What is the 'secret' sauce of successful Care Group implementation: realist synthesis findings on creating an enabling environment for behaviour change adaptation

Abstract Despite great improvements in under-five mortality, too many young children continue to die from preventable diseases. Many deaths can be averted by promoting simple domestic behaviours such as frequent handwashing, bed-net use, timely care-seeking, and exclusive breastfeeding for six months from birth. Promoting such behaviours through existing health facility-based care providers is a challenge, as contact between health professionals and community members simply is not frequent enough. It takes time for those promoting new habits to first build trust within communities and ensure that new behaviours are accepted. This is why lay healthcare providers and community volunteers are best placed to deliver behaviour change communication. Domestic and international NGOs have been supporting the roll-out of behaviour change communication programmes, including Care Groups, for some time; using community-based groups to reach as many households as possible with peer-to-peer communication, and creating conductive environments to promote greater adoption of new behaviours. Methods: This paper presents findings from a realist synthesis of all texts pertaining to the Care Group approach, a community-based peer-to-peer support to promote behaviour change. The question “What works for whom under what circumstances, how and why?” is central to realist research, and helps to explain examples of success, partial success, and failure in, for example, international development interventions. Results: This paper identifies how Care Group implementing agencies have developed strategic approaches to create a conducive environment in which their behaviour change messages are received, improving the uptake of behaviours that can help to reduce under-5 mortality. Implementers of behaviour change interventions may rely on community-based or family decision makers to influence the cultural acceptability of certain new behaviours. NGOs were also found to work with local authorities or the private sector to improve the availability of lay healthcare providers, certain commodities (medicines, test kits, etc.), to remove barriers to uptake of promoted behaviour changes. Conclusion: These strategies employed to improve uptake and therefore the efficacy of behaviour change intervention have not been systematically documented in the Care Group literature and are likely to be relevant for future Care Group programme implementation and other behaviour change interventions.