The Nurturing Care Group (NCG) Core Project Model (CPM) is World Vision’s version of the Care Group approach and addresses issues around poor infant and young child feeding (IYCF), home management and care seeking for sick children and other disease prevention practices (Health and Nutrition); poor early child development and stimulation practices (Education); poor water collection, storage and treatment, and hygiene (including menstrual hygiene) and sanitation practices (WASH); and prevention and reporting of violence against children in all of its forms, including child labour and child marriage (Child Protection). It also can be used to address cross-cutting areas such as gender and faith.
The Care Group approach upon which the NCG CPM is based has already been used in over 28 countries by 28 different INGOs/NGOs and a few governments. The approach has been used successfully in development and fragile and emergency contexts. While most WV enabling models are not expected to achieve impact on their own, the NCG CPM can achieve measurable impact across multiple sectors when used alone or in conjunction with other CPMs. This model also is “plug and play” in terms of the behaviours promoted and is flexible: it is a behaviour change platform for promoting different behaviours from different sectors at the Field Office’s discretion and based on baseline survey data on household behaviours across sectors. In practice, we will suggest that FOs only use the NCG CPM name when using the Care Group approach to promote behaviours in at least two of the five WV sectors.
What is the NCG CPM?
The NCG CPM is a platform that enables the promotion of integrated behaviour change messages and activities based on evidence-based, high-impact interventions that are part of the WHO/UNICEF Nurturing Care Framework (NCF), which has been endorsed by the WHO, UNICEF, the World Bank, ECDAN, EWEC, and the PMNCH. The NCF focuses on five core areas: responsive caregiving, security and safety (which includes caregiver mental health), opportunities for early learning, good health (including water, sanitation and hygiene) and adequate nutrition.
A Nurturing Care Group is a group of 10 to 15 community-based volunteer behaviour change agents who meet every two weeks with project staff or government Community Health Workers (CHWs) for training, and then cascade down behaviour change messages and activities to caregiver groups at the neighbourhood level. They also build social support and cohesion among members, and help link neighbourhoods with community leaders, faith leaders and government services/ staff (e.g. clinics, social workers). Target households in each neighbourhood choose the volunteers that form the NCGs. NCGs create a multiplying effect and equitably reach every beneficiary household through neighbour-to-neighbour contacts using interpersonal behaviour change activities. They enhance behaviour change through peer support and creating new community norms, using both home visits and group meetings, reaching all families in the target group on a fortnightly basis.
What are the Core Components of the NCG CPM?
The NCG CPM is based upon theories of behavioural change including the “Health Belief Model”, the “Theory of Planned Behaviour” and the “Theory of Reasoned Action.” The mix of methods used in NCGs is based on the Trans- theoretical (Stages of Change) Model which emphasizes that people are often at different stages of readiness for change. Many of the techniques built into the NCG modules and lesson plans are based on these models and other state-of-the-art behaviour change science. Field Offices can prioritize about ten, 2-3 month long modules (with 4-6 behaviours promoted per module) from WaSH, Health & Nutrition, Education, and Child Protection. (Livelihood behaviours have also been promoted through the Care Group approach but are not a focus of this NCG CPM.) This 48-72 lesson curricula could be taught over a 24-36 month period, or a shorter curricula can be used for projects with a shorter duration.
The NCG model is a new, enabling, multisectoral CPM.
An essential element of the NCG CPM is having women serve as role models (and sometimes early adopters) and to promote behavioural adoption by their neighbours. There is evidence that “block leaders” can be more effective in promoting adoption of behaviours among their neighbours than others who do not know them as well. In order to establish trust and regular rapport with the caregivers with whom the NCG Volunteer (NCGV) works, it is necessary that the NCGV has at least biweekly contact with them. We expect the overall contact time between the NCGV and the primary caregiver (and others) in the household to correlate positively with behaviour change.
THE EVIDENCE BASE
Studies have shown that over half of under-5 deaths can be prevented with interventions that principally rely on household behaviour change.[i] The NCG CPM works to change harmful household practices to desired practices, which can lead to reduced under-five mortality and morbidity, reduced malnutrition, and other education and child protection gains. When implemented by international NGOs, Care Groups have been remarkably effective in increasing population-level adoption of health, nutrition and WaSH behaviours. There is strong evidence that the CG approach can reduce childhood undernutrition. There is some evidence that the CG approach may dramatically increases adoption of behaviours that improve ECD.
A review of the evidence on the Care Group Approach (upon which this CPM is built) in projects promoting health, nutrition and WaSH behaviours found that Care Group projects have double the behavioural change of other behaviour change platforms,[ii] and reduce under-5 mortality by an average of 32% and underweight by 25% in five years or less.[iii]
In a published study comparing the effectiveness of projects using the Care Group approach to projects using other behaviour change platforms (e.g. traditional CHW home visits) in five countries in Asia and Africa, the projects using the Care Group approach were found to achieve more than double the behaviour change and 52% better estimated reductions in child deaths than non-Care Group projects.[iv]
In a C-RCT in Bolivia that used Care Groups and also promote home water filters,[v] adoption of WaSH behaviours increased substantially, and the prevalence of diarrhoea in young children decreased by 77% (compared to a 14% decrease in control households during the same time period).
Other studies (e.g., Curamericas Global, Liberia, 2013[vi]) have shown remarkable gains in WaSH behavioural adoption (e.g. latrine use, hand washing with soap), often exceeding 90% coverage on the majority of indicators at final evaluation. Average increases in percentage points (during 4-5 year Care Group projects) of other indicators include an average 29 percentage point gain in ANC4, 67 points for IFA, 35 points for IPTp, 44 points for EBF, 22 points for complementary feeding, 41 points for ITN use, 23 points for full vaccination, 40 points for ORT usage, and 77 points for treatment of malaria.[vii] (Impact on Child Protection is forthcoming from a WV Ghana test of the NCG CPM.)
Part of the impetus for the NCG CPM was the growing body of evidence showing that integration of multisectoral activities – such as combining nutrition supplementation with early child stimulation –produces better outcomes for complex problems (e.g., stunting) than single sector activities alone.
Links to peer-reviewed research on Care Groups
QIVC Online Trainings:
[i] Jones G, Steketee R, Bhutta Z, Morris S. and the Bellagio Child Survival Study Group. "How many child deaths can we prevent this year?" Lancet 2003; 362: 65-71. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)13811-1/fulltext
[ii] See George, Davis et al (2015), https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-015-2187-2
[iv] See George, Davis et al (2015), op cit
[v] See Lindquist, Davis et al (2014) : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4080561/
[vi] See Final Evaluation for Nehnwaa CS project: https://www.curamericas.org/wp-content/uploads/2015/06/CS24_LiberiaNehnwaa_Final-Eval-2013.pdf
[vii] ANC4 = 4 or more antenatal care visits, TT2= 2 doses of Tetanus toxoid, IFA = taking 90+ days of iron during pregnancy; IPTp= receiving 2+ doses of SP/Fansidar during pregnancy or sleeping under an ITN; EBF=exclusive breastfeeding; treatment for malaria=Percentage of children aged 0- < 24 months with a febrile episode during the previous 2 weeks who were treated with an effective anti-malarial drug within 24 h after the fever began. Georges, Davis, et al (2015): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556014/