April 23, 2013Carolyn Kruger, Ph.D.

Senior Advisor MNCH, PCI

CARE GROUP TRIOS: AN INNOVATIVE HOUSEHOLD

BEHAVIOR CHANGE MODEL

CORE Group Spring

Meeting 2013

USAID/FFP: PROSHAR – “Program for Strengthening Household Access to Resources”, June 2010 to May 2015

½ million beneficiaries (direct and indirect) in 23 unions of three Upazilas

Implementing partners include : ACDI/ VOCA; PCI; GOB; and three partner NGOs

PROSHAR OVERVIEW

SO1: Income and access to food of poor

and ultra poor households increased

SO2: “Health of pregnant & lactating women and children under 5 (with particular attention to children under 2) improved”

SO3: Institutions and households prepared to

respond effectively to shocks

IR. 2.1. Malnutrition prevented and treatedIR. 2.1. Malnutrition prevented and treated

IR. 2.2. Improved effectiveness of health

clinic services

IR. 2.2. Improved effectiveness of health

clinic services

Goal of PROSHAR: Reduced Food

Insecurity Among Vulnerable Rural

Populations in Selected Upazilas in Khulna

Division

Goal of PROSHAR: Reduced Food

Insecurity Among Vulnerable Rural

Populations in Selected Upazilas in Khulna

Division

IR. 1.2. Market linkages developed and strengthened

IR. 1.2. Market linkages developed and strengthened

IR. 1.1. Agricultural productivity

increased and diversified

IR. 1.1. Agricultural productivity

increased and diversified

IR. 1.3. Non-agriculture opportunities expanded

and diversified

IR. 1.3. Non-agriculture opportunities expanded

and diversified

IR. 3.1. Disaster Risk Reduction Plans (DRRPs)

functional

IR. 3.1. Disaster Risk Reduction Plans (DRRPs)

functional

IR. 3.2. Early warning system

functional

IR. 3.2. Early warning system

functional

IR. 3.3 Increase knowledge and

skills

IR. 3.3 Increase knowledge and

skills

INTEGRATED PROGRAM DESIGN

PCI’s research showed mothers are often the least influential in decisions about nutrition & health care

Fathers & mothers-in-law have strongest influence on behavior change; fathers dictate care seeking behaviors & mothers-in-law set child rearing practices

PCI thus developed “CG trios” that involve fathers & mothers-in-law in order to sustainably change behaviors

DEVELOPMENT OF TRIO CONCEPT

WHO INFLUENCES BEHAVIORS?

Husband Mother-in-law* Sister-in-law Neighbors No one0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

8%6%

2%

24%

41%

10%

22%

12%

28%

40%

Disapproval of pregnant women consuming extra food during pregnancy

NonDoersDoers

Targeting influential people

Sufficient breastmilk

Family Support*

Don't need extra food

Less work load

No expense* Baby doesn't cry

0%

10%

20%

30%

40%

50%

60%

70%

55%

20%

33%

12%

0%

12%

61%57%

31%

14%10%

4%

Perceived self-efficacy: What made it easier for you to exclusively breastfeed?

NonDoersDoers

Improving the knowledge and responsibility of family members on

the importance of EBF and their support of the mother

WHAT INFLUENCES NUTRITION PRACTICES

(E.G. EBF)?

TRADITIONAL CARE GROUP MODEL

Each Care Group Trio consists of 12 leaders each. Mother CGs meet monthly. Grandmothers & Father CGs will meet every three

months with the mother CGs.

(162 Care Group Trios total)

Each paid promoter oversees

approximately 10 Care Group Trios

(12 promoters

total)

Each supervisor oversees

approximately three paid promoters

(4 supervisors total)

Supervisor

PromoterGrandmothers

Mothers Fathers

Promoter

Promoter

PROSHAR TRIO CARE GROUP APPROACH

Each leader will meet with approximately 14 peers regularly (monthly/mothers & quarterly/fathers &

grandmothers) reaching 81,648 HH decision-makers

CG TRIOS MEETING

Care

Group

(Mother Leaders)

• Mother leaders (ML) meet 2x/month• Health promoter (HP) meets with MLs 2x/month; MLs organize

meeting with their groups the following week• Flipchart with specific health & nutrition messages used

Care Group

(Grand

Mother Leaders

)

• Grandmother leaders (GmLs) meet 1x/month• HP meets with GmLs in the first month of the quarter; GmLs meet with their

groups in the following two months• Flash card set is used with specific health & nutrition messages

Care Grou

p (Fath

er Leaders)

• Father leaders (FLs) meet 1x every two months• HP meets with the FL 1x/month; FLs meets with their groups in the following

two months• Flash card set is used with specific messages

Care

Group (Trios meeting)

• Every quarter HP meets with the three leader groups together• Objectives are to discuss: CG activity status; challenges; success stories;

lessons learned and plans for addressing challenges

Flipcharts Flash Cards

BCC MATERIALS DEVELOPED

Puzzles Posters

Stickers

Exclus

ive

Brea

st F

eedi

ng

Early

Initi

atio

n of

BF

3+ A

NC Visits

Post

Par

tum

Vit-

A

3 C

orre

ct IY

CF Be

havior

s0

20

40

60

80

100

31.4 38.2 32.3 34.6 29.2

56

88.7

53

73

40.9

Baseline Sept 2012 Results

BEHAVIOR CHANGE TRENDS

Building capacity of MLs to counsel CG participants using ASPIRE (ask, show, probe, inform, request, examine) – need practice!

ML uses specific CG monitoring tools – picture checklist, registration

Weak MLs are targeted for intensive one-on-one counseling by HPs

High performing CGs & families are recognized to encourage optimal behaviors at household level

Fathers need flexible meeting times that don’t interfere with work schedule

TRIO IMPLEMENTATION

1. The Trio Care Group approach is a “promising practice” that makes a diff erence in changing behaviors among pregnant women.

2. CG Trios overall have had a high level of participation (even for fathers and grandmothers who have greater participation challenges).

3. Focus on household and community behavior change, not just communication messages.

4. The three groups have diff erent roles in the family and community – discuss and demonstrate how their roles can infl uence change.

5. Promote the Trio groups as change agents, not just messengers.

6. Provide pictures of desired mother, father, grandmother desired behaviors and focus on “why the behavior is healthy”.

7. Promote home visits to promote healthy behavior change and focus on “why the behavior is healthy”.

8. Groups should meet together to identify barriers to change, to problem solve for solutions and to be accountable for change in their families and communities.

LESSONS LEARNED TO DATE

Thank You!