Effects of a Nurturing Care Group Behavior Change Program on Child Protection Outcomes in Ghana: A Controlled Before and After Trial

"While behavioral science affirms social norms and parental support as potential factors to influence behavior change, there is still inadequate evidence and understanding of how to cost-effectively change these factors..."

Over one billion children (1 out of every 2 children) experience violence every year, across all regions, countries, and communities. Considerable effort has been invested in changing behaviours in relation to violence against children. However, there has been less engagement of behavioural science in these efforts. The primary research question of this study was to what degree the behaviour change programme model Nurturing Care Groups (NCGs), implemented in Ghana by World Vision (WV), could change child protection (CP) knowledge, attitudes, and practices among caregivers in a low-cost programme with broad reach that could feasibly be scaled.

Nurturing Care Groups (NCGs) are a multi-sectoral version of the Care Group (CG) approach, which has been used by over 27 organisations and governments in over 28 countries to change health, nutrition, and water, sanitation, and hygiene (WASH) behaviours at low cost. The NCGs model is a "two-tiered" (dual) community health worker (CHW) model that is intended to bring about parenting changes through bi-weekly small-group meetings held with NCG volunteers, who then cascade down the behaviour change lessons and messages they learn to the approximately 12 members of their "Neighbor Circle" through a combination of bi-weekly group meetings and home visits. These regular contacts via trusted individuals may contribute to effective social norms change at scale, as well as habit formation. Home visits and meetings with caregivers are used to promote behaviours and skills development (e.g., positive parenting) and to provide opportunities for volunteers and caregivers to provide regular feedback, discuss barriers, and do troubleshooting regarding adoption of targeted behaviours.

The CP lessons were taught consecutively from September to November 2020 and focused on reducing harsh punishment and caregiver stress, spending quality time with children, and identifying and reporting multiple forms of violence against children. The CP lessons and flipcharts (including imagery) were developed by staff from Hesperian Health Guides working with WV CP staff and drew from existing CG curricula and published resources and toolkits. Input and contextualisation was provided by the Ghanaian team members.

The NCG project was implemented in 41 communities, reaching 73,959 caregivers of children under 5, at a cost of US$300,000 over 16 months, promoting both WASH and CP behaviors in an integrated fashion (yielding a cost per beneficiary per year of US$3.04). A total of 1,150 NCG volunteers were trained through this project.

Participants in the intervention arm of the study were selected from those participating in the NCG project intervention area, while the participants in the control arm of the study were selected from 20 nearby communities. Baseline data collection occurred in June 2019, programme implementation took place from September 2019 to November 2020, and endline data collection was completed in December 2020. At baseline, 324 intervention and 431 control surveys were completed, and at endline, a similar 318 and 428 surveys were completed. Standard measures were used to assess changes in practices of violence and abuse, stress experience and management, parenting techniques, and the household environment. Difference-in-difference linear regression was used to compare intervention and control results.

Study results suggest that practices of violence and abuse shifted because of the intervention. A greater share of parents reported not using physical punishment or psychological aggression in the past month (+28.4 difference in percentage points [pp] between the intervention and control group, p < .001), while those who reported practicing minor physical punishment decreased by 26.3 pp. (p < .001). These differences roughly corresponded to reported changes in beliefs that physical punishment was necessary to bring up a child properly (+24.7 pp saying no, p < .001) and parents who could name at least three types of violence that could take place in a household (+25.9 pp, p < .001). There were also statistically significant increases in knowledge related to short- and long-term effects of abuse and neglect (+34.0 pp, p < .001) and adults who responded that they would report a case of child abuse (+39.8 pp, p < .001). Few parents or caregivers (<1% on average) reported using major physical and/or psychological aggression, but a slightly larger amount (about 8% on average) reported doing so moderately, with no significant decrease in the "moderate" category due to the intervention.

While parents and caregivers did not report a difference in stressful and negative experiences, knowledge of negative impacts of stress on parents (+33.2 pp) or children (+32.3 pp) increased, as did ability to name stress reduction techniques (+43.2). However, a much smaller number reported using such techniques in the past two weeks (+10.9 pp, p = .037), indicating perhaps that there were other barriers besides knowledge to the uptake of these practices.

Caregivers who participated in the programme also noted a number of changes toward more positive parenting behaviors, such as spending quality time with children, praising their children, or establishing clear rules with their children.

Thus, this study confirms previous strong evidence that parental training in small-group settings builds caregivers' capacity to help protect children from violence and is effective across many contexts. Per WV: "The results from the Ghana study demonstrate promising impacts for such a low-cost, short intervention (six child protection lessons rolled out over twelve weeks through the NCG volunteers). Some of the distinctives of the NCG model (saturation approach to changing behaviors, ongoing social dialogue facilitated by trained and trusted volunteers, low-cost scalable approach) therefore are recommended for further testing, refining and scale-up." To facilitate future work in this area, the researchers outline a number of avenues for further research and learning. They also explore policy implications.

In conclusion: "The NCG model demonstrated important promising results for changing child protection behaviors in this descriptive study. Statistically-significant decreases in reported physical and psychological punishment and corresponding increases in reported positive discipline indicate that this may be an effective and low-cost intervention for child protection behavior change."