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Care Group Training Notes

PSL 21 IST

April 27th – 30th, 2009

The general objective of this Session is:

To provide a step-by-step technical guide in establishing and working with Care groups.

Learning Objectives: At the end of the session participants will

  1. Learn how Care Groups function,
  2. Discuss the success of the Care Group model in health programs;
  3. Appreciate Care Group model as a strategy for rapid and significant changes in knowledge, practice and coverage,
  4. Define the concept of a Care Group model as a strategy to achieve large-scale coverage;
  5. Appreciate the difference between a Care Group volunteer and a traditional community health worker.
  6. Have the information required to establish Care Groups in their communities;
  7. Be able to develop criteria for selecting appropriate promoters, volunteer leader mothers;
  8. Discuss lessons learned in working with Care Groups.

(ASK:) What is a Care Group?

(Write their responses on newsprint then add the following:)

A Care Group is a group of 10 to 15 volunteer community-based health educators who regularly meet together with project staff for training, supervision and support.

In Care Groups, each volunteer is elected by a set number of target households (usually 6-14) in the neighborhood.

  1. In a child survival and Title II nutrition projects, target households are those withfamilies that have children under five years of age. The numbers of target households vary from 6-14 depending on population density, availability of target households in the neighborhood, funding and volunteer willingness (i.e., how far they are willing to walk to visit mothers and to the meeting site).
  2. In Youth HIV/AIDS program, targets are youth within the specified age groups (10-24 Yr). In the ABY project, Y2Y haven been established:
  3. at the community level for out-of-school youth targeting households with youth10-24 years of age;
  4. in the churches and mosques targeting youth members of the church or mosque; and
  5. in schools targeting students 10-24 years of age.
  6. In forming these groups, we must make sure that the volunteers are living close enough to each other or that they have adequate contact with each other (e.g., spending adequate time together in school). This helps to simplify their regular meetings with the project staff.
  7. Care Groups get trainings from the project staff (promoters). Promoters are project employees who act as a bridge between the Care Groups and the project. They are recruited usually from the community where the project has its program, are trained, and are expected to live in the same community that they serve. (More about promoters role and responsibilities will be discussed later.)
  8. Care Groups meet once every two weeks or once every month depending on the size of the population the project covers and project resources. Obviously, more often – every two weeks – is better if volunteers are willing. These meetings are facilitated by the promoter with help from the co-promoter. Each promoter usually is responsible several groups.
  9. The Care Groups should be organized by gender as “boys only”, “girls only” or “a mix of boys and girls” depending on local preferences. We advise having a mixed group of equal representation. In cases when there is a need to discuss with the two gender groups separately, we can split the group and both groups will be well represented.

Why Care Groups?

Traditionally, a volunteer covers a wide geographic area such as a village or sub-county and his activities target the whole community collectively or a whole segment (e.g., all mothers of preschool children) rather than addressing individual households. The volunteers’ task is focused on creating community mobilization, community awareness,and giving health talks to larger groups, and usually do not have hardly any time to discuss health issues on a one-to-one basis in individual households. Since a volunteer covers a wide geographic area, his/her work demands full time (even if they only dedicate a few hours a week). With no or little incentives, it is hard to maintain the volunteer for a long time. The volunteer is more likely to burnout very quickly.

In most cases, volunteers are hand picked by project or government representative and that leaves their representation and responsiveness questionableby the beneficiaries.

In many cases, volunteers are expected to have basic education, at least to be able to read and write, and this minimizes the chance for the vast majority in rural areas to participate actively in project activities as a volunteer. These more educated promoters are also less likely to speak in the same way; and see things the same way as less educated folks. Communities have their own culture and are conservative. To change the way they do things (when they are unhealthy), you need mass mobilization and a lot of people to catch the vision of the project.

Let’s look at a metaphor for this community mobilization: Getting a fire to burn when you have wood that is a bit wet. What do you need to do to get a fire to burn, especially when the wood is not really dried out? (List what the participants say on a newsprint. After each one, ask, “Is that similar to anything you do when you are doing mass mobilization of a community?” Use questions to help guide them to some of these similarities. Try NOT to just give them the answers. Use probes like, “is it important to stack the wood in a particular way?” “Do you just use wood or do you need to use something else to get it burning?” “Do you just pile up the wood and then it catches on fire, or do you need to add something?” “Is there something you can do [aside from pouring gasoline on it!] to get a fire to burn more hotly so that the flame catches? What?” You would use probes, as well, to help them discover the similarities to mass mobilization.)

To get a fire to burn when the wood is not very dry, you need to… / How this is similar to Mass Mobilization
You need to pile the wood up (rather than spreading it out) so that the flame starting on one piece can spread to another. / You need the right structure. Mothers or youth reached through mass mobilization or broad educational events only are like scattered wood, not organized in a way that they can “spread the flame” and get other youth interested in change. The Care Group structure is our “pile of wood.”
You need to put something under the wood like paper or dry straw that burns more readily than the green wood. / We need to work with one group of women who are more ready to change and ready to make others change. They are the dry straw in our project, ready to catch fire and spread the flame to others more readily.
You then need a spark – without the spark, things will not burn. / The spark is the PCV and their Counterpartthe people who initiates action and gets the mothers excited about change. It’s also the mothers who are “early adopters,” who chose to adopt key health behaviors and tell other mothers about the benefits
You need to either (1) make the fire burn intensely in one small place first, or (2) get the fire going in a lot of different places so that it the heat dries out the wood allowing it to burn more easily. / We will have 2-4 hours a month with the Leader Mothers who will then go out and educate other mothers and caregivers. We expect the change to be more intensive in these groups, but to spread outward to others. The group will provide the supportive environment where change is supported, where the flame can burn easily. This will allow the mothers to go out and share that flame with others. We also distribute the care groups so that we have one leader mother working with a small group of 10 beneficiary mothers so that a lot of “small fires” get going in each group.
You need to fan the flames so that the fire burns more hotly. / Working with community and family members who influential mothers is how we will “fan the flames” – they are outside the fire, but help the fire burn, help the youth change. Other supportive educational activities are also a way we “fan the flames” of change.

(Participants may mention other ways to get the fire to burn. These may or may not be similar to mass mobilization.)

On the basis of the above factors and the demand for reaching more people with appropriate health messages and practices within a short period, WR in Mozambique came up with the Care Group model.

How areCare Groups organized? and what takes place during Care Group Meetings?

Care Groups are organized as follows:

Households with pregnant women and children <5 years are identified by a census and grouped in blocks of 10.

One volunteer is selected from each block in a village; she is responsible for visiting the 10 HH in her block.

10 volunteers form a Care Group that meets every two weeks .

A paid health promoter trains the volunteers during their Care Group meetings, teaching lessons that the volunteers pass on to mothers during home visits

Activities

  1. Nutrition education

•Breast feeding

•Supplementary feeding

•Promotion of Vit. A sweet potato and others vegetables

•Nutrition during pregnancy

  1. Health education

•Malaria

•Sanitation & Hygiene

•Managing diarrhea

•Immunizations

•Malaria

•Reproductive health: Family planning

•STDs and HIV/SIDA

3. GM & Nutrition rehabilitation using the “PD/Hearth model

4. Campaigns - Vitamin A capsule distribution & Deworming

5. Data Collection

What happens during Care Group meetings?

Songs, dramas,

Verbal reporting of vital events and illnesses

Discussion of progress and challenges

Education aided by pictures, stories, songs and dance

Recap of the week’s key messages

Volunteers practice sharing what they have learned

Meetings last about 2 hours

What happens after Care Group Meetings

Each volunteer visits “her” 10 households during the following two weeks.

Each volunteer educates her mothers and grannies on the key messages for the month using flip charts

CG volunteers can work on mothers’ current concerns, Volunteers can seek input from their promoter if they are unsure of how to deal with a difficult situation

What else can volunteers do? Care Group volunteers mobilize mothers for:Immunization, Vitamin A, distribution, Growth monitoring, Deworming

The roles of health promoters, PCVs and Leader Mothers

PCVs and their counterparts (health Promoters) facilitate the Care Group process

Live in the communities where they work

Train and supervise volunteers in up to 8 different Care Groups.

 May provide distribution of services like VAC, deworming tabs, etc.

Establish relationships with village leadership

Help form VHCs

Conduct KPC and quarterly surveys to monitor progress towards objectives

Trains the volunteers during their Care Group meetings

What do the results of Care Groups Show?

[Show slides on FHI results in Mozambique]

Benefits of using Care Groups:

(Small group exercise:) What are the advantages of the Care Group model over the traditional voluntary community health agent?

(Ask for their responses and then add the following:)

  1. A group of volunteers striving towards shared goals works together with greater commitment and support than separate volunteers who are left to work as individuals in their communities. Group solidarity and shared sense of community service can grow very strong in Y2Y groups, sustaining the spirit of volunteerism and preventing volunteer burn-out.
  2. Less work:Responsibilities given to each volunteer are much less than the task given to traditional community health workers i.e. Their geographic area coverage is 10households in the neighborhood unlike the community health agent covering the whole village or sub-county, hence there is lessburnoutand higher retention. The relatively low ratio of beneficiary mothers per volunteer leader mother makes it possible for the Leader Mother to interact with each beneficiary mothers more frequently and develop deeper personal relationships which can be used for promoting behavior change. It builds on small groups of 10 members. Many other community structures and community-building organizations have experienced the fastest growth when built upon on intensive use of small groups.
  3. Multiplied effort:Care Groups enable a relatively small number of paid project staff to reach a large beneficiary population without overburdening staff or individual volunteers. One PCV and their counterpart trains and supervises as many as 3 Care Groups of 10 volunteers so one PCV/counterpart can reach (10 x 3 x 10=) 300 people.
  4. Ensure complete and consistent coverage of the project area. Greater ability to reach all people.
  5. The number of Leader Mothers creates a critical mass for changing health practices. In a participating community, there is at least one Leader Mother volunteer for every 10 beneficiary mothers who is leading the way to better practices. Behavior change becomes more than an individual decision — it becomes a social movement involving the entire community. And when other activities are added to reach community leaders, the leaders can support volunteers’ work, reinforce their messages and work with them to take wider action on behavior change.
  6. Social support is increased so fewer incentives are needed, drop-out is lower, less retraining is necessary, and more happens outside of meetings. Meetings have a social as well as health purpose.
  7. Tasks for community-level volunteers are light (i.e., one visit to a youth per day on average). “Doing less more often” is a useful strategy for populations where literacy is low and volunteers have little free time
  8. Care Group members really “know their households”. Behavior change and identification and follow-up of defaulters is easier.
  9. Help systematize an organization’s approach to assuring equitable access at the community level.
  10. improve program measurability by allowing for more systematic and thorough events reporting
  11. improve sustainability by creating better self-sustaining structures at the community level, and better ties among community leaders, health facilities, and CHWs.
  12. Other health promotion topics can easily be piggy-backed on this model. (Give an example: PD/Hearth, micro-credit.)

Establishing and working through the Care Groups

(Summarize the lesson first:)

There are five core activities that the project should take before establishing Care Groups. These include:

  1. Determining readiness for using the Care Group model.
  2. Preparing the community and other stakeholders.
  3. Identifying promoters and providing training
  4. Ensuring that logistics necessary for the program are in place.
  5. Conducting a census.

We will now talk about determining readiness for the using the model.

  1. Determining readiness for using the Care Group model. What information or resource gaps exist and how do you fill those gaps?

(ASK:) What does it take to the PCV and their counterpart to have an effective Care Group (internal factors)?

(Write their responses on newsprint and add the following:)

  1. Project staff: Technical capacityand commitment.
  2. Commitment and availability of large groups of volunteers which depends mainly on previous experiences of the community with use of volunteers. Some need convincing! Initial doubt is common. For example, when WR wanted to try the Care Group model – created in Mozambique – in Cambodia, Cambodians said that it would never work, that mothers would not volunteer. However, mothers did volunteer and the model has been successful there. It’s important for people to trust the organization that is implementing the model, too.
  3. Support of community leaders: Community leaders, health, education etc relevant sectors, religious leaders/ groups depends on the working relationship with these community groups.
  4. Financial back-up to cover expenses for educational and other materials, Leader Mother Uniforms.
  5. Time:The longer the project period the greater the probability of the Care Group structure to stay firm and be a good channel to introduce other projects that would benefit the community in the project site.
  6. Good monitoring and supervision system in place to carry out a day–to-day follow-up and make changes in a timely way when necessary.
  7. The promoter factor: Communication skills with stakeholders in the community, with volunteers and beneficiaries, how s/hedescribes/identifies herself/himself, how the community describes the promoter (as their own or as a “foreigner”), whether or not the promoter sympathizes with the volunteers etc).

(ASK:) What are external factors that can influence your plan in establishing a Care Group model for your program?