Care Groups: A Proven Community-Based Strategy for Fighting Malnutrition in Burundi

Summary:

Burundi has one of the highest levels of stunting in the world, and a chronic malnutrition rate of 54%. If not addressed immediately, this widespread malnutrition will prevent Burundi from achieving progress on Sustainable Development Goal 2: Zero hunger. The Care Group Approach, first employed in Mozambique in 1995, is being implemented by the World Food Programme and Concern Worldwide since May 2019 in two rural districts of Kirundo Province as a cost-effective community-based strategy for improving nutritional and maternal health behaviour among pregnant and lactating women and their children under two years old. Using a cascade approach, the three-year project spreads nutrition and health messages from community health workers (CHWs) to care group volunteers and on to neighbour women in a personal way that inspires sustainable behaviour change. An essential element is having local women serve as role models and promote new practices. The husband, wife and the mother-in-law commit to implementing the change introduced by the care group volunteer. To ensure the family honours their commitment, the care group volunteer verifies the adoption of the lesson already given before she gives a new lesson. The program limits message dissemination to one message per month, to avoid overwhelming the members with a surfeit of messaging. The model allows for sustained contact and counselling, encouraging the behaviour change needed for positive nutritional outcomes and seeking to catalyse lasting and transformational change.

Background/Objectives:

At least 25 organizations in 28 countries have implemented the Care Group Approach, according to Global Health: Science and Practice in 2015. Concern was an early adopter in Burundi where the original NGO approach, in which NGOs paid care group facilitators, was changed to an alternative approach where facilitators are government CHWs. Concern research had shown that such an approach was as effective as the NGO approach. The objective is to create 367 care groups with 3,670 care group volunteers spreading information to 36,682 households with pregnant or lactating women or children under 2 by 2021.

Description of Intervention and/or Methods/Design:

A 2015 article in Global Health: Science and Practice found that: Care groups have been remarkably effective in increasing population coverage of key child survival interventions, and can reduce childhood undernutrition. After being trained by project staff, CHWs each train 10 care group volunteers (also called Lead Mothers) who pass on nutritional and maternal health knowledge through individual in-home meetings with 10-15 pregnant and lactating women with children less than two years old. The project implements care groups in collaboration with the Ministry of Health (MOH) and promotes use of MOH services and programs. The project is too new to show impact but an end-line outcome survey will be done in 2021. Goals include reducing the prevalence of chronic malnutrition from 63% in 2019 to 59% in 2021, and increasing the percentage of children 6-23 months with a minimum acceptable diet from 17% to 27%.

Results/Lessons Learned:

In the classic Care Group Approach, each promoter (or CHW, in this case) is responsible for supporting 4-9 care groups. Concern Worldwide recognized that 4-9 groups was too onerous for one CHW to manage, especially given their other responsibilities, and would have a negative impact on the quality of their oversight. Therefore, Concern decided that each CHW would be responsible for only one care group (each with 10 care group volunteers), to ensure higher quality and a greater chance that the desired behaviour change would be achieved. The other major lesson learned was that it is best to implement such projects in collaboration with the Ministry of Health, and to use government CHWs as care group facilitators, in order to provide the MOH with a sense of ownership and increase the sustainability of the Care Group Approach.

Discussion/Implications for the Field:

The Care Group Approach is fairly new in Burundi, and even more so in Kirundo. Since it requires care group volunteers going to households and talking to husbands and wives in order to promote behaviour change, cultural barriers may present a challenge to easy uptake of the messages. Another challenge is that as households are taught the importance of handwashing and feeding their children with a rich and diversified diet, a lack of resources may hinder their implementation. That is why this project also sensitizes husbands of care group volunteers who, in turn, sensitize other men in their communities.

Abstract submitted by:

David Jule Olson
Bernard Mendy - World Food Programme
Micheal O. Hiarlaithe - World Food Programme
Kodjo  Niamkeezoua - World Food Programme