Care Groups and Behaviour Change: Lessons from Karamoja

"The Care Group approach in Karamoja is a good example of an intervention gradually learning to harness the power of mothers working together to improve their health and that of their children."

This learning paper describes a social and behaviour change (SBC) approach that uses Mother Care Groups to improve health- and nutrition-related behaviours. The approach is being implemented by Concern Uganda as part of the the Resiliency through Wealth, Agriculture and Nutrition in Karamoja (RWANU) programme in four districts in South Karamoja, Uganda.

As explained in the brief. “Karamoja is one of the most food insecure areas in Uganda. Almost half of the households (46 percent) are food insecure and the prevalence of chronic malnutrition (stunting) is 39.5 percent and the prevalence of acute malnutrition is 12.4 percent (FSNA Dec 2015).” The project therefore seeks to improve maternal and child health, nutrition, and water, sanitation, and hygiene (WASH) practices in the community by reaching out to mothers at the household level using the Care Group approach. This approach seeks to provide frequent and credible sources of nutrition and health information primarily through peer-to-peer dialogue from Care Group Lead Mothers during home visits. The brief describes how this approach works as follows: “The Care Group approach links Concern’s Health Educators and Health Promoters with Mother Care Groups (MCGs) and Household Caregiver Groups (HHCG). The MCGs are comprised of 10 -15 Lead Mothers, who are volunteer community-based health educators. They regularly meet with the programme’s Health Promoters for trainings on messages and behaviours that promote good health and nutrition for children and mothers. Each Lead Mother is responsible for 10-14 households who are grouped into a Household Caregiver Group.” In addition to contributing to behaviour change, the approach is seen to stimulate community participation and strengthen linkages between the community and the health centres.

To complement the Mother Care Groups, the Concern team in Uganda also works with Male Change Agents (MCA) to help men understand how gender norms and perceptions can negatively affect their lives and those of their wives/partners and children. Their training focuses on men’s role in the different topics/ modules implemented as part of the Mother Care Groups. These men therefore reinforce the messaging of the lead mothers, and through their behaviours demonstrate positive health and social norms.

Information gathered from the programme’s monitoring and evaluation system indicates that the Care Group approach is performing well in achieving specific child health and nutrition outcomes. The following are some of the changes that are highlighted in the report:

• An increase from 59 percent to 69 percent with respect to exclusive breastfeeding in the first six months.
• 53 percent of mothers are starting complementary feeding at 6 months and giving 3 meals a day, while 90 percent of mothers of children 9-23 months are giving 3-4 meals a day.
• Handwashing stations: 742 mothers had set up tippy taps within a month of the start of the module on WASH.

The report concludes by sharing lessons emerging from the approach which are just briefly summarised here:

• Empowering “Mothers” does lead to positive health outcomes - "Women’s groups have been in use now for decades, but well-delineated methods for engaging them and mobilizing them to deliver evidence-based interventions that result in scientifically demonstrated improvements in either population coverage of these interventions or improved population-level health outcomes have been lacking until recently." This project has shown that this approach can improve health behaviours.
• The Mother Care Group model can and should be modified to account for contextual factors - As with any development intervention, the Mother Care Group approach must be adapted and modified to ensure that it suits a particular context. The most obvious example of this is designing the modules and lessons based on the barrier analysis, which is used to inform what types of practices need to be changed to allow for healthy communities to thrive.
• The Male Change Agents is a promising addition to the toolkit of the Mother Care Group approach - The approach of using Male Change Agents is leading to positive outcomes for their households and the wider community. The inclusion of men as equal partners, involved caregivers, and supportive members of the community is a responsible approach that considers relationships in a much more holistic manner.
• Only local ownership will drive sustainability - It is critical that Lead Mothers feel involved at the various levels of implementing the Mother Care Group approach in order to ensure sustainability once the programme ends.
• Scaling-up will require flexibility - For the scale-up to be successful, a genuine partnership approach will need to be taken by the Ministry of Health in collaboration with its various development partners. This may cause delays and require adjustments to existing interventions.