Intervention

In Zimbabwe, the peer support group approach has been adopted as an official strategy of the Zimbabwe MoHCC. The Amalima Loko program improves food security in five districts of Zimbabwe’s Matabeleland North region through increased food access and sustainable watershed management. The MoHCC and Amalima Loko refer to these peer support groups as care groups and they define specific roles for participants, which vary from those defined by other literature on the care group model [7, 10, 11, 14, 23]. MoHCC nurses work with program field officers to supervise village health workers who serve as Care Group Promoters (CGPs) and who, in turn, train and support the volunteer group facilitators, called “Lead Mothers.” Community leaders and CGPs select Lead Mothers and they receive training in group facilitation approaches and the health and nutrition messages endorsed by the national government. They invite pregnant women and caregivers of children under five years of age (called “Neighbor Mothers”) from 10–15 nearby households to join. Lead Mothers organize, mobilize, and facilitate regular peer group sessions with Neighbor Mothers to provide training and key messages promoting recommended maternal, child health, and nutrition behaviors; visit homes; and lead other activities in the community. Neighbor Mothers attend and participate in regular meetings, ask questions, and discuss topics. The groups benefit from layered multi-sectoral program delivery; groups are trained in agriculture and often linked to savings and loan and hygiene efforts, among others. This paper refers to Lead Mothers as facilitators and Neighbor Mothers are referred to as members; Lead Mothers and Neighbor Mothers are referred to collectively as participants.

Study design

This implementation research was conducted during September 2022 to January 2023 with women who were members and peer leaders (facilitators) of nutrition and health peer support groups implemented as part of the Amalima Loko program in Zimbabwe. Qualitative methods were used to explore the following questions in three districts of Matabeleland North (Binga, Lupane, and Tsholotsho) (Fig 1): [1] What characterizes quality peer group experiences as defined by group participants? [2] What challenges or experiences limit quality? [3] What do group members and leaders (facilitators) suggest to improve the quality of peer groups?

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Fig 1. Study districts in Matabeleland North, Zimbabwe.

Binga (pink), Lupane (purple), and Tsholotsho (orange) Districts in Matabeleland North, Zimbabwe.

https://doi.org/10.1371/journal.pgph.0003525.g001

Ethics statement

The research protocol received ethical approval from the Medical Research Council of Zimbabwe (MRCZ/A/2957) and John Snow, Inc. (JSI/22-70) in September 2022. Before each interview, enumerators explained the study purpose and the voluntary nature of participation, and sought and obtained written consent for participation and audio recording.

Sampling and data collection

Three districts were selected to represent a range in cultural and contextual differences and stage of implementation: one district (Tsholotsho) had a long-running program, including implementation of the previous Amalima program in (2013–2020), and two districts (Lupane and Binga) had recently initiated groups through the Amalima Loko program. The low population density in Binga allowed an investigation of participation in a different program context characterized by widely dispersed dwellings.

Within three communities in each district, participants—both members and facilitators from multiple peer groups—were interviewed for a total of 64 members and 30 facilitators (Table 1). Subsequently, focus group discussions (FGDs) were conducted within the same sites and peer groups to gather input on the validity of findings and researchers’ interpretations across sites. In each district, one FGD was held with members (7 individuals) and one with group facilitators (5–6 individuals).

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Table 1. Sample size for in-depth interviews and focus group discussions, by district.

https://doi.org/10.1371/journal.pgph.0003525.t001

Separate semi-structured, in-depth interview guides for participants were developed and translated. Interview guides explored participants’ perspectives on quality, benefits, and challenges, as well as their suggestions for improving the quality of their group experiences. Questions included, for example, “Can you describe what we would see if we visited a group session?”, and “what were memorable sessions and topics, and why?” Quality was explored with open-ended questions, and with more specific probes related to domains seen in previous research, including group membership and cohesion, facilitation, and community linkages. For example, “What characteristics of a care group make it high quality for you?” with probes “who is in the group?” and “who leads the group, and how?” among others. Interviewers explored lived experiences of peer groups, including care groups supported by the Amalima Loko program or others. The interview guides for facilitators also explored their roles, responsibilities, and experiences as Lead Mothers and reflections on group sessions and impact.

Interviews were conducted by trained field researchers proficient in the local languages (Tonga, isiNdebele) and lasted approximately 60 minutes. Participants were recruited and interviewed at program food distribution points that were convenient and regularly used for community meetings. Before each interview, enumerators explained the study purpose and the voluntary nature of participation, and sought and obtained written consent for participation and audio recording. The research team conducted the audio-recorded interviews, and transcribed and translated them into English. The research team provided participants with refreshments and U.S.$10 for transportation.

After coding and analyzing the interview data, six FGDs were held to share interview findings, check on variations across settings, gather input on interpretations, and refine recommendations to improve peer group quality. In each district, one FGD with five to seven individuals was held with group members and one with group facilitators; each included participants from multiple peer groups. Participants were compensated for their participation in the same way as interviews.

Data coding and analysis

Data were coded by a team of four co-authors (SRA, NM, PM, LS), which included researchers involved in study design and data collection. Initially, SRA coded a duplicate transcript with each coder to ensure that the four interviews were coded by two researchers who compared and discussed coding to reach consensus and develop a shared codebook. Each coder then met with the codebook author (SRA) to discuss coding of initial interviews before being assigned several additional interviews. All transcripts were independently coded by two people and compared to ensure the consistent application of the code book, with meetings as needed to discuss questions or discrepancies and harmonize coding.

Interview data were coded according to dimensions of quality, challenges, and solutions using Atlas.ti, based on the study objectives. We began with codes derived from four dimensions identified in previous studies of (i.e., membership and group cohesion, facilitation, support of behavior change, and family and community support). Additional thematic codes arose during the coding process. These emergent themes can be characterized as: 1) locally-specific nuance to a quality dimension defined in existing literature, or 2) member-identified challenges (factors) and strategies for improvement (e.g., family support, appreciation for behavior change, etc.).

Themes were defined through a collaborative process between coders wherein the identifying coder proposed a thematic label and description, then discussed and revised the code until a consensus definition and label were defined.

Benefits to participation

Participants described joining the peer group based on a personal relationship with the group facilitator, interest in gaining knowledge on specific topics (e.g., breastfeeding, child care, and hygiene), expectations for financial or in-kind benefits (i.e., access to income generation opportunities), and a desire for social support.

“I joined because I wanted to gain knowledge about caring for my child, what to feed the child, and how to keep the child healthy, as well as to learn about how to always be clean as women.” Neighbor Mother, Lupane

Most participants identified forms of social support as benefits, such as help from group members with household tasks and building hygiene structures, comfort in times of challenge, and reduced stress from talking together.

“We mobilize ourselves as a group to go around helping each other in painting and cleaning each other’s homes. We dug litter bins for each home of members in our group. We visit each other in their homes, teaching and reminding them what we have learned in the previous meeting.” Neighbor Mother, Binga

“The benefit, for now, is that I have people who visit me when [I] have challenges, who come to see me, and comfort me where possible.” Neighbor Mother, Lupane

Participants in Lupane and Tsholotsho also noted increased confidence and personal development as a key benefit of participation. Some expressed pride in being able to help others in their household and community with issues around child feeding.

Hygiene behaviors and vegetable gardening interventions are appreciated by group members, but are delivered by other platforms within the program. Nearly all participants mentioned access to income generating activities because the program offers groups opportunities to engage in other program activities, such as agriculture training and village savings and loan (VS&L).

Challenges

Group facilitators and members in every district frequently mentioned low attendance and lateness to group sessions as challenges. These were often attributed to a lack of family support for women to take time away from household tasks.

“I’ll usually ask my husband to go and attend these meetings so if he allows me, and then people delay coming, it becomes a challenge because I will then go back home late and this causes arguments between me and my husband.” Lead Mother, Lupane

Additionally, some responses suggested that groups wait to begin a session until all or most of the expected members arrived, delaying everyone in returning home. In Binga, where homes are widely dispersed, travel to group sessions made attendance challenging. Although some participants in all districts shared concerns about distance, FGD participants felt that it is a barrier primarily in Binga.

Some participants mentioned times of internal conflict in their group, but noted that the facilitators and CGPs have skills to resolve conflicts. Some shared that grandmothers, as respected elders, can help also.

“I have had conflicts within the group where some women were fighting but the Promoter [CGP] managed to sit them down and emphasize working together because if there are conflicts there is no going forward, but forgiving each other is important.” Lead Mother, Tsholotsho

“Grandmothers assist us when there is a conflict in talking. They can say, ‘that is not the way to talk just because the one who is correcting you is an older figure,’ then we will listen especially to the young mothers.” Neighbor Mother, Lupane

Group membership and cohesion

When asked about similarities and differences among members, the member characteristics mentioned most often were source of livelihood, religious affiliation, marital status, and age. Participants reported that their group members were all female, and most were pregnant or lactating mothers meeting program eligibility requirements. Some groups also included several grandmothers as primary caregivers of young children. The ages of group members varied; some groups included people ranging from 17–67 years, while others had members aged 25–35 years. Most expressed appreciation and/or perceived value in mixed-age groups.

Socio-economic characteristics also varied somewhat between and within groups. In some groups, members were all landholding and of the same faith, while other groups were more diverse. Participants expressed positive views on both more uniform and diverse group compositions. Rather than focusing on similarity to peers, quality group membership was often described in terms of responsiveness to members’ needs and positive, inclusive interpersonal dynamics.

“A quality peer group is one that takes into consideration the needs of its group members. A group that is inclusive in nature—including everyone in the community despite their social status. A high-quality group should be characterized by high levels of respect for each member considering that we are all adults in this group, so we need to be respected.” Neighbor Mother, Binga

Participants talked about a sense of shared identity and belonging with an emphasis on unity, harmony, respect, and love within groups, as well as a willingness “to learn and advise each other” yet be “humble enough to find out information they are not sure about.”

Most participants were satisfied with group dynamics, despite some internal conflicts as noted under the section on challenges. Groups in Tsholotsho reported positive interactions between group members and shared many examples to demonstrate the strength and longevity of these social bonds. In Binga and Lupane, where groups were newly formed, participants made fewer references to members of the groups being friends.

Group facilitation

Members frequently mentioned enjoying active learning methods, such as singing and dramas—activities included in the Amalima Loko program to increase participatory engagement. There was interest in expanding the amount and variety of participatory activities, such as storytelling and creating dramas, as well as practical learning activities. Responses also indicated that the primary instruction format often involved facilitators reading directly from their manual or notes. A few facilitators wished that members would bring topics or points for discussion, suggesting that these facilitators found it challenging to start a dialogue.

When asked about memorable learning, members recalled specific occasions when they learned skills by doing and when they felt acknowledged by the facilitator for practicing the skill correctly or providing relevant information or experiences.

“I felt supported by the facilitator and other members when we discussed the weighing and oedema measurements and later practiced, and the facilitator acknowledged that we did it the right way.” Neighbor Mother, Tsholotsho

Appreciation for behavior change

Most members appreciated the changes they see as a result of participation in the groups and felt that this represented a quality group experience. Participants highlighted concrete evidence of change, such as “toilets, pot racks, improved health and child care among other things” and “smartness,” meaning homes that look clean and hygienic to visitors and community members. Group activities that led to visible changes in households and communities, particularly related to hygiene and breastfeeding, were most often mentioned as memorable and favorite topics.

“The way of drinking water has changed as each person now has his or her own cup for drinking water. We also wash [our] hands after using the toilet using the tippy tap. The toilet itself is a result of the group and so is the rubbish pit, pot racks, and clean yards.” Neighbor Mother, Tsholotsho

Some members felt proud to be able to share new knowledge and skills with their family and friends.

“I taught my friend how to breastfeed her child whilst she is seated because she was doing it wrong compared to what we have been taught in the care group.” Neighbor Mother, Binga

Group facilitators also said that, ideally, a quality group was one in which members would “practice what they have been taught.”

The most common suggestions strengthen sessions to achieve greater behavior change related to tailoring the content so that it is relevant to the age and stage of development of group members’ children. Members suggested additional topics of interest, some of which were beyond the scope of health and nutrition: VS&L activities (such as soap and lotion making), family planning, HIV/AIDs, sick child care, and topics for children over five years of age.

Community linkages

Many participants noted that the groups are recognized by communities because community leaders select group facilitators and link groups to community structures through the CGPs. Additionally, many said that community members appreciate groups for contributing to community development through hygiene and various other ways. Some reported that community members and leaders observe or contribute to peer group meetings.

“Yes, [the community] realizes what we are doing and the village head provides us with information about what is going to happen in the area, and other members comment on how the existence of the group has elevated the community… As Lead Mothers, we were chosen in a community meeting, so the community is aware of the existence of care groups.” Lead Mother, Tsholotsho

Most facilitators, particularly in areas such as Tsholotsho where peer groups were previously established, felt proud of their role. They mentioned signs of increased social status, such as recognition by community leaders, invitations to speak in community meetings, and appreciation from the community. However, some mentioned hearing gossip mocking facilitators for doing the work of village health workers (i.e., growth monitoring) without compensation.

Family support

Lack of family support emerged as a primary barrier to attendance. In areas where this or another program previously implemented peer group activities, many participants reported family approval and even enthusiasm for their participation which was attributed to the visible improvements in households and children’s hygiene. In new program areas, however, family approval for attendance was a common challenge; some questioned the benefits of participation and others preferred the woman focus her time on household tasks. Some facilitators reported visiting families to encourage participation and to reduce absenteeism and tardiness, but this increased their workload and is not a planned program activity. Some members invite their husbands to join to enable attendance.

“The most common challenge among care groups is men who do not allow their wives to attend meetings. But with our care group we do not face such a challenge because we visit the group member the day before the meeting and inform them in the presence of the husband that we will have a meeting and inform them about the lessons that we are going to be having so that the husband gets to know about the program as well.” Lead Mother, Lupane

Some participants also noted that family support, especially from mothers-in-law, is critical to trying recommended nutrition behaviors they discuss in groups, especially related to infant and young child feeding.

“In most households, the young mothers especially have their mother-in-law who wants to feed the grandchildren some food items instead of them practicing exclusive breastfeeding.” Lead Mother, Tsholotsho

Strengths and limitations of the research

A key strength of this research is the focus on understanding program quality from the perspective of key stakeholders during the implementation period. Gathering the perspectives of group members and facilitators, and including both long running and recently initiated groups, was informative and provided diverse viewpoints. These stakeholders are often overlooked in design phases, and it is essential for effective, sustainable programs and engagement of communities to gain these perspectives during implementation on what is or is not working.

The results presented here provide insights that can be helpful for social and behavior change nutrition program design implemented through peer support groups.

This implementation research was designed to gather input from participants on their perceptions of the quality of on-going program activities, and as such, the design revolved around capturing what was currently happening. For this reason, data collection focused on participants rather than a representative sample of women in these communities. We could not reach women who had not participated in peer groups or who had dropped out. Interviews with women who did not participate, or women who had dropped out, might have been valuable for understanding additional challenges such as any negative group interactions and relevance of topics, among others. However, such women may have been reluctant to speak forthrightly due to social desirability since it could impact relationships with neighbors. Additionally, the scope of this research focused on the perspectives of those participating in care groups.

The focus on current implementation of a multi-year program also meant that there were different stages of implementation across districts as the program rolled out over time. The intention was intended to be as flexible and participatory as possible, to allow for adaptive learning on what peer group members valued and perceived to be important for a quality experience as well as their suggestions and priorities for improving implementation and quality. Follow-up FGDs were useful for checking whether findings from one district applied to other communities and for gaining additional insights to guide and refine interpretation.

It was notable that when asked about how to improve the quality of peer groups, the group participants in FGDs tended to focus more on how they could do better, rather than how the program or facilitator could do better, referring to the need to be more accepting of group members or take more steps to improve their behavior. This may reflect cultural and gender norms in this setting or other personal values. However, as in all research asking people to critique a program in which they participate, it is possible that, to some extent, responses reflect social desirability and concern for the feelings of those implementing the program.

In summary, members appreciate peer groups for gaining practical information, skills, and pride, and group membership offers benefits for women beyond nutrition and health. It is important to consider how to sustain this cohesion, even after women have completed the curriculum. Examples in Amalima Loko include groups focused on VS&L or other beneficial activities, but input from stakeholders could identify other priorities. Balancing fidelity to peer group program goals, methods, and curricula with opportunities (and capacity strengthening) for facilitators to adapt to the context and interests of group participants is important for effective implementation of peer group models [31, 36]. If well managed, such adaptation could support the application of adult learning principles by giving members choices about topics and activities, having them lead discussions or develop dramas, facilitating discussion among the different group members with similar situations, such as age of child, and allowing time for reflection and problem solving related to behavior change.