TTC – A Family-Inclusive Behaviour Change Model for the Life-course
World Vision’s Timed and Targeted Counselling (TTC) is a family-inclusive behaviour change communication (BCC) approach targeting families of young children, especially the most vulnerable and marginalized. TTC encompasses a wide range of life-saving health practices through appropriately timed messages delivered using interactive story-telling. It applies a dialogue counselling methodology based on the assessment of current needs and practices and negotiation of progressive improvements. Importantly, TTC seeks to engage both parents and decision-makers, embracing a family-inclusive and gender-transformative model of child health and development in which the positive contribution of fathers is emphasized. TTC can be delivered by a range of cadres including officially recognized community health workers (CHWs), guide mothers or volunteers.
Since 1990, global child mortality has dropped by 59%, but 5.4 million children still die each year, of which newborns account for one third, and children under five years for two thirds. Despite progress in medical science, 80% of child deaths are due to preventable causes, that can largely be averted by practices such as health facility delivery, prompt care-seeking for childhood illness, appropriate breastfeeding and child nutrition.[i] In addition, studies in child development show that the first 1,000 days are a critical window where foundations for lifelong health and mental development are laid down. During this period, undernutrition, poor caregiver mental health, lack of stimulation, poor hygiene and high burden of disease can have permanent negative effects, and mean that children, fail achieve their full potential. CHWs are the most cost-effective way to reach vulnerable families and communities to transform child health. One study modelling community-based primary healthcare impact showed achieving 50% and 90% coverage of key interventions over the period of 2016-2020, could alone have averted between 3 and 6 million child deaths, with Africa predicting the greatest benefit (58% of the lives saved at 90% coverage would be in Africa). However, CHWs often fail to achieve full impact due to lack of support structures and legitimation in healthcare systems endorsed in the WHO CHW guidelines, to which World Vision’s future and existing CHW and TTC programmes need to lend their strength. Furthermore, BCC interventions can under-achieve for various reasons, which TTC aims to resolve:
- Messages may be given too early or too late, whereas in TTC messages are “Timed” at the right time to act;
- CHWs often target only women, and yet culture, gender and family dynamics can be barriers as lack of power, financial resources and influence prevent mothers from taking action, even with the right information - TTC is “Targeted” at women together with their supporters such as husbands, mothers-in-law or grandmothers. TTC uses positive male role models in stories to challenge gender norms;
- CHWs typically give information, without considering family context, value or feasibility. In TTC they use a barriers assessment interview technique to identify barriers and negotiate change based on circumstance;
- CHWs often apply a ‘one size fits all’ approach, yet in reality only reach a portion of the community. TTC (2018 Edition), now aims to assess and track vulnerable families, focussing on family context, especially adolescent mothers, those with physical and mental health or psychosocial difficulties.
WHAT IS THE TTC PROJECT MODEL?
TTC targets families of young children during pregnancy to two years of life, to promote health behaviours, nutrition and early childhood development (ECD). The dialogue-based counselling methodology, and positive and negative stories is based on Home Based Life Saving Skills (HBLSS) method, but has evolved over time. TTC storybooks depict key themes of positive fatherhood, caregiver mental health, and family decision-making for pregnancy and newborn care and nutrition. A review of CHW curricula by the WHO in 2013, found TTC to be one of the most comprehensive life-course models. Messages and topics were based on World Vision’s “7-11” strategy for maternal, newborn and child health and nutrition in the 1,000 day period from conception to two years, then updated in 2014 to include ECD, stimulation and play and psychosocial support for maternal mental health, alongside chlorhexidine core care, newborn care, care for the small baby, and the HIV exposed infants.
Now, the 2018 edition takes a flexible approach, improving CHW systems support, and offering a range of optional modules to enable better fit with national CHW systems. During national adoption of TTC in Ghana, Kenya, Lesotho and Sierra Leone, content was created to cover the full range of CHW service packages, to include household health, WaSH, child health (2-19 years), and emerging areas of adolescent health, and prevention of violence against children. Content has also been developed for Integrated Community Case Management (ICCM) and support to community treatment of malnutrition.
ALIGNMENT TO THE SDGS
TTC aligns to World Vision's Our Promise by deepening commitment to vulnerable families, enabling better use of resources by partnering with communities and health systems to strengthen CHW programmes.
TTC is aligned directly to several of the Sustainable Development Goals:
SDG 2.2 By 2030 end all forms of malnutrition, achieving targets on stunting and wasting
SDG 3.1 By 2030, reduce the global maternal mortality ratio.
SDG 3.2 By 2030, end preventable deaths of newborns and children under 5 years of age
SDG 3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria/communicable diseases
SDG 3.4 By 2030, reduce by one third premature mortality from non-communicable diseases
SDG 4.2 By 2030, ensure access to quality early childhood development, care & pre-primary education
The WHO’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) and the Sustainable Development Goals outline a vision where all children and families are supported to ensure optimum conditions to survive, thrive, and fulfil their potential. The WHO’s Nurturing Care framework articulates 5 components to be applied through a life course approach, with which TTC has a high level of agreement (Figure 1).
Figure 1. How TTC aligns to the Nurturing Care Framework
CORE COMPONENTS OF TTC
The TTC-HVs conduct home visits for pregnant women to promote antenatal care and planning for skilled care at birth. They visit newborns in the hours and days following birth, identify danger signs and refer appropriately, and advise on appropriate home care for the newborn. They continue to visit families at regular intervals until the child reaches 2 years of age, delivering messages to the family members throughout this important period in the child’s life. In the 2018 edition, HV also conduct routine visits for families of children aged 2-19 years to assess other household and family health issues.
Goals: Improved outcomes for pregnancy and child health, nutrition and child development
Outcomes: Increased adoption of household behaviours, especially improved breastfeeding and complementary feeding practices for young children, care-seeking behaviour and uptake of health services
Target populations: (1) Pregnant women and children under 2 years (including orphans and looked after children). (2) Women and girls of childbearing age to promote health pregnancy timing and spacing and (3) the most vulnerable families who might need additional support.
Since its inception in 2010, TTC has been implemented in 38 countries. Evidence includes impact evaluations from 10 countries and research contributing to a diverse portfolio. TTC has demonstrated consistent impact on behaviours determined at the household level such has hygiene, newborn care and appropriate breastfeeding behaviour. TTC’s impact on newborn care and breastfeeding alone contribute to a high estimate of Lives Saved (LiST) and cost effectiveness as demonstrated through research undertaken in Jerusalem and West Bank, and the AIM Health Grant (Table 3). Results from grant-based evaluations include some of the following key findings:
- Pragati study, World Vision India, FHI360 - the four-year USAID-funded Pragati project in India showed improvements across a range of health behaviours, and that family planning more than doubled;
- Ethiopia Alive and Thrive project – TTC delivered by peer mothers found improvement in IYCF practices, reduced need for therapeutic feeding, improved treatment of diarrhoea, in a ‘dose-response’ effect, i.e. more visits led to more improvement.  The Ministry of Health approved scale-up in 28 districts.
- A cost-effective scale-up in Palestine - TTC implemented by CHWs found high impact on practices related to newborn care, reduced harmful newborn practices, improved IYCF and care-seeking A cost-effective analysis found a cost per life saved of $197 USD, therefore TTC is highly cost-effective.
- East Africa MNCH grant funded by AusAID - A 3-year TTC/CVA project in Kenya, Uganda, Rwanda and Tanzania, demonstrated consistently positive effects for IYCF indicators across all four countries, wasting/underweight in children was reduced in 3 of 4 countries and stunting reduced in 2 of 4 countries.
Table 2: Lives Saved (LiST) analysis from AIM Health programProgramme Partnership Agreement (PPA) DFID program – A 6-year DFID-funded programme implemented TTC and CVA in Sierra Leone (SL), Kenya and Somalia, evaluation was further accompanied by a ‘Realist Analysis’ to look at qualitative elements of implementation identified challenges and success-factors such as (1) importance of integration with the National CHW programme (2) loss of fidelity of the model (3) intensive start-up requirements (4) variable targeting of vulnerable groups (5) variable commitment to gender-equity component of TTC (5) High CHW/V workloads and (6) insecurity leading to high turnover and loss of quality in fragile contexts.
- Irish AID Funded AIM Health program - implemented TTC in Kenya, Tanzania, Uganda, Mauritania and Sierra Leone. Exclusive breastfeeding met or exceeded the programme target of 80 percent in all locations with six locations exceeding 90 percent. A Lives-Saved analysis estimated up to 71% and 28% reduction in newborn and maternal deaths (Table 2), except for Sierra Leone during the 2015 Ebola outbreak.
COST PER BENEFICIARY
Costs of TTC are weighted heavily at started up due to training and production of materials. Estimated costs per beneficiary amongst several countries are shown below. The table below shows the estimated cost per child under 5 per year as US$5.36. This can be taken as an estimate of the costs of CHW programme per beneficiary. This data excludes the Palestine project, where cost per life saved was estimated at $197 per life saved, as cost-per-beneficiary in this setting was based on CHWs receiving a full-time salary, which is not the case in any of the other programmes.
IMPLEMENTATION AND SCALE
World Vision is currently implementing the TTC model in the following countries (Table 4).
Table 4. World Vision Country Offices who have adopted ttC approach as of March 2015
INNOVATION AND TECHNOLOGY
TTC mHealth Application - The CommCare-based mTTC app enables real-time data reporting, sends reminders for visits and follow up, and includes audio-visuals in local languages and press-play messages. mTTC has been used in 7 countries with 4000 users, and reports show improved quality of data and timely referral.
ICCM integration – Several countries the ICCM have been integrated within TTC and the mTTC app;
Healthy Families – Ghana, Kenya, Lesotho, DRC and Haiti have all included Healthy Families module in TTC
CMAM support and the nutrition root cause assessment – CHWs in Sierra Leone, Mauritania, Ghana all include a root cause assessment at household level for CHWs implementing CMAM support;
Prevention of child marriage – module and storybooks have been developed and being tested in Mauritania;
Prevention detection and reporting of violence against children – a training module, storybooks and referral forms for prevention and referral of VAC has been developed and is being tested in Lesotho and Haiti.
For more information about TTC contact email@example.com
Sibley L, Buffington ST, Beck D, Armbruster D (2001). Home based life saving skills: promoting safe motherhood through innovative community- based interventions. J Midwifery Womens Health. 2001 Jul-Aug;46(4):258-66.
 Tran et al., 2014 ‘Developing Capacities of Community Health Workers in Sexual and Reproductive, Maternal, Newborn, Child, and Adolescent Health: A Mapping and Review of Training Resources’. PLoS ONE 9(4): e94948.
 The 7-11 Start Up Field Guide. http://www.wvi.org/health/publication/7-11-start-field-guide
 Lancet Series. ‘Child Development in Developing Countries’ Series 1 (2007) & 2 (2011).
 Lancet series. ‘Perinatal Mental Health’. November 14, 2014
 Imdad et al. ‘Umbilical cord antiseptics for preventing sepsis and death among newborns’. Cochrane Systematic Reviews 2013, Issue 5. CD008635.
 WHO/UNICEF Joint Statement (2009), ‘Home visits for the newborn child: A strategy to improve survival’. WHO/FCH/CAH/09.02
 Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential ISBN 978-92-4-151406-4 © World Health Organization 2018
 World Vision US/USAID (2009) “The Right Messages—to the Right People—at the Right Time” www.wvi.org/sites/.../World%20Vision%20India%20Case%20Study.pdf
 How many lives did ttC save in Palestine and at what cost? A. Trujillo 2013. http://www.annalsofglobalhealth.org/article/S2214- 9996(15)00922-4/fulltext
 Midterm evaluation of the Bonthe AIM health program showed strong positive trends up to 2014, however the ebola epidemic dramatically cut uptake of health services at facilities, which had a strong negative impact on the Lived Saved findings.
 Chou, Victoria B et al. “Expanding the population coverage of evidence-based interventions with community health workers to save the lives of mothers and children: an analysis of potential global impact using the Lives Saved Tool (LiST).” Journal of global health vol. 7,2 (2017): 020401.