs. what was possible to achieve.
Note that there was a 65% gap closure for the impact indicator in this CG project – the % of children who were underweight – and for the other indicators, many of them almost reached perfection – close to 100% closure of the gap, and close to 100% coverage by the end of the four-year project. This was for a wide variety of outcomes: vaccines, WASH indicators, ITN use, clinical services, care seeking, etc.
For 40 of the 43 indicators that Curamericas measured, they closed more than half of the indicator gap.