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A forum to connect and share resources, strategies, and innovations collectively so we can go global with Group Care through implementation, scale up, and integration into health systems.
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Evaluation report
The objective of this report is to provide an overview of the evaluation findings from the GC_1000 project, involving seven countries: Belgium, Ghana, the Netherlands, Kosovo, Suriname, South Africa, and the United Kingdom.
A realist evaluation design was used to synthesise findings from data gathered and analysed at each stage of the programme, through from the situational analysis and adaptation plans, the implementation process, fidelity and experience and impact. Using mixed methods, the evaluation examines these different dimensions from a range of perspectives, to explore and understand how group care, as a complex, person-centred intervention was implemented and experienced in these diverse settings.
We report on the barriers and facilitators experienced, the ways in which group care was adapted and provided in each country, and the experiences of both providers and care participants. Analysis of contextual influences was guided by the Consolidated Framework for Implementation Research; fidelity was examined with reference to two published conceptual models for group care and experiences were mapped onto a framework of mechanisms of effect derived from the literature to illuminate how group care achieves beneficial outcomes and to understand whether these mechanisms were found across all country contexts.
Finally, the costs of providing group care in each country were calculated and their implications for scale-up and sustainability were considered.
The strengths and limitations of this evaluation are discussed and the findings considered in the light of the wider published literature. Indications for further research and development are also provided.
Lessons Learned
The objective of the report is to synthesize lessons from the GC_1000 project, in which Centering-based Group Care was successfully adopted and implemented in seven countries, including Belgium, Ghana, the Netherlands, Kosovo, Suriname, South Africa, and the United Kingdom. The lessons reflect the complexities of adopting and adapting Centering-based Group Care in diverse settings and provide information regarding the impact of socio-cultural, economic, and infrastructural factors that impact implementation. Insights drawn from the Consolidated Framework for Implementation Research (CFIR) emphasize the critical role of committed personnel, leadership, community engagement, cultural sensitivity and the support of policymakers and all levels of staff in organizations for the successful implementation of Centering-based Group Care.
Throughout the report, there is a focus on the challenges encountered during the implementation process and how they were overcome. These can serve as valuable guidance for preventing similar obstacles that can be encountered in future implementations of the model in new sites and countries. The lessons learnt serve as recommendations on how to address these challenges and ensure adoption and implementation. Lessons include issues related to capacity building of healthcare providers for this model, engaging stakeholders, securing policy support, and addressing financial and any context or site-specific challenges.
Adaptating the model to the local context
At the start of the Group Care 1000 project, we conducted context analyses to gain in-depth understanding of the implementation context of the participating sites. This way, anticipated challenges occurring in all participating implementation sites were identified and structured in the Anticipated Challenges Framework. Two of these anticipated challenges were highlighted: how to operationalize the health assessment within Group Care, and how to schedule Group Care within the regular care. Therefore, the adaptation process of these two challenges was analysed and mapped using the Framework for Adaptations and Modifications to Evidence-based Interventions-Expanded (FRAME). Recurrent adaptation strategies were found, with mainly adaptations in the context or implementation strategies, and only minor changes to the model itself. Both planned and unplanned adaptations occurred, both rather early in the implementation process. It were mainly joint decisions to adapt, with typically the facilitators and the management at the site involved. The adaptations aimed to optimize Group Care for participants and facilitators, and were influenced more by the healthcare organization than the socioeconomic situation of a site. Creative solutions were found for space and scheduling constraints, demonstrating flexibility in various cultural and policy contexts. Good practices are described, such as adapting the booking system to optimize enrolment and evaluation. To ensure sustainable implementation, the participating implementation sites focused on aligning the Group Care implementation with the local and national policies.
The analysis of the adaptation process underscores the value of collaboration and learning from different healthcare systems to overcome challenges and achieve a sustainable implementation of Group Care.
Group Care Implementation Modules available!
Are you curious about what Group Care is and how it can work in your health system? Are you ready to embark on implementing Group Care in your setting and health system? If the answer to either of these questions is, “yes”, this comprehensive set of modules can support you in your process.
https://groupcare.global/group-care-implementation-modules/en/
SUMMARY PROJECT PROGRESS 2021
GC_1000 GROUP CARE FOR THE FIRST 1000 DAYS
If it takes a village to raise a child, group care is the first step
This project focuses on in-depth understanding and a systematic development of acceptable, feasible and sustainable strategies to integrate group care into health systems for antenatal and postnatal care during the first 1000 days. Group care is evidence-based, transforms the delivery of maternal, newborn and child health care, reduces inequities in services utilization, improves the quality of services and makes a significant positive impact on the health and wellbeing of mothers, families and children. No evidence-based guidelines exist for health systems to establish and sustain this transformative model. Care in a group changes the user(s)-provider experience, encourages self-care, is empowering and enables end-users to learn to increase healthy behaviours for themselves and for their children. It breaks the vicious circle of poor quality and inadequate utilization of services by offering comprehensive antenatal and postnatal care that meets the needs of the end users, care providers and health systems by combining quality clinical care with health promotion and health information activities. The European funded project GC_1000 included demonstration sites in 4 low- and middle-income countries, as well as in 3 high-income countries in settings that serve the most vulnerable women and girls. GC_1000 will deliver group antenatal and postnatal care. The three aims of this project are:
- Implement group antenatal and postnatal care in selected demonstration sites in collaborative ways that set the groundwork for sustained service delivery and possibilities for scaling- up;
- Analyse within country data that emerge from the implementation process to create country-specific blueprints for scale-up.
- Use cross-country synthesis to develop a global implementation strategy toolbox for the adaptation, implementation and scale up of facilitated group care within the first 1000 days, particularly to reach the most vulnerable groups of women and girls globally.
What happened so far?
During the first 18 months of the project all necessary actions were undertaken within the consortium, countries, and the work packages to prepare the achievement of the three aims of the project. Second, the infrastructure for an effective operating, accessible and outreaching consortium was developed and implemented.
To achieve the first aim the country leads of the Netherlands, Belgium, Suriname, Kosovo, Ghana, South Africa and United Kingdom, in collaboration with Work Package (WP) 2 and 3 teams, have set up stakeholders' engagement groups and country teams that will advise, co-create and implement group care, which will support all WP’s.
The WP2 team developed a research protocol and carried out rapid qualitative inquiries (RQI) in prenatal settings in six of the seven countries (276 interviews in total) to provide evidence, contextual relevant information, and recommendations for country and site-specific adaptions of the content, delivery, and implementation strategies of existing models of group-based care. This will support the successful implementation of group-based care during the first 1000 days.
The WP3 team contributed to the RQI’s in the countries. RQI's were structured according to the Consolidated Framework for Implementation Research (CFIR framework). After performing a RQI, a preliminary analysis of the results was conducted and fed back to each country team and the WP4 team. Adaptations will be further structured at the level of surface adaptations, deep structure adaptations and cultural adaptations during an in-depth analysis planned for the next period.
To further prepare implementation and training per site in each country, the WP4 team designed a learning process focussing on 12 online modules. Additionally, Simavi developed training modules for health workers in Ghana to use the Check2Gether diagnostic tool. For the training of healthcare providers at sites both asynchronous materials focusing on model start-up and implementation as well as synchronous materials (live and in real time) focusing on the training curricula (both in-person and virtual options) were developed. At this moment, care providers in 13 sites have been trained.
To achieve the second aim the WP5 team together with the WP2, 3 and 4 teams developed a research protocol for the collection of existing data in the participating countries. Data collection tools were refined and adapted after feedback from all countries - and available for local researchers and the WP5 team to evaluate the implementation in each country and site context. Data collection procedures are designed to match specific country/site ethics requirements and context.
To achieve the third aim the WP6 team focused on the development of a conceptual framework to support and structure the contents of the work package, the country-specific blueprints and an implementation toolbox for implementation and scale-up. For this the literature needed to be reviewed, and three systematic reviews are being undertaken: lessons learnt, clinical outcome effects, and maternal satisfaction of perinatal group care.
In WP1 activities were undertaken to streamline, coordinate and monitor all the activities in the work packages and countries. A kick-off meeting (live), General Assembly (GA) meeting (online) and 2 Board meetings (online) as well as monthly telephone conferences were held. An Advisory Board was installed and members participated in two meetings. To strengthen external contacts an affiliation with the Group Antenatal Care Collaborative was started and a meeting with the other 4 related EU projects was held.
Within WP7 the aim, process, and findings of this project are communicated with the public by setting up a website, and regular feeding into a variety of social media channels initiated by GC-1000. Furthermore, a short, animated video highlighting this project has been finalized and will be launched September 2021.
Overall, it can be concluded that, despite the challenges caused by Covid, most of the planned preparative work during this first 18-month period has been executed. We experienced some delays due to Covid but we still anticipate finalizing the project in time, under the assumption of a status quo or decline of the Covid pandemic.
Expected impact of GC_1000
Antenatal and postnatal care services need to undergo transformation to provide quality care ensuring that women, babies, and families thrive as well as survive during pregnancy and following childbirth.
Transition from a traditional model of service provision (provider-to-user) to group care has been shown to improve the uptake of services, reducing the inequities in access and appropriate use. The integrated model of clinical health assessment combined with facilitated discussion for health information and promotion addresses good maternal and child health more comprehensively and contributes to short-and-long term health gains for mothers and babies that during the first 1000 days. It adds to quality care and a shift from medical based care to a medical-and-value based model that centres on the recipient of care achieving positive health, wellbeing, and development.
Addressing the specific needs of vulnerable groups of pregnant migrants, ethnic minorities, and adolescents (including burden of disease, social, economic, and educational status and values and norms) tackles the higher threshold to appropriate use of services and poorer health outcomes in these groups.
Virtual learning modules developed by Group Care Global and CAI Global
In 2020, Group Care Global (GCG), together with partners in seven countries, launched GC_1000. GCG's main role in GC_1000 is to lead Work Package 4 (WP4) to guide and support timely implementation and sustaining of specific group care protocols (antenatal, postnatal+) in demonstration sites in seven countries. Even before the COVID-19 pandemic hit the world, GCG knew that the only way to have consistent global reach would be to use virtual learning as one core way to provide initial orientation to the group care model. With the pandemic, virtual platforms have become a standard way for people to meet, learn, and interact. Our work in GC_1000 is no different.
To develop the virtual modules, GCG partnered with CAI Global, a diverse, mission-driven nonprofit organization dedicated to improving the quality of health care and social services delivered to marginalized populations worldwide. The modules are linked with GCG's Site Implementation Guide and serve as a partner's first step towards model
implementation. GCG Consultants partner with country lead and health care sites to then offer training and ongoing support to site staff so that implementation proceeds smoothly. GCG and CAI developed 12 interactive online learning modules, The learning modules and accompanying training videos are designed to meet the needs of learners around the world as they implement Centering-based group care in their communities and to help local partners assess their readiness, potential challenges, and assets for their model implementation. Site staff and GCG consultant experiences will help to further refine the modules, providing site-level feedback about the appropriateness, usefulness, and applicability of the information and formats for diverse sites around the world.
Future plans include a robust evaluation of the modules’ effectiveness and level of user engagement, and enhanced elements such as translation, country-specific graphics, and accessibility features.
Scientific publications
Martens N, Crone MR, Hindori-Mohangoo A, Hindori M, Reis R, Hoxha IS, Abanga J, Matthews S, Berry L, van der Kleij RMJJ, van den Akker-van Marle ME, van Damme A, Talrich F, Beeckman K, Court CM, Rising SS, Billings DL, Rijnders M. Group Care in the first 1000 days: implementation and process evaluation of contextually adapted antenatal and postnatal group care targeting diverse vulnerable populations in high-, middle- and low-resource settings. Implement Sci Commun. 2022 Nov 24;3(1):125. doi: 10.1186/s43058-022-00370-7. PMID: 36424641; PMCID: PMC9694875.
Martens, N., Crone, M.R., Hindori-Mohangoo, A. et al. Group Care in the first 1000 days: implementation and process evaluation of contextually adapted antenatal and postnatal group care targeting diverse vulnerable populations in high-, middle- and low-resource settings. Implement Sci Commun 3, 125 (2022). https://doi.org/10.1186/s43058-022-00370-7
Martens, N., Hindori-Mohangoo, A.D., Hindori, M.P. Damme AV, Beeckman K, Reis R, Crone MR, van der Kleij RR. Anticipated benefits and challenges of implementing group care in Suriname’s maternity and child care sector: a contextual analysis. BMC Pregnancy Childbirth 23, 592 (2023). https://doi.org/10.1186/s12884-023-05904-y
Rijnders R., Jans S., Crone M. GANC in the Netherlands: implementation results. The Pract.Midwife, July 2024. 24-29.
Sadiku F, Bucinca H, Talrich F, et al. Maternal satisfaction with group care: a systematic review. AJOG Glob Rep. 2023;4(1):100301. 2023 Dec 24. doi:10.1016/j.xagr.2023.100301
Talrich F, Van Damme A, Bastiaens H, Rijnders M, Bergs J, Beeckman K. It takes two to tango: the recruiter's role in accepting or refusing to participate in group antenatal care among pregnant women-an exploration through in-depth interviews. Fam Med Community Health. 2023;11(3):e002167. doi:10.1136/fmch-2023-002167
Talrich F, Van Damme A, Bastiaens HLA, Bergs J, Rijnders MEB, Beeckman K. How to Support the Referral Towards Group Antenatal Care in Belgian Primary Healthcare Organizations: A Qualitative Study. Int J Womens Health. 2023;15:33-49. 2023 Jan 6. doi:10.2147/IJWH.S384269
Talrich F, Van Damme A, Bastiaens HLA, Bergs J, Rijnders MEB, Beeckman K. How to Support the Referral Towards Group Antenatal Care in Belgian Primary Healthcare Organization: A Qualitative Study [Response to Letter]. Int J Womens Health. 2023;15:341-342. 2023 Feb 28. doi:10.2147/IJWH.S408394
Veenstra-Kwakkel, S., Hindori, M.P., Grunberg, A.W. et al. Enablers and barriers associated with successful implementation of group antenatal care in primary care facilities in Suriname: a qualitative evaluation study. Discov Health Systems 3, 17 (2024). https://doi.org/10.1007/s44250-024-00082-w
This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 848147. This website reflects only the authors' view and the European Commission is not responsible for any use that may be made of the information it contains.
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