To understand how Care Groups achieve successful behaviour change outcomes, we developed a total of 9 initial programme theories (IPTs) and constructed 11 Context-Mechanism-Outcome configurations (see supplementary file 1). Two major themes emerged out of this realist synthesis; one clustered around the motivational drivers of community groups (such as Care Groups), which were described in an earlier publication [27] and the theme that is described in this paper; focused on Care Group implementers creating enabling environments for the uptake of healthy behaviours, by reaching out to decision makers in families and in the community, and working with relevant health infrastructures.
Creating enabling environments and removing uptake barriers
According to Care Group programme guidance documents, implementing NGOs should have a strategy for engaging with local healthcare providers, health authorities and with family and community structures, while they introduce Care Groups to communities [15]. The evidence of strategic engagement we found, pointed to sophisticated tactics being employed to create conducive environments where Care Groups can spread knowledge about lifesaving practices such as prompt care seeking or exclusive breastfeeding. The extent of this came as some surprise, as the general guidance on Care Groups provides few practical tips, and little or no reference exists to the types of evidence we found. The programme evaluations and case studies showed that many Care Group interventions contained ‘strategic engagement’ components that support the success of the Care Group’s behaviour change aims.
CMO-1
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C=Communities where husbands, mothers-in-law, elders and others in community have influence in a woman’s decision-making regarding birth spacing, place where she delivers, matters regarding breastfeeding, either directly, or indirectly due to upholding of traditions regarding reproductive, maternal & child health (RMCH) practices.
Intervention: Care Group Volunteers engaging with husbands, mothers-in-law, elders, TBAs in community to explain the healthcare messages it promotes
M=Acceptance, empathy of ‘power holders’ e.g. husbands, mothers (in-law)
O1=Women allowed to, encouraged to adopt healthy RMCH behaviours, modern medicine.
O2=Reduction in traditional beliefs regarding sickness being due to spells cast by others, or by women’s promiscuous behaviour.
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CMO-2
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C=CGVs are linked with local health facilities and/or CHWs, formal or informal networks are created, CGVs link back and forth between community and other care providers, passing on health messages, vaccination schedules, vital events data, making CG NGMs aware of health services, create confidence in health services, facilitating outreach visits by health service to communities.
M=Facilitating connections, promoting confidence in MoH healthcare delivery
O1=Greater uptake of MoH services
O2=Sustainability of Care Groups if integrated/linked to existing (paid) MoH staff such as CHWs; sustainability of improved healthcare uptake if citizens experience MoH health services for first/sustained time
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CMO-3
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C=MoH at national or sub-national level are actively engaged in supporting Care Group structures, have nominated individuals to take responsibilities for teaching and supportive supervision tasks.
M=Facilitation and/or formal integration of new responsibilities
O1=Training, support and supervision of CGs successfully taken on by MoH staff, CG structure and CG work sustained
O2 = Establishment (with NGO) of integrated Community Case Management (iCCM) bringing increased primary healthcare demand and supply in balance.
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The data extraction and analysis phase of the realist synthesis allowed us to examine the Care Group data that we extracted in relation to each stakeholder, including passages about extended family members and health facility staff. This brought the interactions between the Care Group-supporting NGOs and the wider implementation context into sharper focus, hereby allowing us to identify where conducive environment creating strategies had been implemented within Care Group interventions. A thorough search of our literature revealed that Care Group guidance documents contained only a handful of relevant passages, for example, about creating greater acceptability of health behaviour change by encouraging CGVs to have regular chats with husbands and mothers-in-law during their health education home visits. A Care Group implementation manual suggests:
“It is usually very difficult for a mother to change her behaviour without the support of the household. Other family members — husbands, grandmothers and elders — often have decision-making power about how a young child is raised. Care Group volunteers should find ways to influence these other key decision makers” [15].
Evidence from the peer reviewed articles and grey literature suggests that a conducive environment for behaviour change adaptation can often be created by ensuring that Care Group promotors, who support the CGVs and their groups, are in regular contact with the village leadership and the community’s elders. Ensuring that leaders are kept abreast of the lesson’s content every month helps to create understanding and acceptance of ‘new behaviours’, which in turn allows women to act on the knowledge they receive through their neighborhood groups. In some cases, this allows women to break with traditions, such as continuing to breastfeed an infant while pregnant with a subsequent baby, which contravenes tradition in some communities in Malawi [28]. Similarly, positive outcomes in terms of CGV self-esteem and practical linkages with local health facilities can be generated when the implementing NGO staff make efforts to facilitate regular contact:
A major achievement of the program has been the linkage of Care Groups with the formal health services delivery system through the participation of [Community Health Workers] and other cadres of health staff in I-LIFE [a Care Group programme’s] activities [29].
‘Influencing community and family power holders’ appeared to be most important strategic engagement in terms of changing the conducive environments. These actions were often less visible but their importance was usually understood to those implementing the intervention:
Rural Malawians live in collective societies and decision making for child care and feeding goes well beyond the individual mother, so strong community mobilization and gender activities are needed to address socio-cultural determinants of behaviors to produce changes in social norms [30].
In settings with very strict codes of behaviour for women, such as in northern Nigeria, this component of an intervention is especially important:
Initially when trying to establish the Care Group program, [NGO] program staff approached village Community Leaders to explain the intentions and benefits of the proposed program. [They knew] it would be a challenge to recruit adolescent girls into the program because their husbands did not allow them to be engaged in social activities or even interact with their peers. Access to adolescents was achieved through…Care Group Lead Mothers [CGVs]. These Lead Mothers, and at times in coordination with Community Leaders, set out recruiting mothers through community mobilization and house-to-house visits, …encouraging husbands to provide permission for their adolescent wives to join the program [31].
In some exceptional cases, Care Group interventions specifically target the individuals who influence women’s reproductive health decisions with dedicated program components. For example, a Care Group intervention in Bangladesh simultaneously established a ‘fathers’ group’ and an ‘in-law/grandmother groups’ as well as regular Care Group neighborhood groups, which targeted mothers. Acknowledging the traditional power dynamics, the implementing NGO openly stated that this was
“…based on the three principal decision-makers at household level – mothers as the primary caregivers, fathers as the primary supporters of mothers as well as the purchasers of household food and health services, and in-laws as the primary advisors on maternal and child health and nutrition” [32].
Influencing basic healthcare provision and commodities
In addition to working with the volunteer peer-to-peer learning promotors at community level, the review of the texts showed that NGOs that use the Care Group approach were also found to have positively influenced the supply of basic healthcare provision on quite a few occasions. Successful Care Groups often drive up the demand for healthcare: regular attendance to ante-natal care is being promoted, as well as timely inoculations and recognising and seeking treatment for common childhood illnesses such as malaria, diarrhoea, and chest infections. The Care Group literature shows that multiple NGOs implementing Care Groups resorted to establishing an improved supply of medication to be accessed by the communities they worked in, because the increased demand that was created by the Care Groups highlighted a pre-existing lack of access. In most cases this meant working with the Ministry of Health to ensure that vital healthcare commodities are within reach of communities when they need them. Even the very first Care Group intervention in Mozambique encountered this challenge, which led to the establishment (by the Care Group implementing NGO, together with the Mozambican Ministry of Health) of one of the first drug distribution networks by lay volunteers called Socorristas, which is Portuguese for ‘rescuers’ or ‘carers’:
… the [Ministry of Health] recognized that it did not have the capacity to carry out this kind of activity. The MOH authorized the selection, training, and support of the Socorristas. Importantly, the MOH has authorized the Socorristas to diagnose and provide antibiotics for childhood malaria and childhood pneumonia, a policy that many other MOHs in Africa have not yet adopted. All of these contributed to the success of the Socorrista program [33].
Sometimes it is the question of who is allowed to sell lifesaving medicines that needs to be resolved:
Care groups in Rwanda found access to malaria drugs to be a large obstacle in their area. Only government-approved pharmacies could dispense the drugs — and these pharmacies were few and far between. Volunteers and the Child Survival Program (CSP) [Care Group programme] proposed an innovative solution to the government — authorize care group leaders to sell anti-malarials to the communities they serve. Now, World Relief’s CSP and several other projects are starting a government-sanctioned pilot project, where care group leaders dispense drugs to mothers seeking treatment for children with malaria [34].
In each of the above examples, the actions that seek to positively influence the attitude of community elders or the Ministry of Health’s drug supplies, have a direct impact on the activities that of the CGVs and their neighborhood groups: CMO-1 shows that as part of the NGO intervention, CGVs visit the community elders to explain the lessons that are going to be taught to the women within the neighborhood group. The outcome of this action is a change in context, a more conducive environment, in which the women who are part of the neighborhood group are able, feel more comfortable, or are allowed, to adopt the behaviours promoted by the CGVs.
In realist research this phenomenon is described as a certain outcome (O) ‘acting as context (C)’ for another context-mechanism-outcome configuration. It can be argued that the initial actions are vital for certain subsequent CMOCs to occur. The outcomes (O) of CMO configurations 1, 2 and 3, targeting the extended family and community leadership or the health facilities/authorities are designed to improve the context (C) for the CGV and CG-NGMs, as depicted in figure 2 below. This example shows how a Care Group that promotes ante-natal care (ANC) visits is likely to work at two levels; i) by ensuring that the CGVs cover this lessons during her group chats with her neighborhood group, ii) by ensuring that the CGVs and the CG promoter (the person who teaches the CG volunteers) talks with village leaders, traditional birth attendants, etc. to check on their attitude to ANC, and to see if they can promote it during a community gathering.
The finding that many of the NGO activities that are ‘beyond direct CGVs and CG-NGMs support’ are specifically designed to create a conducive environment for behaviour change at CGVs and CG-NGMs level prompted us to create a separate coding sheet for all the explicit references of this phenomenon. Within the literature, we also recorded notable evidence of a lack of uptake of new behaviours in situations where the conducive environment, in this case improved supply of basic, yet lifesaving medications, was not created:
Although ‘Knowledge Practice Coverage’ [survey] results for the indicator of the “percentage of mothers of children age[d] 0 to 23 months who know at least two signs of childhood illness that indicate the need for referral” showed great improvement (40.4% at Baseline, 94.7% at Mid-Term Evaluation), improvement was not found for specific care seeking indicators for malaria nor use of ORS. It is likely that the lack of essential medicines seen during Health Facility Assessment in Years 1 and Years 2 … is affecting care seeking decisions [35].
This illustrates that when Care Group interventions create demand for healthcare, its success can be undermined in a context where the supply of healthcare (providers or commodities) is limited.
It suggests that those who design Care Group interventions should be advised to critically examine a context in which they aim to establish Care Groups and, where needed, devise an explicit strategy to create or improve the environment for the uptake of the health behaviours that are being promoted. In cases where the ‘blockage’ is not a supply issue but a community’s traditional or cultural beliefs, it is even more important that an implementing NGO is aware of these barriers and tries to use its influence to make certain health behaviours more acceptable.
… baseline coverage for these indicators was very low and many were tied to strong beliefs and cultural practices. Childhood diarrhoea was explained away as evidence of the parent’s (mostly the mother’s) infidelity; breastfeeding could not be initiated promptly because the breast first had to be cleansed soon after birth… The project was therefore amazed at the end-term evaluation to find out that it had achieved and even exceeded it targets on some of these very “difficult” indicators. …They attributed these changes to the intensive health information, education and counselling provided by the [Care Group intervention and CGVs] [36].
Figure 3 is an illustration of how ‘influencing community and household leaders’ during Care Group interventions can change the context for women who are members of neighborhood care groups.