Can Care Groups Improve Health Seeking Behaviours? Results of an Impact Evaluation in North-Eastern Nigeria
The approach combines cascaded training and peer support groups and aims to reach at least 80% of pregnant women, mothers and caregivers of children under two years in the area of intervention. In 2018, an impact study was carried out in the two states to assess the strength of the programme.
THE CARE GROUP APPROACH IN NORTH-EAST NIGERIA
In the Care Group approach, a structured curriculum of lessons is delivered, focusing on key aspects of maternal and child health, including optimal infant and young child feeding and maternal nutrition practices, hygiene practices, common diseases and utilisation of healthcare services. Every month, Action Against Hunger nutrition staff trained field-based female health promoters selected from target communities. In turn, the promoters cascade the learning to 10-16 volunteers who then replicate it with a further 10-15 households through meetings and home visits. This strategy enabled one nutrition staff to reach between 5,400–8,100 households every month (Figure 1), and in total, approximately 146,500 household are reached each month through face-to-face activities.
EVALUATION OF THE CARE GROUP APPROACH
Demographic and Health Survey (DHS) data from the Nigerian Federal Ministry of Health were reviewed for evidence of outcome-level improvements in health seeking behaviours. Indicators examined were antenatal carevisits, postnatal care visits, healthy facility utilisation rates, infant mortality rates, and low birth weight rates.
Changes in indicators were modeled over time and compared between baseline (2015) and post-implementation of the Care Group approach (2018).
WHAT DID THE CARE GROUP APPROACH CHANGE?
The results detailed in table two are summarised here:
- The greatest improvements were observed in antenatal care attendance and facility utilisation rates. This included an increase in the number of women attending all four antenatal visits.
- Postnatal visits also increased following the start of Care Group activities.
- Data quality issues meant that the effect on infant mortality and low birth weight could not be assessed. No significant impact on changes to mean infant mortality rates and due to lack of data or its quality.
LESSONS LEARNED ON THE EVALUATION PROCESS
The evaluation methodology was cost efficient as it used existing routine data from the monitoring health system that are robust enough to ensure representation of the population. However, as with all existing data sets used for secondary analysis, there is a risk of data quality issues. Ensuring best practices in data collection and management would improve greatly the quality of future evaluations.
LESSONS LEARNED ON PROJECT IMPLEMENTATION
Based on this experience, we can see that there is a great potential of behaviour change using the Care Group approach, as this model allows implementation at scale and with positive effect on entire populations. Several good practices were identified by the project team during a review workshop, such as introducing an additional layer to the original model, importance of constructive supervision, adjusting promoter’s workload, replacing pregnant volunteers close to delivery period, and the importance of participatory methods such as games and storytelling that make the sessions more attractive.
Based on the evaluation results, we believe that the approach can still be improved to support behaviour maintenance for antenatal care. The antenatal care lesson should be introduced at the start of the curriculum and more opportunities to reinforce the behaviour could be created. Attending all antenatal visits is a complex behaviour, that requires planning, time, and reorganising household task. Promotors should be trained on techniques to help women manage these difficulties, like using reminders and goal setting. In addition, behaviour change intervention at individual and peer level might not be enough. The project should assess, and address barriers linked to the physical environment and the social and gender norms,which may hinder women’s access to health services.
HOW ARE WE MOVING ON?
The evaluation was presented at the 3rd R4NUT Research for Nutrition Conference in November 2019 and at UNICEF Workshop on wasting, in Senegal, in November 2019 where implementation, cost and curriculum design were discussed.
MSF Belgium also reached to Action Against Hunger staff to build on their experience. The care group curriculum implemented by Action Against Hunger in Uganda was adapted based on the recommendations provided by our study.
Care groups can be implemented at large scale, and influence positively health-seeking behaviors of a large population. Future implementers should embed these lessons learned in similar interventions, assess their impact and share their findings to ensure continuous learning and programme improvement.
Author: Ali Mohamed Nassur, Epidemiologist and Biostatistician, France; Armelle Sacher, Social and Behavior Change Technical Advisor, USA; Dieynaba S N’Diaye, Research and Analysis Advisor, France; Stephanie Stern, Action Against Hunger Knowledge LAB Advisor, France