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Community-Based Impact-Oriented Child Survival

in Huehuetenango, Guatemala

USAID Child Survival and Health Grants Program

October 1, 2011 – September 30, 2015 Cooperative Agreement No: AID-OAA-A-11-00041

Qualitative Analysis of Care Group Implementation

Corey Gregg MPH August 2015

CURAMERICAS GLOBAL 318 West Millbrook Road, Suite 105, Raleigh, NC 27609

Tel: 919-510-8787; Fax: 919-510-8611

The Community-Based Impact-Oriented Child Survival in Huehuetenango, Guatemala Project in Huehuetenango, Guatemala is

supported by the American people through the United States Agency for International Development (USAID) through its Child

Survival and Health Grants Program. The Project is managed by Curamericas Global, Inc. under Cooperative Agreement No.

AID-OAA-A-11-00041. The views expressed in this material do not necessarily reflect the views of USAID or the United States

Government. For more information about The Community-Based Impact-Oriented Child Survival in Huehuetenango,

Guatemala Project, visit: http://www.curamericas.org/

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Table of Contents Executive Summary 3 Background 7 Research Questions and Themes 9 Methods 10 Results 12 Discussion 27 Conclusions 31 Limitations 32 Recommendations 33 Annex 37

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Qualitative Analysis of Care Group Implementation

Author: Corey Gregg

Executive Summary

Background: The Community-Based Impact-Oriented Child Survival Project in Huehuetenano Guaemala was begun in 2011 to improve the health of the local rural indigenous population, and was implemented in the municipalities of San Sebastian Coatán, San Miguel Acatán, and Santa Eulalia. Funded by USAID, the four-year Child Survival Health Grants Project aimed to reduce preventable disease and death among children under five and women of reproductive age via community empowerment, increased health education, and increased healthy behaviors. Fundamental to the project was the intention to increase the status and agency of women in the project area by increasing their health-related decision-making autonomy, educating them to achieve health-related behavior changes, and increasing their participation in community affairs. The project’s primary service platform was the Community-Based Impact-Oriented (CBIO) Methodology, developed by Curamericas Global. The CBIO approach to primary care services has provided effective and efficient health care to marginalized populations since the 1980s. The approach seeks to create and maintain an up-to-date health census of the communities in which it works through routine home visitation and the ongoing collection and analysis of vital events data , including new pregnancies, births, disease incidence, and deaths in order to target resources toward the greatest contributors to illness and poor health. The Care Group methodology, originally developed by World Relief, has been successfully implemented by various community-based health programs in Africa, South Asia, and Latin America since the 1990’s, providing health education through a training cascade comprised primarily of female volunteers, through which large numbers of individual households and families can be reached at little cost. In the Care Group model, paid Promoters train female peer educators, called Care Group Volunteers, to teach lessons on appropriate health behaviors utilizing participatory methods for non-literate adult audiences; this cadre of volunteer peer educators is called the Care Group. These volunteers, in turn, teach 8-15 reproductive age women in their communities these lessons on potentially life-saving behavior change, through Self-Help Groups (also called Neighborhood Women Groups) employing identical participatory education methods. Curamericas’ Child Survival Project in Huehuetenango, Guatemala, utilized as its basic service platform a novel combination of the Community-Based Impact Oriented (CBIO) methodology and Care Groups (CBIO+Care Group), in which the female Care Group Volunteers were charged with both educating their neighbors in a top-down educational cascade, and with collecting vital events health data from those same neighbors to pass on to the project’s monitoring and evaluation staff for analysis and data-based decision-making. The combined approach was intended as a response to the challenge of finding a sustainable way both to provide both life-saving behavior change education and also to collect vital events data through community-based health surveillance. The project had a robust Operations Research (OR) arm, which evaluated the effectiveness of the CBIO+CG platform, and ways in which it can be improved. One objective was to understand the experience of the participants in the Care Group cascade: if they were satisfied with their training and learning, if we could find ways to improve the implementation of the Care Groups and their integration with CBIO, and if the Care Group experience resulted in greater empowerment and decision-making autonomy for their reproductive age women participants. To that end research was needed on: 1) the Increasing of self-efficacy among Comunicadoras and Community Facilitators; 2) the increasing of

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agency and empowerment among Comunicadoras, Community Facilitators, and Self-Help Group Participants; 3) the facilitators and barriers to the implementation of the Care Groups; and 4) ways to improve the integration of the Care Groups with CBIO.

In pursuit of those topics, the following research questions were developed:

1. How effective do the Community Facilitators and Comunicadoras feel they were in imparting life-saving knowledge and achieving behavior change? How well did the women in the Self-Help Groups (SHGs) feel they were taught by the Comunicadoras?

a. What factors do the CFs and Comunicadoras feel facilitated or impeded their effectiveness as trainers?

b. How well did the CFs/Comunicadoras/Self-Help Group women feel they were trained? What facilitated or impeded their training?

c. How effective were the training materials and tools provided? How can those materials be improved?

d. How receptive were the Comunicadoras/SHG women to their training? What could have made them more receptive?

e. What behavior changes did the CFs/Comunicadoras notice in the Comunicadoras/SHG women? What factors facilitated or impeded behavior changes? What behavior changes did the CFs, Comunicadoras, and SHG members notice in themselves?

f. What recommendations does each participant have to increase their own effectiveness and that of the Care Group educational cascade?

2. Do the CFs, Comunicadoras, and SHG members feel that they have more control over their lives and the decisions that affect their lives and are they more engaged in community affairs?

a. Do the CFs/Comunicadoras/SHG members feel that they can now participate more freely in community meetings and projects?

b. How do they think that the Care Groups helped improve their participation in the community?

3. What facilitated and what impeded implementation of the Care Group model? What facilitated or impeded involvement of participants?

a. What recommendations does each member have to increase retention and participation?

b. What recommendations does each member have to improve the entire program? 4. How well were the CFs and Comunicadoras able to acquire and record vital events?

a. What barriers did they face in recording and communicating vital events? b. What helped them to record and communicate the vital events? c. How could the process of acquiring vital events be improved?

Methods: A qualitative, interview-based study design was used to evaluate the effects of the Care Group training cascade upon Community Facilitators (CFs), Comunicadoras (Care Group Volunteers), and women participating in the Self-Help Groups, regarding self-efficacy and empowerment. The study also sought to identify areas for quality improvement related to logistical implementation of the project. Informants from six randomly-selected communities, one from each Phase in each of the project’s three municipalities, were interviewed by trained local interviewers in their native Mayan language. In each of the six communities, the Community Facilitator was interviewed individually; a focus group discussion was held with the Comunicadoras (Care Group Volunteers) of that community; and a second focus group discussion held with the women of a randomly-selected Self-Help Group (Grupo de autocuidado]. The focus group discussion were groups of 6 to 9 women. In total, there were 6 CF interviews, 6 focus group discussions with Comunicadoras, 6 focus groups discussions with

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women from Self Help Groups. A note-taker took notes in Spanish during the interviews and focus group discussions and these notes were transcribed into written Spanish transcripts, which were then then translated from Spanish to English. The data from the transcripts was analyzed for themes using a constant comparative approach, in conjunction with deductive assessment around several preconceived themes. Findings: During analysis several themes emerged, which focused primarily upon: changing attitudes, health beliefs and health behaviors; empowerment of female project participants and other community members; sustainability of the model; logistical issues related to implementation of the care groups; incorporation of the Care Group methodology with Community-Based Impact-Oriented methodology (CBIO+Care Group) for vital events surveillance; recommendations for improvement of the model. Changing Attitudes, Health Beliefs, and Health Behaviors – Every woman interviewed had a positive view of the Care Groups and were satisfied with their experience and role in the project. Most expressed that their satisfaction resulted from their ability to make a positive impact upon the health of their community. Many stated that participation by women in the Care Groups and Self-Help Groups was low initially, but that women were eventually convinced to participate by the apparent health improvements noted in the families of those who did participate. Likewise, those who participated initially continued to do so and sustained behavior changes because of the health benefits seen in their children and themselves. Among Comunicadoras and Self-Help Group participants, continued participation was also influenced by enjoyment of the interactive, group-learning methods. Care Group cascade participants at each level of the cascade were able to express knowledge of the scientific rationale for their behavior changes and of basic disease etiology; the highest level of such knowledge was conveyed by the FCs. All levels of the cascade spoke of making specific health behavior changes, and the Self-Help Group participants reported the largest breadth of behavior changes, including those related to sanitation, care-seeking, nutrition, pregnancy, delivery, and treatment and prevention of childhood illness. Barriers cited to behavior change centered on lack of attendance at Care Groups and Self-Help Groups. Empowerment of Female Participants – Care Group cascade participants reported increased social status, increased self-efficacy, and increased decision-making autonomy. Reasons given for increased social status were related to their roles in a program considered effective by their community, including their role as health advisers; and their leadership experience, which translated to greater participation in community events. Increased social status was expressed more frequently by FCs and Comunicadoras, when compared to Self-Help Group participants. Increased self-efficacy resulted from practical knowledge of illness and health gained through the Care Groups, as well as awareness gained about the rights of women. They reported increased decision-making autonomy, which resulted from heightened confidence among the participants in their ability to make correct decisions, increased belief in their right to make those decisions, and practice making decisions during the Care Groups and Self-Help Groups. Increased decision-making autonomy was reported for both health and non-health decisions, and the women stated that the new knowledge translated to increased power over their own lives. Women also cited financial savings due to decreased illness among the families of participants, creating more family disposable income. Logistics and Implementation – The women stated that facilitators of the success of the Care Group cascade included: community leadership, which informed women of the time and place of Self-Help Groups; increased bridging social capital from FCs, Comunicadoras, and Self-Help Group participants to community leadership; and increased bonding social capital among the Care Group cascade

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participants. Some barriers they cited to implementation of the model and attendance included: lack of time, distance of travel required to attend, opportunity cost, disapproving husbands, religious and familial obligations, desire for financial payment, and belief among some women that they already knew how to take care of their children. Training materials used in the cascade were generally favorably received. Participants expressed the importance of continuing the interactive group learning methods, using graphics and role-playing. FCs and Comunicadoras stressed the ease of teaching using the same methodology through which they themselves learned, and doing their own teaching quickly after learning the material themselves, while the lessons were fresh. Incorporation of the Care Group Methodology with CBIO Methodology – FCs and Comunicadoras expressed that doing home visits themselves increased trust among Self-Help Group participants, which in turn increased learning and health behavior change. Trust gained at Care Groups and Self-Help Groups also facilitated collection of vital events data. The Care Group cascade proved an effective method to train participants to collect vital events. Recommendations for Improvements– FCs asked for more materials, including more drawings, manuals and guidebooks. Comunicadoras asked for more durable materials and for materials that they could give to the Self-Help Group participants, which could serve as reminders of behavior changes previously learned. Some participants asked for more training on new topics, while others asked for repeated training of old topics. No participants asked for fewer trainings. Some asked for medicines to be dispensed by the organization. Discussion: The Care Group Cascade was implemented in communities where the participants understood the severity of illness and their own susceptibility to it through first-hand experience, but lacked the knowledge or skills to reduce this susceptibility and improve their health. Through increased theoretical and practical knowledge, and through increased self-efficacy and social status, the cascade empowered them to make positive health behavior changes in their own lives, for themselves and for their families. Learning the theoretical basis of new health behaviors was key to the practice of the behavior and the women’s sense of empowerment. This empowerment increased the social status of the Care Group cascade participants in their communities, reduced their timidity and fear and increased their self-esteem and decision-making autonomy. This empowerment was facilitated by increasing bridging social capital with community leaders and bonding social capital among the women themselves, and reinforced by the visible results of the practical application of the health knowledge itself in the form of improved health for themselves and their children. Empowerment and increased agency resulted in reduced effects of machismo, increased participation of women in community meetings, and community capacity building. The training methodology successfully engaged the participants in a culturally and educationally appropriate manner and led to behavior change. That the training methodology does not rely on gifted instructors but rather on the fidelity of the application of the teaching model enhances its replicability and ease of implementation. When looking at impediments to women’s participation, the need to work (usually as migrant labor) and interference from machista husbands were the prime impediments cited, which may imply that the poorest and most repressed women are not be being reached and that efforts must be made to reduce these impediments to their participation. Limitations: Bias may have resulted from interviewing only Care Group cascade participants and not triangulating with observations from non-participants outside the cascade (e.g., husbands, mothers-in-law). Bias may have also resulted from errors translating from indigenous languages to Spanish, then Spanish to English. Additionally, responses were themed and analyzed by a single researcher.

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Recommendations: Recommendations for future projects arose from both successes and areas to be improved in the current Care Group cascade: 1) Use testimonials to disseminate early results in health improvements in the community to build trust and attendance; 2) enlist trusted community members to be FCs and Comunicadoras to facilitate behavior change; 3) respect the capacity of Care Group cascade participants to understand the scientific rationale for their new behaviors; 4) gain the support of community leadership to achieve high Self-Help Group attendance and to build bridging social capital; 5) provide FCs with a manual to increase fidelity of teachings; 6) provide Comunicadoras and Self-Help Group participants with graphic learning aids to take home for recollection and sustained behavior change; 7) teach explicitly about female empowerment and self-worth to increase female agency; 8) continue to use engaging, graphical, and dramatic teaching methods; 9) teach FCs and Comunicadoras basic evaluation techniques so they can customize Care Groups and Self-Help Groups to the ability and pace of the participants in attendance; 10) include the most vulnerable, as the poorest and most marginalized are also those least likely to have the ability to participate; 11) continue to combine CBIO with the Care Group methodology, as both serve to reinforce and facilitate each other; 12) leverage the increased status of participants; 13) expand Care Groups to include more kinds of participants, such as adolescents, men, and mothers-in-law. Conclusions: The combined CBIO+Care Group methodology as implemented by the project resulted in increased empowerment of female participants, community capacity, and self-reported health behavior change, while generating important recommendations for project replication and quality improvement. I. Background The mountainous Guatemalan department of Huehuetenango is an area of geographic isolation inhabited primarily by indigenous Mayan people, many of whom suffer from endemic poverty and historical marginalization, lacking clean water, sufficient nutritious food, and access to education and health care. The inhabitants of these communities live high in the mountains, far from hospitals, physicians, and paved roads. Due to strong male dominance in the Latino and Mayan cultures, women are frequently the most marginalized, resulting in female disempowerment and high rates of female illiteracy. The rural northern area of the department possesses some of its most isolated and impoverished communities. Often referred to as the “Triangle of Death”, the region’s population currently suffers a maternal mortality ratio of 681/100,000, more than five times the national ratio, and the third-highest U5MR in the Americas (MSPAS data for Huehuetenango Department). Chronic malnutrition affects 65% of children under 5. Most maternal and U5 deaths are from readily preventable causes, such as pneumonia, diarrhea, and complications of home deliveries. As such, much of the disease and death in the region could be prevented with health education, access to prompt treatment, and changes in health-related behaviors. These behaviors include prompt care seeking for complications of pregnancy and delivery; for treatment of acute respiratory or diarrheal illness in children; proper hand-washing, and exclusive breastfeeding of infants less than six months of age. In response to this health burden, a Child Survival Project was implemented in this region of northern Huehuetenango by Curamericas Global and its in-country partner, Curamericas

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Guatemala, from 2002 to 2007. A second Child Survival Project was begun in 2011 to build upon on the achievements of the first and to further improve the health of the population, and was implemented in the municipalities of San Sebastian Coatán, San Miguel Acatán, and Santa Eulalia. Funded by USAID, the four-year Child Survival Health Grants Project that began in 2011 aimed to reduce preventable disease and death among children under five and women of reproductive age via community empowerment, increased health education, and increased healthy behaviors. Fundamental to the project was the intention to increase the status and agency of women in the project area by increasing their health-related decision-making autonomy, educating them to achieve health-related behavior changes, and increasing their participation in community affairs. The project’s primary service platform was the Community-Based Impact-Oriented (CBIO) Methodology, developed by Curamericas Global. The CBIO approach to primary care services has provided effective and efficient health care to marginalized populations since the 1980s. The approach seeks to create and maintain an up-to-date health census of the communities in which it works through routine home visitation and the ongoing collection and analysis of vital events data , including new pregnancies, births, disease incidence, and deaths in order to target resources toward the greatest contributors to illness and poor health. The Care Group methodology, originally developed by World Relief, has been successfully implemented by various community-based health programs in Africa, South Asia, and Latin America since the 1990’s, providing health education through a training cascade comprised primarily of female volunteers, through which large numbers of individual households and families can be reached at little cost. In the Care Group model, paid Promoters train female peer educators, called Care Group Volunteers, to teach lessons on appropriate health behaviors utilizing participatory methods for non-literate adult audiences; this cadre of volunteer peer educators is called the Care Group. These volunteers, in turn, teach 8-15 reproductive age women in their communities these lessons on potentially life-saving behavior change, through Self-Help Groups (also called Neighborhood Women Groups) employing identical participatory education methods.

Curamericas’ Child Survival Project in Huehuetenango, Guatemala, utilized as its basic service platform a novel combination of the Community-Based Impact Oriented (CBIO) methodology and Care Groups (CBIO+Care Group), in which the female Care Group Volunteers were charged with both educating their neighbors in a top-down educational cascade, and with collecting vital events health data from those same neighbors to pass on to the project’s monitoring and evaluation staff for analysis and data-based decision-making. The combined approach was intended as a response to the challenge of finding a sustainable way both to provide both life-saving behavior change education and also to collect vital events data through community-based health surveillance. A paid staff Educator (Educadora) trained a Community Facilitator (CF) in each village how to teach lessons on topics such as the recognition of and prompt response to complications during pregnancy and labor; how to use oral rehydration therapy (ORT) to rehydrate children during diarrheal illness; and the importance and practicalities of proper sanitation. The CF

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was then tasked with training seven to fifteen volunteers in her community, called Comunicadoras (the Care Group Volunteers); this cadre of Comunicadoras constituted the Care Group (which is also the name given to the entire methodology). They were taught by the CF how to teach these same lessons during twice-monthly meetings called Care Group meetings. The CF was not staff, but she received a small stipend for her time. The Comunicadoras then taught these lessons to ten to fifteen of their neighbors in twice-monthly Self-Help Groups. Comunicadoras and Self-Help Group participants were all mothers of children under five years of age. Care Groups and Self-Help Groups were conducted in the indigenous Maya language; teaching techniques at all levels were interactive, non-literary, and culturally appropriate, and they included songs, pictures, and role-playing. Through this cascade 26 Educators were able to impact 14,448 mothers who participated in the Self-Help Groups, and their families (Table 1). Table 1: Care Group Cascade

Staff/Volunteer San Sebastian

Coatán San Miguel

Acatán Santa Eulalia Total

Educator Supervisors (staff) 1 1 1 3

Educators (staff) 8 8 10 26

Community Facilitators (volunteer with stipend) 47 43 59 149

Comunicadoras (volunteer) in Care Groups 276 239 264 779

Mothers of under-5 children in Self-Help Groups 2424 4761 7303 14488

To execute community vital events surveillance, Comunicadoras were charged with collecting information about births, deaths, migrations, disease incidence, health practices, and new pregnancies from the neighborhood women during the Self-Help Groups. That data was then relayed to the CF at the next Care Group meeting, and from the CF up through the Care Group cascade to the Educator Supervisors, who worked directly with program administrative and M&E staff to update the health censuses of the communities and to constantly re-evaluate health-related needs. II. Research Questions and Themes The project had a robust Operations Research (OR) arm, which evaluated the effectiveness of the CBIO+CG platform, and ways in which it can be improved. One objective was to understand the experience of the participants in the Care Group cascade: if they were satisfied with their training and learning, if we could find ways to improve the implementation of the Care Groups and their integration with CBIO, and if the Care Group experience resulted in greater empowerment and decision-making autonomy. To that end the interview questions attempted to elucidate responses that related to:

1) Self-efficacy of Comunicadoras and Community Facilitators; 2) Empowerment of Comunicadoras, Community Facilitators, and Self-Help Group

Participants; 3) Implementation of the Care Groups; 4) Integration of the Care Groups with CBIO.

In pursuit of those topics, the following research questions were developed:

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5. How effective do the Community Facilitators and Comunicadoras feel they were in imparting life-saving knowledge and achieving behavior change? How well did the women in the Self-Help Groups (SHGs) feel they were taught by the Comunicadoras?

a. What factors do the CFs and Comunicadoras feel facilitated or impeded their effectiveness as trainers?

b. How well did the CFs/Comunicadoras/Self-Help Group women feel they were trained? What facilitated or impeded their training?

c. How effective were the training materials and tools provided? How can those materials be improved?

d. How receptive were the Comunicadoras/SHG women to their training? What could have made them more receptive?

e. What behavior changes did the CFs/Comunicadoras notice in the Comunicadoras/SHG women? What factors facilitated or impeded behavior changes? What behavior changes did the CFs, Comunicadoras, and SHG members notice in themselves?

f. What recommendations does each participant have to increase their own effectiveness and that of the Care Group educational cascade?

6. Do the CFs, Comunicadoras, and SHG members feel that they have more control over their lives and the decisions that affect their lives and are they more engaged in community affairs?

a. Do the CFs/Comunicadoras/SHG members feel that they can now participate more freely in community meetings and projects?

b. How do they think that the Care Groups helped improve their participation in the community?

7. What facilitated and what impeded implementation of the Care Group model? What facilitated or impeded involvement of participants?

a. What recommendations does each member have to increase retention and participation?

b. What recommendations does each member have to improve the entire program?

8. How well were the CFs and Comunicadoras able to acquire and record vital events? a. What barriers did they face in recording and communicating vital events? b. What helped them to record and communicate the vital events? c. How could the process of acquiring vital events be improved?

The interview guides that were used in pursuit of the above research questions are included in Annex A. III. Methods For this study, a qualitative, interview-based study design was chosen in order to answer the research questions. The Child Survival Project included a quantitative evaluation of effects of the CBIO-Care Group methodology upon behavior change, care-seeking, morbidity and mortality, and this qualitative study sought to complement that quantitative evaluation by gaining an understanding of effects of the Care Group training cascade upon Community

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Facilitators, Comunicadoras, and women in the Self-Help Groups, regarding self-efficacy and empowerment. This study also sought to identify areas for quality improvement related to logistical implementation of the project. Community Facilitator interviews were conducted as individual interviews, while Comunicadoras and Self-Help Group participant interviews were conducted in group interview format. Interviews were conducted in the local Maya language of each municipality. Group interviews were chosen over focus group discussions due to the lack of sufficient time available to the investigator to train interviewers in the more demanding skills necessary to conduct a quality focus group. The interview questions were designed to elicit information necessary to answer our four research questions and their sub-questions. Three interviewers with at least secondary-level education were hired from each municipality. Each interviewer was a native speaker of the local Maya language of that municipality and also spoke Spanish fluently. The nine interviewers were trained in the methods of group interviews, as well as in the purpose of the Child Survival Project, the fundamentals of qualitative evaluation, and in the content of the interviews. The interview questions had been previously translated from English to Spanish using a team of two bilingual native English speakers and three Guatemalan native Spanish speakers. The interviewers then translated each interview question from Spanish into the local Maya language collaboratively in teams of three. Interviews were conducted in the local Maya language by the team of three interviewers, with one asking questions, one writing down responses in Spanish, and a third noting behavior and verifying the transcription of the responses. Interviews were conducted during May 20th and May 21st of 2015, in the communities of Ququilum and Jajhuitz, San Sebastian Coatán; Paiconop Grande and Aldea Poza, San Miguel Acatán; and Altamiranda and Kanajaw Xixilack, in Santa Eulalia. Communities were chosen purposefully by the Educator Supervisors, who believed the communities to be representative of the Care Group experience in each municipality, and through convenience sampling, being physically accessible in the limited time available. As part of its OR study design, the project had been implemented in two Phases, with the 92 Phase 1 communities receiving project services, including Care Groups, for the full 4 years of the project, and the 88 Phase 2 communities only for the final 2 years. Therefore, the communities represented one Phase 1 community and one Phase 2 community in each municipality. In each community the CF, the women of the Care Group, and the women of a randomly selected Self-Help Group were interviewed. There were 6 to 8 women in each Care Group interview and 8 to 9 in each Self-Help Group interview. Ages of the participants of the Care Groups and Self-Help groups interviewed ranged between 20 and 35 years old. To reduce possible bias, interview team members alternated between the role of interviewer, secretary/transcriber, and observer. Due to lack of time necessary to transcribe digital recordings, the interviews were not recorded. Instead, the team secretary took notes in Spanish, which were reviewed by the other team members at the conclusion of the interview for accuracy and completeness and corrected or augmented as needed. These Spanish

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transcripts of the interview were then translated to English for evaluation and analysis. Following translation to English the data was analyzed for themes using a constant comparative approach, which gave rise to five distinct themes, each possessing several sub-themes, in conjunction with deductive assessment around several preconceived themes. Interview responses and subsequent themes were then compared for differences by Phase of the community, by municipality, and by role in the Care Group cascade as a Community Facilitator, Comunicadora or Self-Help group member. The results of that analysis follow. IV. Results During analysis, several themes emerged:

1. Changing attitudes, health beliefs and health behaviors; 2. Empowerment of female project participants and other community members; 3. Logistical issues related to implementation of the care groups; 4. Incorporation of the Care Group methodology with CBIO methodology for vital

events surveillance; 5. Recommendations for improvement of the model.

Changing Attitudes, Health Beliefs, and Health Behaviors Changing Attitudes toward the Project Every CF interviewed had a positive view of the Care Groups and of their experience and role in the project. Most expressed this to be due to the ability to improve the health of the community. One Community Facilitator stated that she felt nervous about her role at the beginning of the project, but that in time, it gave her confidence. Another CF stated that she entered the work with an open mind, but with interest, and that she was convinced of the importance of the project through directly witnessing results. Additionally, the CFs reported that the Comunicadoras and Self-Help Group participants with whom they worked had positive views of the project. Only one CF described an active unwillingness among Care Group members and Self-Help Group members to participate, which she blamed on a desire for payment. That CF stated that—in most cases—those who initially did not participate were convinced of the importance of the project by its early results. That is, those who did not initially participate saw improved health in their community, and their attendance increased as a result. All CFs described a trend of increasing attendance over time. Before when I was not an CF, I did not have knowledge about how to maintain good health, but when I accepted this job, I could know and learn about my own health care and that of my family. I have realized that by practicing these teachings, our way of life improves and we also avoid illness. -Community Facilitator [There was an] initial lack of participation of some mothers but with time they realized the importance. -Community Facilitator

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To accomplish increased attendance, the CFs stressed the importance of trust-building with the women, the home visits (which built trust and familiarity), and the importance of community leadership, which is more thoroughly discussed under the Logistics and Implementation theme. The CFs reported that both they and the women whom they trained began to participate more consistently due to the perceived effectiveness of the project. Initially, the women that were not participating, because they wanted something in exchange. Bit by bit they realized that the trainings were effective on their own. -Community Facilitator Similarly, the Comunicadoras had a very positive perception of the project. Primarily, this perception resulted from three benefits: 1) The Comunicadoras witnessed health improvements among their own children and in their communities and therefore they valued the knowledge gained for its practical, medical effects, as related primarily to children; 2) the Comunicadoras enjoyed being able to learn the knowledge through interactive, visual, and didactic methods; and 3) some stated that they enjoyed the trust gained from the Self Help Group women. [the Comunicadoras] liked it because [they] got good knowledge about health and how to care for [their] children and—today—they do not get sick very often. -Comunicadora Likewise, Self-Help Group participants had a very positive view of the project because they saw the results in their own homes, and many expressed a desire that the project continue. They believed their children to be sick less often, and they believed that the knowledge gained through the project was inherently valuable—for their own health and for that of their children. According to one Self-Help Group participant: We like it because they train us to care for our children, because now they tell us which foods are good for them and also which are bad, which we can feed them and which we should not feed them, and also how we can teach them to wash their hands; Before I would give ‘chicharrones’ [deep fried pork rinds] to my children but this is bad, and it is better to give them fruits. We like that about our group. -Self-Help Group participant There were no differences noted in the responses of participants with respect to Phase or municipality. Changing Health Beliefs The Community Facilitators spoke of the influence of the relevance of the teachings for creating behavior changes. That is, the seriousness with which the Community Facilitators considered their health and that of their communities, and the perceived effectiveness of the behavior changes for preventing illness. According to the Community Facilitators and the Comunicadoras, that perceived effectiveness was accomplished through respectful, detailed explanation of the causes and effects of illness and the rationale of treatment. The CFs and the

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Comunicadoras emphasized the importance of understanding the causes of illness, and why behavior change would improve health. Regarding changes that I have seen in my own life, before I did not give nutritious food to my children, now I do because it is beneficial to them and to me. -Community Facilitator Before we would not do what we practiced [during the group meetings]. Today we have changed, for example, as mothers, we now know the importance of colostrum, that it serves like the baby’s first vaccine, and also [the importance of] hygiene before eating. -Comunicadora Fewer women in the Self-Help Groups mentioned the mechanisms through which their behavior changes resulted in increased health. That said, a clear understanding that behavior changes improved health was apparent. The responses of the women in the Self-Help group were less theoretical and more practical than those of the Comunicadoras and Community Facilitators. The women in the Self-Help Groups did, however, express basic understanding of disease causation, which led them to change behavior. But it was the improved health of their families that convinced them to continue their new behaviors. We breastfeed the children younger until 6 months to prevent disease, but before we stopped at 3 months, and [it was easy to change] because we saw them stop being sick quickly. This is the change that we see now and this made it easy to change our behavior. -Self-Help Group participant Changing Health Behaviors Regarding the behaviors themselves, participants from each level of the cascade reported significant changes in their own lives and behaviors. The Community Facilitators spoke primarily of health behavior changes among the Comunicadoras and the Self-Help Group women, including: increased family/child hygiene, increased personal hygiene, better nutrition during pregnancy and four prenatal visits to medical professionals, knowledge of the danger signs during pregnancy, increased use of health centers during delivery, increased use of colostrum after birth, and increased nutritious foods for children and decreased junk food. We have achieved behavior change in the women… in the births that are complicated they will go to doctors or to the health center in the town; now there are fewer infant deaths. -Community Facilitator Additionally, the Comunicadoras and the women in the Self-Help groups frequently expressed interest in learning the practical behaviors that they could adopt. They cited interest in learning danger signs and symptoms that would require visiting a health worker, and which specific health behaviors were applicable to their own families, particularly during emergency situations. The Comunicadoras spoke of changes in themselves and in the Self-Help Group women. They named each of the aforementioned behavior changes, and specifically highlighted washing their hands after defecating and before cooking. Additionally, they spoke

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specifically of quickly using ORT to rehydrate their children during diarrheal illness, of boiling all water for consumption, and of vaccination. We did not boil our water before drinking it, now we do it and our children know to drink boiled water. -Comunicadora Now when some pregnant mothers have a lot of symptoms like: headaches, vaginal hemorrhage, nausea, we can compare them to the posters, to the graphics, and then they can go see the attendants at the maternity clinic [Casa Materna]. We also learned about exclusive breastfeeding and we shared that with the mothers, and about the colostrum. -Comunicadora Our family situation has changed because the children say that they should wash their hands with soap and water after going to the bathroom, as well as when they eat. And they wash the kitchen utensils with soap, before they did not do that. -Comunicadora Of all the informants, the women in the Self-Help Groups spoke the most about behavior changes that they had made. They cited the same behavior changes cited by the Comunicadoras. In addition, they specifically spoke of being able to identify symptoms of pneumonia in their children, which would cause them to seek medical attention. Of note, the women in the Self-Help Groups did not mention family planning. …we receive training about the good care of the children and we identify pregnant women. We also help when pregnant women give birth, if there are any complications we take them to the doctors. -Self-Help Group participant …the behavior changes that we have achieved as a Self-Help Group are: an understanding of the importance of natural foods, which are essential because they contain a lot more vitamins than do junk foods. Similarly, we now place importance upon the first milk called ‘colostrum’ that we give to our newborn children because this is the first vaccine.

-Self-Help Group participant No differences in reported behavior changes could be noted between Phase 1 and Phase 2 communities, or between municipalities. Reported Barriers to Behavior Changes Each group was asked if they believed that anything impeded behavior change in themselves or in the groups that they trained. While several Community Facilitators, Comunicadoras, and Self-Help Group women reported that there were no impediments, the majority of women did believe that impediments to behavior change existed. Among the Community Facilitators, lack of attendance by the Comunicadoras at Care Group meetings was the most frequently cited reason for failure to change behaviors. Additionally, both Santa Eulalia CFs reported lack of interest among the Comunicadoras as an obstacle to behavior change. Disinterest as a barrier was not expressed by Community Facilitators in the other two municipalities.

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By comparison, the Comunicadoras did not mention their own lack of behavior change or their lack of attendance, as described by the CFs. All but one group of Comunicadoras reported as an obstacle to behavior change the lack of participation, interest, or punctuality among the mothers in the Self-Help Groups. In contrast to the Comunicadoras, the women in the Self-Help Groups did not locate the impediment to behavior change with another level of the cascade and took full responsibility for any failures to participate or change behaviors. Each of the Self-Help Group interview participants expressed that their lack of attendance was the primary impediment to behavior change. The reasons cited for lack of attendance included large distance to travel to attend meetings, their occasional lack of interest, and lack of time. “Well it depends upon us, if we came to the trainings. Time is what impeded our behavior changes.” -Self-Help Group participant One group described forgetfulness as an impediment to behavior change. All that they said we are doing it now in practice, but sometimes we don’t remember everything that they say because we are old people and we forget. -Self-Help Group participant Reasons for lack of attendance will be described below in greater detail since they include several factors external to the women themselves. Empowerment of Community Facilitators, Comunicadoras, and Self-Help Group Participants In the responses to the questions, several concepts related to empowerment arose, and can be categorized as follows:

1. Increased social status among care group cascade members; 2. Increased decision-making including self-efficacy and agency.

Increased Social and Economic Status among Care Group Cascade Members A benefit frequently described by Care Group cascade members was an increase in social status that they enjoyed from their participation in the project. The Community Facilitators reported increased status in their communities for various reasons. All of them reported that their leadership role had increased their community standing. The majority of Community Facilitators indicated that increased status in the community and decision-making power in their own lives resulted from the knowledge that they gained through the trainings, and the effectiveness of that knowledge to members of the community, translating into reductions in illness and death. …they would turn to me for help when someone is sick, or someone needs my help. -Community Facilitator

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Additionally, one Community Facilitator mentioned that being charged with her job “awakened” in her an interest in participating in the community, resulting in additional community leadership roles. In fact, as a result of their leadership in the maternal and child health project, the Community Facilitators were asked to give assistance during illness of members of their communities, and this position resulted in requests for their opinions on other, non-care group-related community decisions.

…before I was not interested in the community meetings, now they ask for my participation, now they involve me a lot in the community meetings and they ask my opinion. -Community Facilitator

One Community Facilitator indicated that the money saved from reduction of illness in

her household resulted in increased financial status. Because the training that we have received helped us to practice child hygiene and

hygiene in the house, and so we avoid illness and because of this we save more money. -Community Facilitator

Furthermore, many CFs also indicated that they saw increased social status in

themselves and in other women involved in the Care Group cascade as a result of specific teachings about the rights of women to make decisions, which they reported not having known previously. Additionally, one CF reported increased status in the community and increased participation in community meetings due to familiarity with community leaders, gained through their assistance in the project.

…it is very easy to be able to participate because now we are very familiar with the leaders, now they can support us, because we value our rights as women. -Community Facilitator

Similar to the Community Facilitators, the Comunicadoras reported that they experienced increased social status through their role as teachers of knowledge accepted by the community as important and useful. …because we have participated a lot in the trainings, and they ask us for our opinions. -Comunicadora One Comunicadora reported that her role made it easier for her to ask community leaders for new community projects that may benefit her and her family. Some Comunicadoras also reported that community members now ask for their advice at community meetings as trusted, respected women. Comunicadoras also indicated that the knowledge gained from the Care Group cascade resulted in greater confidence in their own decisions resulting in increased decision making autonomy in their personal lives.

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The truth is that we now have more knowledge and know the importance of the topics and there are situations in which we find ourselves now being able to make our own decisions. -Comunicadora Many of them also indicated increased control as a result of their knowledge, including power over one’s body regarding family planning, which has also resulted in financial security due to a reduction in costs associated with raising unplanned children. …we can decide how many children we want to have so that we can support them well. -Comunicadora Likewise, some of the women in the Self-Help Groups reported an increase in social and economic status. According to the women, the knowledge that they gained served as a vehicle of personal power to make decisions in their own homes, as will be presented in the following section. It also served to elevate their personal status to trusted members of the community, to be called upon for help during medical illness and emergencies. Yes, because the people come to us for help because of what we have learned. -Self-Help Group participant Some Self-Help Group women also spoke of an increased ease of participation in community projects, which they ascribed to the knowledge gained in the Self-Help Groups of their own worthiness and value in the community. Several women also stated that they were initially timid about speaking in public and that the experience gained through the Care Groups rid them of this fear. This reduction in timidity translated to increased participation in community projects and meetings. They also expressed the importance of gaining experience speaking in public and speaking their minds at the Care Groups, which they believed to have helped them speak in public in situations other than the care groups, at community meetings We can now participate easily [in community meetings], because through the trainings we obtained knowledge about our rights to participate in community projects. -Self-Help Group participant Increased Decision-Making Autonomy Most women interviewed stated that they have more ability to make decisions compared to before the project, and that they now make their own decisions. They asserted that they have more confidence in their own decisions due to the knowledge gained, and that those decisions result in improved health for their families. I make my own decisions because with the position that they gave me as an CF, I am very informed. -Community Facilitator Now we can make our own decisions because if it is about the health of our children we act fast, before we would be too late.

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-Community Facilitator …at the beginning of the trainings I was a little afraid, but now I always feel free to make my own decisions and they benefit my children and my community. -Community Facilitator

One CF indicated that she gained greater power over her own body from the newfound knowledge of and access to family planning.

When I was not a Community Facilitator, I did not know about anything that they [Educators] taught me. Now I know how to care of myself, when to seek assistance from a doctor and now I can make my own decisions, to have children if I want to. -Community Facilitator These decisions related to their private lives, and they also each stated that they can and do participate more now in community projects and meetings. Additionally, some women spoke of changing dynamics between their husbands and themselves. I have more freedom to make my own decisions and I never let my husband control me even though I have not studied very much. For example, I now have the privilege of participating in meetings that benefit the health of my family. -Community Facilitator Similarly, the Comunicadoras related that since beginning the intervention their confidence in their own abilities and decisions had increased, leading them to make more decisions. Furthermore, they are now able to make those decisions due to loss of fear to participate privately and publicly, and new knowledge of their own value acquired through the Care Group teachings. They have lost fear of their mothers-in-law, of public speaking and of public action. They now participated more in the community and they are asked for their opinions more frequently. They also expressed that they are now more interested in community meetings that do not relate to health. Yes, we believe that we can participate more easily in community meetings and projects because now we have lost our fear, through the trainings that have been given to us; now we have knowledge. -Comunicadora As described previously, the Comunicadoras cited increased use of family planning, resulted in greater control over their own bodies and finances. Yes [we have more control over our lives], because before we were Comunicadoras we would do what our elders told us to do, such as: don’t give colostrum and sometimes our mothers-in-law were in charge of caring for our newborns and they would give them coffee or sugary drinks (refrescos), but now we do not let them do this, thanks to the teachings that we were given. Today our young mothers take good care of their children, and they also have knowledge about family planning. -Comunicadora

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Similar to Community Facilitators and Comunicadoras, many Self-Help Group women related increased decision-making autonomy and decreased domination by their male partners. According to the women, greater confidence in personal decisions was gained due to newfound knowledge. Yes, more, because now we are informed and we are capable of deciding for ourselves. -Self-Help Group participant One group noted that they gained confidence in their ability to make decisions from the decision-making practiced during the Self-Help Groups. The women expressed that they now take ownership of their health and that of their family. They conveyed new experiences of standing up to mothers-in-law and husbands, and nearly every woman interviewed stated that she now had more control of her own life. More control, because now we can decide things without consulting anybody, we realize now the importance of our own opinions. -Self-Help Group participant They reported that they lost fear of participating publicly and that they are currently participating more frequently. “Yes, we can participate more easily because now we have lost the fear and the shame of speaking in the community meetings and projects. For example, now we only notify our husbands that we are going to a community meeting or project.” -Self-Help Group participant “Before, we participated very little, now we like to participate in any meeting that there might be, health-related or otherwise, we participate and they value our opinions.” -Self-Help Group participant Logistics and Implementation For the purposes of improvement of the model, interview questions sought to elicit both facilitators and impediments to Care Group implementation. The following themes emerged:

1. Facilitating effects of community leadership and of bridging and bonding social capital;

2. Barriers to attendance and participation along the Care Group cascade; 3. Facilitating and impeding effects of training and teaching methods and

materials used. Bridging and Bonding Social Capital Built The Community Facilitators repeatedly expressed the importance of community leadership support to properly fulfilling their responsibilities. They expressed that some community leaders actively supported the project by alerting the women of the time and place of Care Group and Self Help Group meetings, and that other community leaders gave implicit support to the project. Active support also included information given to the Community Facilitators

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by the community leaders—many of whom were community gatekeepers—to facilitate CBIO vital events data collection. Nearly all Community Facilitators commented upon the importance of community leadership for the success of their program. Support from community leadership also facilitated the empowerment of individual Community Facilitators: It is very easy to be able to participate because now we are very familiar with the leaders, now they can support us, because we value our rights as women. -Community Facilitator In contrast to the Community Facilitators, many Comunicadoras spoke of the importance of the bonding among the women in their Self-Help Groups. They cited the importance of group learning as a method for acquiring information, and building a sense of community among themselves. They also frequently expressed the value of their new relationships with the community leaders. Similar to the Community Facilitators, the women in the Self-Help Groups stressed the importance of community leadership support for their own attendance. They conveyed that they were reminded of date, time, and place by the community leaders. …the community leaders would come house to house to tell us when we would be trained. -Self-Help Group participant …the community leaders would tell us before so that we could organize what we had to do and make time for the trainings. -Self-Help Group participant They also spoke of the importance of group learning, which helped them share experiences with each other, increasing trust and they cited this newfound trust as a fundamental catalyst of their own behavior change. We did not find anything about the trainings to be difficult, because we help ourselves by sharing the information of each of the themes with each other. -Self-Help Group participant Facilitators and barriers to attendance and participation Overall, the Community Facilitators expressed satisfaction with the participation among themselves and the Comunicadoras whom they taught. The most common reason given for attendance at and participation during the Care Groups was the Comunicadoras’ interest in the knowledge itself, for the better care of their children. One CF expressed that the routine home visitations vital to the CBIO method helped increase participation for the Care Groups, because she was able to plan a time that worked for everyone while doing the CBIO domestic visits, and that after the Care Groups she was able to clarify any topics that were unclear at the home visits as well. One CF indicated the importance of trust and relationships among the Comunicadoras and for the CF, which increased participation. The CFs relayed that the greatest challenge of the job to be lack of attendance among the Comunicadoras. Reasons given for lack of participation and attendance included: other obligations including religious obligations and sick family members; lack of time; belief

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among women that they already knew how to take care of their children as mothers; distance necessary to travel for the trainings; and desire for something in return such as money. Many Comunicadoras expressed frustration at the lack of participation among the mothers in Self-Help Groups. For the Comunicadoras, lack of attendance and participation at Self-Help Groups was the most difficult part of their job. They did not mention their own lack of participation, as described by the Community Facilitators. The reasons given by Comunicadoras for lack of participation among Self-Help Group participants included other obligations including church and sick family members; need to work; lack of time; not knowing when trainings would be held; desire for something in exchange (money); boredom during trainings; husbands not letting them; belief that they already knew how to care for their children; and criticism from friends. Sometimes they had other commitments or they had to work for months in another place. These factors impeded the attendance of women. -Community Facilitator …Some women did not attend because their husbands did not let them. Some said that there was no salary. Other women said that they already knew how to care for their children. -Comunicadora Maybe some women did not attend because they had to work in the fields, and others would go to the fincas [large commercial farms hiring manual labor] because they suffer from extreme poverty, and for that reason they could not participate. -Comunicadora Women in the Self-Help Groups expressed frustration with the lack of participation among themselves and their peers. The reasons given included: other obligations in the church; desire for something in exchange (gift or money); lack of knowledge of time and location of Self-Help Groups; desire for more advanced notice to organize their time; distance travelled; migrant laboring; belief that they already knew how to care for their children. …we live in places that are far away and it is difficult for us to arrive at the meeting place; the interest of each mother that attended; sometimes we traveled for several days if we left work; we had other obligations. -Self-Help Group participant Some friends said that they already knew how to care for their children, and others were hoping for a gift in exchange. -Self-Help Group participant Training and Teaching Methods and Materials - Facilitators of Learning and Teaching The Community Facilitators stressed how easy it was to learn the material and to train the women. Generally, they attributed this ease to the project’s system: 1) Educators training the Community Facilitators and—in turn—the CFs would teach the same way to the Comunicadoras, which made teaching easier and more effective; 2) learning through interactive didactics including graphics, illustrations, songs, dramatic enactments and

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practical examples (which they stressed was very important due to the high incidence of illiteracy); 3) teaching Care Groups soon after they themselves received the teaching while the lessons were fresh, to maintain fidelity; 4) receiving a manual for guidance when necessary. Only one Community Facilitator remarked on the importance of any inherent didactic skills of her Educator trainer; rather, each of the other Community Facilitators (including her) stressed the importance of the methods and materials of the lessons themselves. One mentioned the importance of the frequency of her trainings with the Educator, who came to her house every two weeks, to train and to reinforce the knowledge. The materials are effective because of the large drawings so that the mothers understand the topics that we are teaching them better. Because the graphics speak for themselves, and there are women who do not know how to read or write. -Community Facilitator The materials were effective because I learned well, and at the same time I would try to train my groups in the same way, so that they would also be able to understand the knowledge just as well as I did. -Community Facilitator Much like the Community Facilitators, the Comunicadoras expressed the ease of learning and training. They stressed the importance of training the way you teach; of the materials and methods including graphics, posters, dynamic teachings, songs, and one group called for even more graphics; and the importance of it being in their language. How they teach us is the same technique that we apply to teach the women, and it’s the best possible way, using posters, graphics and this way we achieve an understanding of the topics. -Comunicadora Yes, she [the CF] trained us well because she spoke in Chuj [local Maya language] and this is the way that we understand the topics best. -Comunicadora She [the CF] helped us through practical demonstrations of good baskets of food and bad baskets of food; at that time she evaluated whether we could differentiate between [the health effects of] fruits and junk food. The fruits have more vitamins and the junk food is not good because it has no nutrition. -Comunicadora Every Self-Help Group participant interviewed mentioned the importance of the materials and methods, which made things much easier for them to understand. Specifically, they cited the use of dynamic teachings, songs, drawings, and graphics to increase interest and circumvent illiteracy. Many wanted posters and graphics to take home. Additionally, one group stressed the importance of the round-table technique.

Yes, (they were effective), they were a lot of help because we are illiterate and the technique of using illustrations was very effective.

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…because the themes interested us, because we realized that it prevented a lot of illness, and the way that we were trained was very interesting.

Yes, the training materials were effective, because we learned what we should give our children to drink. When we breastfeed our children we have to do it for a half hour—they taught us this with drawings. All of the materials were good and because of them we understood well how we to take care of our children. -Self-Help Group participants Training and Teaching Methods and Materials - Impediments to Learning and Teaching In general, most of the complaints were about attendance (their own), and that they want trainings on more topics, using the same methods. The method that we used was good, the only thing that could improve would be if new topics were taught using the same methods. -Comunicadora Additionally, some Self-Help Group participants desired more drawings and more pictures to help them understand. Several responses indicated a desire to take materials home—drawings and pictures—to better understand the material and to be able to practice the knowledge more easily. …if it would be possible to give the graphics to each of us so that we would be able to review in our houses. -Self-Help Group Participant Additionally, the Comunicadoras and Self-Help Group women in one community wanted the materials to be laminated, so that they would be more durable. Increase them, laminate them, cover them in nylon so that they last longer, and so that they help us in the talks/topics. -Self-Help Group Participant Integration of the CBIO Methodology with the Care Group Methodology for vital events surveillance The Community Facilitators and Comunicadoras reported several benefits and some difficulties of combining the two methodologies. Two of the Community Facilitators indicated that the combining of CBIO with the Care Group methodology strengthened both methodologies: The communication that I have with the Comunicadoras and the mothers, and also the community leaders bring information and this way I am able to record vital events. -Community Facilitator Additionally, one Community Facilitator indicated the importance of the Comunicadoras in helping her to collect the vital events. The Community Facilitators all expressed the ease of learning to capture the vital events through the interactive, graphic learning from the Educator, and none expressed difficulties in learning to capture vital events data

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Lots of training that the Educator gave me, like how to classify each vital event and also because we trained with physical materials (formats). Also it was easy because I was very passionate about the job, and so I was very interested and strived to learn fast. -Community Facilitator Additionally, the Comunicadoras stressed the importance of the networks built from Comunicadoras to the Self Help Group women, and from Comunicadoras to CFs, for the continuous relaying of information up the Care Group cascade. While most Community Facilitators believed that recording the vital events was fairly easy—learning to do it and also in practice—some difficulties were mentioned, which included difficulty traveling to the homes of the women; difficulty finding the homes of the women; poor training from the Educator on data collection and desire that the Educator receive more training; and some trouble eliciting sensitive information from the women. …some women were embarrassed to be pregnant so they do not tell me when I ask them, they are afraid because they lack education. -Community Facilitator Recommendations for Improvements Each of the women interviewed were asked for recommendations to improve specific aspects of the Care Groups as well as for recommendations to improve the methodology in general. The recommendations related to 1) the training materials, 2) the amount or frequency of trainings, and 3) miscellaneous recommendations. Regarding Training Materials Every CF asked for more materials so that they could train better. Additionally, many asked for more drawings, more illustrations within those materials. Several asked for more manuals, guides, and texts in order to guide their training better, as well. Several also asked for more materials to give away to their Comunicadoras. In agreement with the Community Facilitators, the Comunicadoras wanted more drawings and more graphics, as well as larger graphics. Many also desired that they give away materials, including posters, graphics, but also literature—because while most cannot read, their children can, as nearly all of their children go to primary school now. One expressed a desired for laminated materials for more durability. …if they gave us posters to see and remember the themes/topics that we have learned, or books. Although we cannot read, we have children who can read. -Comunicadoras Similarly, many Self-Help Group participants asked for more materials, with more graphics. Several also asked for the Comunicadoras to give away materials that they could take home to review in their homes. One suggested laminated materials, presumably for durability.

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Several suggested improved materials, but the only improvements mentioned were more graphics. Regarding the Number and Frequency of Trainings Many of the Community Facilitators wanted more trainings on new topics. They wanted to learn more. One specifically suggested new topics that would focus upon the health of women. Several also indicate that they want more and more frequent trainings with their Comunicadoras in order to reinforce the learning. One suggested that her Educator receive more training to reinforce her knowledge. Another suggested that they include young people in the groups to share knowledge, thus expanding the groups. Most Comunicadoras wanted more trainings for new knowledge; most also wanted more training for the reinforcement of their own knowledge. Several suggested the expansion of the program to include all community mothers [rather than targeting only women with under-5 children]. One Care Group of Comunicadoras suggested the expansion of the program to form youth groups, children’s groups, more women’s groups, and men’s groups. Another Comunicadora Care Group suggested that adding trainings on new subjects would prevent attrition in the groups. Several groups lamented that the group meetings were not frequent enough, that they would prefer more frequency to reinforce their knowledge. One group of Comunicadoras wanted more trainings on subjects related to women’s health. Among the Self-Help Group participants, most women wanted more trainings for reinforcement of existing knowledge. Some also suggested more training on new topics. One suggested more inclusion of young people and more women, and more topics on women’s health. Invite the women, the young people, regardless of age so that they could be informed. Include topics about women’s health. -Self-Help Group Participant Miscellaneous Recommendations These recommendations were expressed by only one or two individuals. Among the Community Facilitators, one suggested that the Educator meet more frequently with the communities so that it would be easier for her to collect the vital events, through a better understanding of the locations of more mobile residents. One Community Facilitator desired that the Care Groups be more binding in order to prevent drop out. Common to several women in the Self-Help Groups, Comunicadoras, and one Community Facilitator was a desire that Curamericas Guatemala dispense more medicine. According to one woman in the Self-Help Group, this would increase interaction with the training cascade and informal health system:

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…[may] there be medicines in the Health Center [local Ministry of Health clinic], because when we visit the Center they only prescribe them to buy in the pharmacies and if it stays like this, it’s better not to visit the Center at all because sometimes there are no medicines. -Self-Help Group Participant V. Discussion Changing health beliefs The inhabitants of the highlands of Guatemala represent a population frequently deficient in both financial capital and traditional education. Therefore, while significant external barriers to behavior change certainly exist, much opportunity for alteration of behaviors through health education and belief modification in the highlands is possible as well, and a frequent theme that resulted from the interviews with the Community Facilitators, Comunicadoras, and Self-Help Group participants was the extent to which individual health beliefs were altered, healthy practices became preferred, and demand for health services was created. Community Facilitators, Comunicadoras, and Self-Help Group participants all reported a very positive attitude toward the project and of their participation in the project, and many interviewees spontaneously expressed a desire for the project to continue. The primary reasons given for this opinion of the project were direct observation of improvements in health in their own families, selves, and communities; the personal purpose and trust of community members gained through the project; and the inherent value of the knowledge gained. Perceived susceptibility to illness and severity of illness existed prior to project implementation due to first-hand experience of the effects of untreated illness in children and pregnant women, and the project needed only to convince of the benefits of behavior change, and the ability of the women to do so. According to the Health Belief Model, beliefs about susceptibility to risk and efficacy of behaviors help catalyze behavior change. Therefore, in order to change behavior, the project had to teach the women effectively, and to increase their agency to use those teachings to better their health and that of their family. The interviews revealed the success of the CBIO+Care Group approach in accomplishing this behavior change. While nearly all interviewees focused upon the importance of understanding the effectiveness of behavior change and the risks of unchanged behavior for the alteration of their own behaviors related to health, the understanding of the etiological relationships between certain behaviors and health was significantly less detailed among women in the Self-Help Groups when compared to the Comunicadoras and Community Facilitators. Nevertheless, a clear correlation existed in the minds of the Self-Help Group participants between behavior change and increased personal and familial health due to their direct observation of the health benefits of the new behaviors on their own and their children’s health. Change was particularly effective for behaviors focused upon prevention of illness, behaviors which are frequently inexpensive to practice and easily adopted, and new beliefs about the importance of changing behavior was the greatest influence upon behavior change.

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The importance of rapid, apparent results seemed to be the most important factor for the continued engagement of individuals and communities in the project. Poor attendance at the Care Groups and Self-Help Groups was cited as the greatest impediment to health behavior change, and the project may have been able to increase attendance through greater dissemination of the health improvements achieved by the project to individual community members and to community gatekeepers, as those results became available. The women in the Self-Help Groups reported changes in behaviors related to pregnancy and birth, family hygiene, responses to child illness, and nutrition. Community Facilitators and Comunicadoras spoke about family planning, while women in the Self-Help Groups did not. No differences in reported behavior changes could be noted between Phase 1 and Phase 2 communities, or between municipalities. Many women expressed that the greatest factor that led to participation among Self-Help Group participants was the significance of the knowledge they were learning as evidenced by improvements to community and individual health. Indeed, exposure to and remembrance of the education imparted may be the primary predictors of behavior change and alterations to the protocol to increase those two factors may increase behavior change. Among both Comunicadoras and women in the Self-Help Groups, the primary impediment to behavior change was likely lack of attendance, due primarily to factors external to the women themselves, including disapproving husbands and financial opportunity cost of attendance. Empowerment The Care Group cascade frequently increased the social status of its participants. Improved social status resulted primarily from a newfound respect and power in the community that resulted from greater knowledge. Self-Help Group participants experienced increased social status due to community perceptions of them as health advisors, while Community Facilitators and Comunicadoras experienced increased social status due to community perceptions of them as health advisors and leaders. The Self-Help Group participants reported an increased sense of self-worth, which resulted in greater community participation, and all experienced greater power in their own homes. To a lesser extent, increased economic status resulted from savings achieved through the enactment of that knowledge. Increased savings may then translate to greater control over one’s health and health habits, weakening the cycle of poverty and illness. These benefits were most prominent among Community Facilitators and Comunicadoras. Reports of increased decision-making autonomy among the Care Group cascade participants can be separated into two categories: 1) increased self-efficacy and increased confidence in one’s own decision (internal ability to make decision); and 2) reduction of external barriers to decision-making (e.g. negative influence of husband or mother-in-law). The Care Groups seemed both to increase the extent to which participation of the Care Group cascade members was welcomed at community meetings, and to increased agency and ability in personal and public life. Thus, participants were now capable of making decisions and they were able act upon them as well. Both factors resulted in increased decision-making autonomy among Care Group cascade members. Presumably, increased participation of women in community affairs

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will result in more community projects and decisions that benefit women directly, who are a substantially marginalized population. Every interview group reported increased self-efficacy as evidenced by increased confidence in their importance in the Care Group cascade. Many Care Group cascade participants spoke of the importance of the knowledge that they have received for their own confidence in their decisions, and their ability to make those decisions publicly. Their confidence to speak their mind publicly and to participate in community decisions has increased, and their dependence on their husbands for personal decisions has decreased. That reduction in fear of public assertion also extended to the women in the Self-Help Groups, even though they were not charged with educating other members or with public teaching. Those women shared everything with each other in the Self Help Groups, and it may be an effect of group learning as well as the material that was taught. Logistical Implementation Vital to the empowerment of disempowered groups is the creation of social capital. Bonding social capital refers to the creation of social networks between socially homogeneous groups; bridging social capital refers to the creation of social networks between socially heterogeneous or hierarchal groups. Therefore, bonding social capital may result in increased organization, consensus, and resolve within a disempowered groups, while bridging capital may result in the ability to establish alliances and use organization to effect change. Both types of capital were fostered by the Care Group cascade according to the women interviewed. While participants at all levels of the Care Group cascade stressed the importance of both bridging and bonding capital for the success of the program, the Community Facilitators and the Self-Help Group women emphasized the role of bridging social capital with community leadership for logistical and theoretical support of the program, while the Comunicadoras and the Self-Help Group women spoke of bonding social capital through the benefits of group learning and trust built among the participants themselves for successful behavior change. New relationships of Community Facilitators with community leadership increased their social standing and confidence in their own ability to effect change in their community. New relationships among Comunicadoras and Self-Help Group participants made working through the didactic material easier and more enjoyable, and improved understanding of that material. Essential to Self-Help Group participation was the bridging social capital of community leadership and community buy-in. Community Facilitators, Comunicadoras and Self-Help Group participants all emphasized the role of existing community leaders—including those that were not directly affiliated with the Care Group cascade—in facilitating attendance and community buy-in. Community leaders were reported to alert Care Group and Self-Help Group members of upcoming meeting places and times, which was particularly important because of the prevalence of illiteracy among Care Group cascade members, who could not rely on written reminders.

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Training and Training Materials Each person interviewed related the importance of the materials and the methods, and only one CF mentioned inherent qualities of her teacher (the Educator). A key finding is that the model as implemented does not rely on skilled trainers per se but rather on a highly effective training methodology and curriculum based on solid pedagogy. Fidelity of the educational cascade was maintained through a commitment to training in the same way that one learned the material, and very shortly after learning it. Many Community Facilitators expressed a desire for a formal teaching manual, although they also expressed that they had very little difficulty imparting their new knowledge without manuals. When questioned about the materials, Community Facilitators, Comunicadoras and Self-Help Group participants rarely mentioned personal qualities or individual talents of their trainers. Rather, they focused upon the materials and the methods of the teachings, suggesting their reproducibility in communities in disparate countries. Because few doctors live and practice in the area, and because so many languages are spoken there, an American-style health dissemination from doctor to patient would be very difficult. Most of the Self-Help Group women only spoke Maya, and nearly all Community Facilitators, Comunicadoras, and Self-Help Group women were more comfortable speaking their native Maya languages than Spanish. They also spoke of the importance of dynamic, engaging, and graphical lessons, as many of the women were entirely unaccustomed to traditional didactic education. This engagement increased retention of knowledge and behavior change. Nearly all those interviewed believed that they were trained well and that—in the case of CFs and Comunicadoras—they trained their groups well. There were very few difficulties with the material itself, rather attendance and participation were the impediments to behavior change. While the medium through which the health information was communicated was intentionally tailored for an illiterate audience, unaccustomed to traditional lectures and classrooms, the information itself was scientifically accurate, and the women frequently reported their behavior change to result from a newfound understanding of the reasons for health behaviors, including germ theory, basic understanding of obstetrical complications, and key principles of nutrition and sanitation. This was particularly true of Community Facilitators and Comunicadoras, but women in the Self-Help Groups also conveyed basic knowledge of the mechanisms of disease etiology and prevention. While the academic level of the teachings frequently surpassed that which would be deemed necessary for a person without a medical background in a wealthier country, the women involved in the Care Group cascade frequently expressed that they desired more such teachings; that they were capable and willing to learn in even greater breadth and depth than received during the project. Another key findings is that most important to many of the participants interviewed was that the information imparted, when applied to behavior change, produced clear and tangible health benefits in their own households and in their communities. CBIO+Care Group Methodology Synergy According to the informants, it was easier to record vital events because of relationship between CFs and Comunicadoras built through the Care Groups. This was achieved through trust and through relationships built between the CFs, Comunicadoras, and the community

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(including the Self-Help Group participants) through the interactions during the Care Groups and the practice of gathering and recording vital events. Sustainability The project relied upon primarily volunteer female labor from local communities, reducing cost and resulting in utility, increased education, and empowerment of local women. Rather than dependency, the incorporation of the Care Group model fostered sustainability and self-efficacy, as local women of varying social stature and education, now possessed useful knowledge about health and the confidence to translate that knowledge into healthy behaviors. As evidenced by the interviews, Community Facilitators, Comunicadoras, and women in the Self-Help Groups each now view the health of their communities as their responsibility, and they now possess the knowledge and agency to translate that knowledge into improved community health. To the extent to which changes in women’s empowerment can be considered to be sustainable, this may change context and norms within the community, including reduction of machismo. Each of the health behavior changes adopted can also change the norms of the community. Additionally, social capital building likely will result in tangible capacity-building in the future as well. Regarding practical health delivery, the Community Facilitators and Comunicadoras can now advise families on the need to use local health facilities for maternal or child healthcare, and FCs can potentially provide basic treatment and/or referrals, saving lives, time, and money for the community. This capacity is unlikely to disappear after the termination of the project. Additionally, the Comunicadoras expressed that long-held incorrect notions and practices about health had been broken, and they relayed that the children in the community now practice correct habits, indicating a lasting change in the health of the community, as the children were never directly trained, but rather taught by their participating mothers. The training cascade did not end with the Self-Help Group women, but continued to their children. Health Equity Regarding equity of delivery of health services and healthy behavior change, it is possible that this project was unable to reach the most vulnerable populations. The project was community-based and implemented a vast number of female volunteers, ensuring large distribution throughout the targeted communities. Still, significant room for improvement existed, as suggested by the interview responses. Common reasons for lack of participation in the Self-Help Groups were financial and social. Some women were reported to have to work, either in their own communities or as migrant labor, and therefore could not attend the Self-Help Group meetings. Other women were reported to be disallowed from attending by their husbands. Therefore, it is possible that the project was unable to include the community’s most marginalized women: the poorest and those most affected by male dominance. VI. Conclusion Machismo, poverty, and lack of formal education each contribute to the inability of many female indigenous highland inhabitants to make their own decisions regarding their own health and that of their family. The Child Survival Project used a volunteer workforce nearly

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entirely comprised of women. As evidenced by the results, the education of women about their own health gave them the confidence to make their own decisions. It also increased their bridging and bonding capital, resulting in individual empowerment on a large scale, which allowed them the freedom to make those decisions. Some women experienced decreased poverty due to a reduction in the costs associated with illness in their family, which allowed them greater freedom to make their own decisions in the future. Through the project, many women gained powerful allies in their community and are now participating in community events and meetings. This newfound involvement should result in the introduction of more services tailored to their own interests. Therefore, individual education and group participation have decreased the effects of male dominance on both personal and public stages, effectively changing the context in communities in which the maternal and child health project worked. Women reported increased self-efficacy and increased agency to make their own decisions, resulting in healthy behavior changes at each of the three levels of the Care Group cascade that were evaluated. Increased empowerment and ability to make one’s own decisions resulted from the power of the position for Community Facilitators and Comunicadoras. Self-Help Group participants also experienced increased decision-making autonomy, but they were more likely to attribute their empowerment to notions of self-worth gained from the teachings themselves. Therefore, through the CBIO+Care Group model, women were empowered through their place in the model, through the education that they received, and through social bridging and bonding social capital built through the process. VII. Limitations This study possessed several limitations. Although steps were taken to include representative Care Groups and Self-Help Groups, as an interview-based qualitative study, the limited number of groups chosen may not have been representative of the entire project area. Additionally, it is possible that the group interview format of Care Groups and Self-Help Groups led to some bias, in that certain group members were discouraged from speaking their minds or were influenced by previous responses. Additionally, only Care Group cascade participants were interviewed, and it is likely that more insights would have been gained by interviewing non-participants (e.g., husbands, mothers-in-law, community leaders). The interview questions themselves were translated twice: from English to Spanish, then from Spanish to three Maya languages. Again, the interview responses were translated during the transcription of the interviews from the Mayan languages to Spanish, and then from Spanish to English. Each translation occurred in a group format to increase fidelity of meaning, but it is likely that some meaning was lost in translation. Finally, themes were elucidated by an individual researcher, and more themes may have been discovered if the responses were analyzed by a team of researchers.

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VIII. Recommendations Several lessons were learned from this study, which can be used to improve the Curamericas Guatemala project and to guide other health projects in the future. 1) Use testimonials to disseminate the results early CFs, Comunicadoras, and Self-Help Group women routinely viewed lack of attendance as the greatest impediment to behavior change, and they cited the inherent health benefits of the project as the most important reason for attendance. Therefore, greater and earlier publication of results within the communities themselves, aimed at the most vulnerable populations, may increase attendance and effect greater behavior change. One method may be personal testimonials of Self-Help Group participants at community meetings or during home visitations. 2) Enlist trusted members of the community as CFs and Comunicadoras While the value of the information itself resulted in continued participation in the Care Group cascade, respect for those disseminating the knowledge was essential to gain initial support among community mothers. Additionally, respected members of the community were more likely to have existing relationships with community leaders, who would prove essential in reminder the women in the Self-Help Groups of the times and locations of upcoming sessions. 3) Respect the capacity of participants to understand scientific rationale of their behaviors Most of the CFs and the Comunicadoras, and many of the women in the Self-Help Groups, spoke of the importance of understanding the rationale behind their behavior changes. They learned essentials of germ theory, nutrition, and the science of vaccination and pregnancy. The Care Group cascade participants possessed very little formal education, often none at all, and all cited the importance of reasonable explanation. No women believed that they were incapable of understanding the lessons, and few women asked for lessons to be reinforced. In fact, the women frequently expressed that the education gained was both practical and empowering, giving them confidence in their decisions and actions both related and unrelated to health. 4) Gain the support of community leadership Community leadership both increased the attendance at the Self-Help Groups, and increased the social status of those who participated. The new familiarity of the participating women with community leadership may make it easier to bring future health projects to the community, particularly those focused upon women and child health, and may serve as a method to empower impoverished women. It will also ensure community buy-in.

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5) Provide Community Facilitators with a manual This may be difficult in areas in which literacy is low, but CFs are all literate as a requirement of their role, and providing a manual for CFs would increase recollection and fidelity of teachings. The manual can be graphical or textual. 6) Provide Comunicadoras and women in Self-Help Groups with graphics to take home Similar to the CFs, many Care Group and Self-Help Group members expressed a desire for reminders to take home. This would increase behavior change and sustainability of behavior change upon conclusion of the project. Many emphasized that while perhaps they were illiterate, they had children who could read. Written material can also be used due to increasing literacy among family members in project areas. 7) Specifically teach about female empowerment and self-worth If machismo or male chauvinism impedes female agency, specifically teach about the value of women and practice making decisions during Care Groups and Self-Help Groups. 8) Continue to use engaging, graphical, and dramatic teaching methods Many of the Care Group cascade participants had no formal education and were unaccustomed to traditional didactic teaching methods. They reported that they learned best through role-playing, songs, and group discussion, and that these methods resulted in the greatest behavior change. 9) Customize the Care Groups to the capacity of the participants Community Facilitators and Comunicadoras can be taught to evaluate the knowledge gained by each participant, and to tailor the teaching accordingly. Some women in the Self-Help Groups expressed that they stopped attending because they were not learning new material. Some women expressed that they would have preferred to relearn some topics because they needed reinforcement. The curriculum of Self-Help Groups should be flexible and tailored to the progress of the individuals in each group. In addition, those with a quicker grasp of the material can be enlisted to teach their peers, further empowering them as teachers. 10) Include the most vulnerable The Care Group cascade is intended to include every reproductive age woman to affect behavior change. The greatest impediment to behavior change was attendance at the Self-Help Groups, and group members frequently cited the need to work or disapproving husbands as reasons for absence. Therefore the poorest and the least empowered may be left out of the Care Group cascade. It is possible that the female empowerment and health education from the cascade may change the community context, and in so doing indirectly

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benefit the most vulnerable, but large efforts should be made to achieve total participation of the community, in order to create the greatest behavior change. 11) Continue to combine CBIO and Care Groups Care Groups represent a method to gather comprehensive health data about a community cheaply and sustainably. They also allow health and health education providers to directly target the greatest epidemiological threats to health identified through the data collection. As the data gatherers are community members themselves, more data and more timely data can be gathered about the births, deaths, pregnancies, and morbidity within a community. The act of door-to-door data collection also builds trust between Community Facilitators, Comunicadoras, and community members, which lends more weight to the knowledge provided through Self-Help Groups, and which ultimately results in greater behavior change. 12) Leverage the new status of the participants The Care Group cascade resulted in increased social status of its participants, and that new status can be leveraged to place the FCs and Comunicadoras into greater leadership positions within the cascade or their communities. They could also be trained to deliver health services, in a role similar to community health workers. Their place in the Care Group cascade could be replaced by other women, and in this way a glass ceiling within the organization would be prevented, and continuous organizational and personal growth facilitated. 13) Expand Care Groups to include new classes of participants Participants frequently expressed their desire that Care Groups be expanded to include women of non-reproductive age, children, and men. Care Groups could target specific subsets of the population to teach essential health knowledge and practices, in order to have a broader impact.

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Annex A – Interview Questions

Interview Guide Questions

For the CFs

1. Tell me what you do as an CF. a. What do you like about it? b. What don’t you like about it? c. What would make your work as a CF easier and more effective?

2. How effective do you think you were training the Comunicadoras to teach life-saving knowledge and to get women in the SHGs to change their behavior?

a. What helped you be an effective teacher? b. What made the teaching difficult? c. How could you have taught them better?

3. How well did the Educators train you to record and communicate vital events? a. What facilitated your ability to record and communicate vital events? b. What made it difficult? c. What could have made it easier to record and communicate the vital events?

4. How effective do you think the Educator was at teaching you life-saving knowledge and at teaching you to teach the Comunicadoras?

a. What helped her be an effective teacher? b. What made the teaching difficult? c. How could she have taught you better?

5. How effective were the training materials you were provided? a. How could the training materials be improved?

6. What behavior changes have you noticed in the Comunicadoras? a. What behavior changes that you wanted to see did not happen? b. What do you think helped the Comunicadoras change their behavior?

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c. What do you think prevented the Comunicadoras from changing their behavior? 7. Do you feel that you have more or less control over your life now compared to before you were a

CF? Please elaborate. a. Do you have more or less control over your own decisions now? b. Has your status in the community changed at all? c. Do you think that you could participate more easily in community meetings and projects?

Explain. 8. What do you think made it easy for the Comunicadoras to keep attending and participating in the

Care Groups? a. What do you think made it difficult for them? b. What improvements could be made to keep the Comunicadoras more interested and

engaged? 9. What recommendations do you have for improving the Care Groups and the SHGs?

For the Comunicadoras

1. Tell me what you do as a Comunicadora a. What do you like about it? b. What don’t you like about it? c. What would make your work as a Comunicadora easier and more effective?

2. How effective do you think you were training the SHGs to teach life-saving knowledge and to change their behavior?

a. What helped you be an effective teacher? b. What made the teaching difficult? c. How could you have taught them better?

3. How well did the Community Facilitators train you to record and communicate vital events? a. What facilitated your ability to record and communicate vital events? b. What made it difficult? c. What could have made it easier to record and communicate the vital events?

4. How effective do you think the CF was at teaching you life-saving knowledge and at teaching you to teach the SHGs?

a. What helped her be an effective teacher? b. What made the teaching difficult? c. How could she have taught you better?

5. How effective were the training materials you were provided? a. How could the training materials be improved?

6. What behavior changes have you noticed in the SHG women? a. What behavior changes you wanted to see did not happen? b. What do you think helped the SHG women change their behavior? c. What do you think prevented the SHG women from changing their behavior?

7. Do you feel that you have more or less control over your life now compared to before you were a Comunicadora? Please elaborate.

a. Do you have more or less control over your own decisions now? b. Has your status in the community changed at all? c. Do you think that you could participate more or less easily in community meetings and

projects? Explain. 8. What do you think made it easy for the SHG women to keep attending and participating in the Self-

Help Groups? a. What do you think made it difficult for them? b. What improvements could be made to keep the SHG women more interested and engaged?

9. What recommendations do you have for improving the Care Groups and the SHGs?

For the Self-Help Groups

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1. Tell me what you do in the SHG. a. What do you like about the SHG? b. What don’t you like about it?

2. How effective do you think the Comunicadora was at teaching you life-saving knowledge? a. What helped her be an effective teacher? b. What made the teaching difficult? c. How could she have taught you better?

3. How effective were the training materials used? a. How could the training materials be improved?

4. What behavior changes have you noticed in yourself and each other? a. What helped you change your behavior? b. What made it difficult?

5. Do you feel that you have more or less control over your life now compared to before you participated in the SHG? Please elaborate.

a. Do you have more or less control over your own decisions now? b. Has your status in the community changed at all? c. Do you think that you could participate more or less easily in community meetings and

projects? Explain. 6. What things made it easy for you to come to and participate in the SHGs?

a. What things made it difficult to come to and participate in the SHGs? 7. What recommendations do you have to improve the SHGs?