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Mother Mentors for Child Development [updated Jan 5]

Mother Mentors provides strength and support to mothers and families so that young children can thrive. Strength and support comes in the form of a long-term mentorship, which starts with the development of an individualized plan. The aim is to ensure that the pregnant woman and her family have all that they need to provide their child with cognitive stimulation, good nutrition, and to prevent recurrent infections, all critical to good health and development. The mother and families' strengths and challenges are continually assessed and addressed over the first three years of the child's life.

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Pregnant women would enroll in the Mother Mentors for Child Development program, and be paired with a trained Mentor. An initial assessment would consider the mother’s and family’s strengths and challenges, and an individualized plan would be devised. The plan would have components unique to each family, for example, constructing a latrine, and components that are constant for all families, such as nutrition education and support. The Mentor would visit the mother at regular intervals from pregnancy until age three of the child’s life, with more frequent visits during infancy. 

Visits would be structured based on the age and needs of the child, and would likely include health monitoring, advice and training, as well as provision of needed items, e.g. insecticide treated nets. Visits would be supplemented with mobile phone check-ins or reminders and play groups.

Known challenges to healthy development in our communities
We know some of the challenges in our communities for young children in the domains of cognitive stimulation, nutrition and recurrent infections based on our program monitoring. Examples include:

Cognitive Stimulation: 70% of households with children age 1-4 years have no child-friendly books and only 25% were read to in the prior 3 days.

Nutrition: 48% of children under age 5 years with moderate or severe stunting, and only 55% were exclusively breastfed for 6 months.

Recurrent Infections: 16% of children under age 5 years had diarrhea in the preceding two weeks; 58% slept under an insecticide treated net the prior night; 73% use improved drinking water, while only 67% of households have a latrine.

Pregnancy health (from our refinement interviews and prototyping): women often cite not feeling supported by their husbands; there are many nutritional myths that may be detrimental to the woman and fetus.

Expected outcomes
1.    Decreased prevalence of stunting and wasting
2.    Decreased prevalence of diarrhea and malaria
3.    Improved language and cognitive development
4.    Decreased stress on mothers and fathers

Possible program components (please see attached "reimagined program" document for additions and changes)

Cognitive stimulation of the child:
  • Provision of children’s books and training for parents and siblings on how to use them to engage their children regardless of literacy.
  • Training and modelling on other methods of stimulation like singing, talking and play.
  • Play spaces and supplies, and facilitated play groups housed in our community library.

Nutrition:
  • In pregnancy: nutrition education and support, dispelling myths
  • Breastfeeding support for exclusive breastfeeding until 6 months and continued breastfeeding until 24 months
  • Complementary food provision or subsidization/education starting at 6 months of age

Recurrent infections:
  • Provision and maintenance of insecticide treated nets from pregnancy onward
  • Assistance with obtaining a latrine, if not present
  • Creation of a station for handwashing with soap, if not present
  • Evaluation of drinking water safety
  • Ensuring child vaccinations and other preventative health visits happen on time

Other:
  • Strengthening of the relationship between clinic staff and mothers at child wellness clinics so that they are more effective
  • Engaging fathers throughout pregnancy, and early childhood


What this might look like to someone in our community (see file under documents to be able to read some of the small print)





Why we believe this idea will succeed (updated 12/28)
We are uniquely poised to tackle this idea, as we are a child-focused organization working in the sectors of health and education. We have the knowledge and experience that comes from many years of programming in our communities.  We have tried different approaches over the years to various community health and education concerns, and have learned a tremendous amount from both our failures and successes (see attached document on our lessons learned).  
 
We know the community, we ARE the community
Our staff, including the leadership, is almost entirely comprised of community members who were raised here.  We built the organization over the past eleven years. We have a unique investment because our families and friends are the beneficiaries.
 
Additionally, we have a strong partnership with the district government education and health departments, as well as local leaders. 

Most importantly, we know that the health and development of this age group is a priority for our communities, so we would have their buy-in, enthusiasm, and support.
 
We have demonstrated success
On an exam taken after middle school to obtain entry into high school, we’ve seen a ten-fold increase in the high pass rate for girls, while the district has had a two-fold increase between 2001 and 2013.  99% of children have passed this test for the past five years, whereas the country keeps passing rates at ~63% annually, and our community started with only 4% of girls passing in 2001.
Diarrhea prevalence in young children decreased from 31% to 17% and has been sustained over the past five years, without significant changes in other factors.  Our community uses insecticide treated bednets at a much higher rate than nationally (58% vs. 39%).

Intensive individual investment is right for our community and the pregnancy through age three age group
Individual relationships built through mentorship gives a depth that cannot be obtained through group lectures or meetings.  There are intangible mentorship opportunities that don’t fit into categories of nutrition or prevention of malaria.  One example that we learned during this refinement period is the stress that first time pregnant moms endure over preparations for the physical environment for the baby, which ultimately is linked to how women are perceived by community members. 

We recognize our upcoming challenges
We recognize that it is bold, and some might criticize as foolhardy to focus on pregnancy health, child nutrition, stimulation and infection prevention when creating an effective program for one of these components is challenging.  However, we believe that, to maximize the outcomes for the child, we need this comprehensive investment.  It is unusual to focus broadly when so much of development work is done in silos of nutrition, malaria prevention etc.

To overcome the potential barriers of a broad focus, we will do the following:
  • Start our program with pregnant women, not with women and children at different stages.  This gives us some flexibility to focus on the initial needs and assets assessment and pregnancy programming, while refining programming for complementary feeding and other areas, which will come later.
  • We will draw on resources and expertise within our network, primarily at UCLA, but also hopefully with some partnership of programs in this challenge (Hands to Hearts International, for example) in the areas where we aren’t as knowledgeable.

Why this idea is unique (added 12/28)
This idea is new to GHEI: we have education programming for children age 5-18, with most of it individualized and intense, and health programming that is community-based with small individual investments.  This would be the first time we could truly merge our two sectors and this would be the first time we invest significantly in very young children.

Globally, there are one to one programs elsewhere that aren’t as comprehensive (i.e. include nutrition and cognitive development, but not infection control and pregnancy health) or have somewhat different focus on some social outcomes domestically (i.e. Family-Nurse Partnership in NYC).  This program is unique because it supports the pregnant woman and child through a comprehensive approach tackling nutrition, infection prevention and cognitive stimulation simultaneously to maximize a child’s health and development.  Equally important, it is delivered through a close mentorship relationship, allowing for support that doesn’t neatly fall into the category of nutrition or cognitive stimulation etc.

We have extensive program design and monitoring and evaluation systems in place to continually prove our programs are working or modify and discontinue them when they aren’t.  We plan to apply the same rigorous program improvement and evaluation systems with this program, so that after we achieve our goals, the program can be replicated elsewhere.


Update 12/10/14- Initial mother interviews

We conducted brief individual interviews with five mothers with young children- themes and insights below

What is challenging about being a mother of a child under age 3? Financially difficult (2 of 5 women): “Had to purchase all the delivery supplies prior to birth and supplies for the baby, which are expensive, there is a lot to buy”; Nutrition concerns (2/5):  including poor growth, difficulty breastfeeding; Health concerns (4/5) including “falling sick” often; Worrying about development (1/5) unsure when the child should be talking and walking.
 
What would make your family’s life better during this time?  Being financially more secure (4/5); Health (2/5): “keep [the child] from falling sick”, “having a healthy family.”           
 
What would make your baby/child healthier?  Nutrition (5/5) including “give baby adequate nutrition” and “breastfeed well”; Sleep under a bednet (5/5).
 
What could GHEI do to support you and your family?  Provide items (3/5) including bednets, soap for handwashing, items needed for delivery.  Provide money (2/5).  Include children in GHEI programs (5/5)[note that GHEI does not currently offer programs for this age group).
 
  • Insights to take forward 
    • Women are concerned about financial costs, recurrent infections, and providing proper nutrition.  They appropriately see prevention of malaria and proper nutrition as ways to improve the child’s nutrition. 
      • What does proper nutrition mean to them? What approaches are they currently taking to provide good nutrition? What are the barriers? What changes would be feasible for them?
      • Stimulation is missing from all responses.  Need to explore current practices, beliefs and potential program design.
    • They would like to see GHEI provide items to improve health or money.  How can we make this expensive time period less so?  Or at least ensure that we are not asking women to do things that cost more than they already spend? 
    • They universally mention having their children enroll in GHEI programs (which are for older children).  This may be an endorsement of programming in general, and maybe they would respond positively to programming for this young age group as well.

 

Update 12/18/14- Stakeholder analysis

We completed a stakeholder analysis, which is posted under documents. Interviews are underway with these key groups.  

 

Update 12/18/14- Lessons learned

OpenIDEO asked what we have learned that will help us implement this idea.  We had a discussion with five Ghanaian and two foreign staff members and received email responses from five past coordinators (foreigners who served 1+years on-site with us).  It was a very fruitful discussion, and the results are posted on this site.


 

Update 12/19/14- User experience map completed (see above and posted under documents)

Update 12/24/14- interviews with local authorities, clinic nurses, additional mothers, one father

To gain additional insight from stakeholders, GHEI staff interviewed the queenmother (traditional authority member), a local leader from a church, five nurses from the clinic, six mothers and one father.


 
Interesting excerpts:
[traditional authority member] How can a health program for pregnant women using Mother Mentors help the community? Many women learn the right things to do after their first or second child, seeing the mistakes they made. A Mother Mentor would help women do the right things to help their child from the beginning.
 
[traditional authority member] What are some of the problems that pregnant women, especially first time mothers, face in the community? Many feel sick and weak during pregnancy, and in a farming community, this means they cannot work and creates problems in the family. Sometimes they are still forced to work and do not get much help or support from family members.
 
[traditional authority member] Do we have permission to start this program? Yes, and have the support of the Chief and Queen Mother to help promote the program, identify participants, and inform the community about the benefits of the program.
 
[clinic nurse] What can GHEI do to support women during pregnancy, and how can we support each other without duplicating efforts? GHEI can help by encouraging women to continue coming to the clinic after the baby is born, help the clinic obtain needed supplies and supplements, and help people enroll in health insurance.
 
[clinic nurse] Nurses also provide family planning counseling at these visits, but most women are not interested, think it is actually harmful to their health to not continue giving birth regularly.
 
[clinic nurse] What do you think about a program like this? Like the program idea and it could be very helpful for the community and for the nurses. Should involve husbands and encourage them to come with their wives to ANC visits so that they know what is going on and to accompany them when it’s time to deliver (many do not).
 
[mothers] Did you self-medicate, or use herbs, during your pregnancy and/or during breastfeeding? Used herbs during first trimester to help make it easier (1/6); used herbs at end of pregnancy to rid the womb of harmful things, protect baby, ensure safe delivery (3/6); only what was given by hospital/doctor (e.g. to prevent malaria) (3/6); during breastfeeding only (1/6); no, didn’t take anything (1/6).
 
[mothers] What are some of the challenges or problems you encountered during pregnancy? Paying for health insurance; affording doctor’s visits/ANC (4/6); still being expected to go to farm and do hard physical labor during pregnancy; sickness, weakness, loss of appetite (4/6); getting good nutrition.
 
[mothers] If we started a program focused on helping pregnant women and mothers of young children, what kinds of help/support would be most helpful? How would such a program have helped you? Help mothers provide good food/nutrition (4/6); help women afford ANC (3/6); help women with health insurance (2/6); enroll the children in GHEI education programs; provide books and learning materials; provide bednets for all members of family; provide clothes for mother and baby; have someone to advise mother; help/encourage mother to get to the hospital; help during nursing with taking care of the baby, so mother can rest and work; teach parents how to help child with literacy, especially if parents illiterate.
 
[father] Do you think this program will help fathers? They think pregnancy is the duty of the woman, so if we involve them and enlighten them about their duties, it may help.
 
Themes/insights to take forward
  • Nutrition always mentioned as something that’s important, but that people have a hard time affording, especially for the child.
  • Food myths during pregnancy widely held – all mothers we interviewed mentioned these and believed them.
  • Supporting child wellness clinics is a huge opportunity for our program – large disconnect here between mothers and nurses, both are dissatisfied with what the other is doing (nurses don’t think the women listen to what they tell them, just stop coming to the post-natal visits because they’re not receiving anything from the clinic; mothers feel the nurses don’t explain things to them or give them enough information about their health or their baby’s health, what they should be doing to ensure they’re healthy, etc).
  • Health insurance is something people need help with – either helping them to afford the annual fee, or make it easier for them to enroll (currently, people have to go all the way to Bibiani ~45 mins  away to enroll, and people don’t have the time or money to do this).
  • Because farming is their livelihood, pregnant women still expected to go to farm, even though they feel weak and husbands/family aren’t very understanding.
  • Husbands can do a lot more to support their wives, not just financially – help out around the house, allow wife to stay home from farm and rest, provide emotional support by accompanying her to ANC visits and delivery of the child. 
 

Update 12/28/14: Summary of feedback/learnings from prototype

Who: pregnant women, mothers of children 0-6 months, and 6 months-3 years (15 total)

What: skits demonstrating what the three main phases of the program might look like, to test different components of our idea and get feedback
Where: Humjibre community center



 
The good
  • These women really seemed to like the idea of having a Mother Mentor, someone working with them on a one-on-one basis, visiting them regularly to give advice and provide individualized support to the mother, to build a long-term relationship with, to be able to contact if any problems/questions/concerns.
  • They liked the idea of the Mother Mentor introducing good health behaviors to the mother and helping her to teach the child early on (i.e. washing hands with soap).
  • They liked the idea of the Mother Mentor helping to monitor the child’s development and showing the mother how to help her child progress through the development milestones.
  • They were excited about receiving more support and information during the first few years of their child’s life, as they don’t feel they are getting the support or counseling they need from the local child wellness clinics.
  • Many liked the idea of receiving bednets for their home, handwashing supplies, nutrition support for both the mother and the child, children’s books.
  • They were excited about the possibility of us providing latrines, as many said their family does not have one and they use the local trash dump.
  • They liked the idea of continuing to provide items commonly requested at the clinic for delivery, as it is difficult for many of them to afford to deliver at the clinic/hospital.
  • All said they would value a program like this and they would accept any/all of the things we proposed to offer them. 



The bad
  • No one had anything negative to say about the different components of the program, there was nothing they said we should take out or change.
  • They had ideas for things that we could add – for example, helping them to pay ultrasound fees (which are not covered by ANC), giving them a baby crib or play pen, helping to pay daycare fees, etc. So, we will need to further investigate to determine what components would be most helpful and what we can afford to do. 



The unexpected
It was interesting to hear how they feel about child wellness clinics, that they don’t feel they are given enough information about their child and what they should be feeding it or doing to help it grow/develop on schedule. For example, they are given a baby weighing card that has very good information on nutrition for the child, growth monitoring, etc, but many of these women cannot read and no one explains the information to them or how to use it.


Update 1/1/15: Lessons and applications from the refinement period; re-imagined program

After discussions of our findings and how they inform our program design, we created two documents attached.

Who will benefit from this idea and where are they located?

Primary beneficiaries are pregnant women and their families in five villages in rural Western Ghana, with a total population of approximately 9,000. We have ongoing programming (although not every program) in each of the five villages currently. [12/15/14] Most of the population farms cocoa as their primary occupation. One-third of the adult population has had no formal education, and most of those with no education are women.

How could you test this idea in a quick and low-cost way right now?

[12/28/14] Progress since ideas phase: 1. We have completed a user experience map (posted document), identified questions for prototyping, held prototyping meetings and are writing up the results. 2. Completed a stakeholder analysis (posted document) and posted stakeholder interviews results (see above). 3. We are in the midst of an extensive review of global health and development literature and best practices to guide program design and approaches. 4. Thanks to a helpful comment from the Ideo team, we held a discussion to review lessons learned and insights to be carried forward in this program (posted document).

What kind of help would you need to make your idea real?

Specific examples of input needed include: 1. One of our goals is to decrease stress on mothers and families during a very stressful time- does anyone have thoughts on indicators/measurement tools for this? 2. We are considering a tiered subsidization program for certain elements. For example, a family that could afford to pay a small amount would receive a subsidized cost for a latrine, but a family that could not afford it would not have to pay anything. The reason for this is that paying something seems to improve the value attributed and decreases our expenditures, however, ANY cost can make assistance out of reach for some families. Does anyone have any experience with tiered subsidization with community programs? How do you assess wealth? Any problems with perception/jealousy in the community? We know of programs that do this for health care in the US, for example, but not in communities where paystubs are not common (since almost everyone earns income from farming cocoa).

Is this an idea that you or your organization would like to take forward?

  • Yes. I am ready and interested in testing this idea and making it real in my community.

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In practical terms the idea is happening already and indications are that first time mothers are supportive and appreciative.

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