Integration of WASH and nutrition through the care group approach: A qualitative study of behavior change approaches in rural Western Kenya Open Access

Abstract

Chronic environmental enteropathy is associated with poor growth and stunting, and in Kenya, stunting affects more than one-quarter of children. Researchers at Emory University developed Chakruok Makare, an integrated WASH and nutrition intervention utilizing an existing care group-based approach to address missed opportunities in the traditional Care Group Model. We conducted qualitative research with beneficiaries in two counties in Western Kenya to determine the facilitators and barriers to the uptake of targeted behaviors within areas of high intervention fidelity. We found the following key results:

Facilitators:

·  Strengthening CHV and CGV facilitation skills

·  Reducing number of messages per package, simplifying message structure, reviewing previous messaging

·  Supervisors providing immediate feedback to CGVs improving message fidelity

·  Creating pledges, keeping IEC materials in the household

·  Engaging family members in home visits and household goals

·  Encouraging caregivers to designate household tasks to family members

·  Encouraging income-generating activities during NWGs

·  Providing hardware made from local materials or demonstrating how to make hardware using local materials

·  Learning the “why” behind a behavior, focusing on benefits of a behavior

Barriers:

·  Caregivers receiving contradictory messages to traditional child rearing practices

·  Belief that CGVs were benefiting on behalf of caregivers

·  Caregivers not disseminating messages to family members

·  Home visits too lengthy

·  Family members away from home during home visits

·  Learning new behaviors is a lower priority to competing responsibilities

Consider the following key recommendations in interventions utilizing care groups:

·  incorporate income-generating activities in NWGs

·  employ case managers to improve project monitoring

·  train CGVs on facilitation skills

·  keep IEC materials in the households

·  design specific, succinct messages, and limit to four per session, and focus on benefits of behaviors

·  form neighbor groups for family members to engage in intervention messaging

·  employ more CGVs to reduce the number of households per CGV

·  consider incentivizing CGVs to increase motivation

·  continue peer-selection of CGVs and ensure that roles are well understood by all

·  integrate care groups into MOH; create case manager position with decreasing supervision of CGVs

·  conduct formative research to understand regionally specific contextual factors

Table of Contents

INTRODUCTION 1

REVIEW OF THE LITERATURE 3

MANUSCRIPT 11

Introduction 11

Methods 14

Background 14

Data collection 17

Table 1. Research activities and population, May-June 2018 18

Data management and analysis 18

Ethical approval 19

Results 20

Table 2. Demographic characteristics of FGD participants 20

Capability 21

Opportunity 24

Motivation 31

Table 3. Comparison of facilitators and barriers 34

Discussion 36

Strengths and limitations 41

Conclusion 42

PUBLIC HEALTH IMPLICATIONS 43

REFERENCES 48

APPENDIX A: Summary of outcomes of interest 52

APPENDIX B: Key informant interview guides 54

APPENDIX C: Focus group discussion guides 62

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Education Health Sciences, Public Health Health Sciences, Nutrition
Keyword	Theory Maternal, Newborn, and Child Health Behavior Change Community Health Workers Care Groups Health Promotion Qualitative Evaluation
Committee Chair / Thesis Advisor	Matthew Freeman, Emory University Anna Ellis, Emory University

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