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Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach - A Field Guide

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Designing a Community-Based Nutrition Program
Using the Hearth Model and the
Positive Deviance Approach - A Field Guide
Monique Sternin
Jerry Sternin
David Marsh
December 1998
This publication was made possible through support provided by
The Partnership for Child Health Care, Inc./BASICS with financing from the
US Agency for International Development, under the terms of Contract No. HRN-C-00-93-00031.
The opinions expressed herein are those of the authors and do not necessarily reflect
the views of the US Agency for International Development or the BASICS project.
® 1998, Save the Children Federation, Inc. All rights reserved.
PREFACE
It is hard to describe the sense of relief and completion I have with the publication of this manual.
From 1987-92 I headed a five country study of Positive Deviance in Nutrition. It was the most
expensive piece of nutrition research that UNICEF ever centrally funded. We turned out four
books, a couple dozen
j
ournal articles and book chapters, six Ph.Ds. and countless reports.
But we never produced the practical field guide which was a major goal of the research. This
preface explains why by answering obvious questions.
What is positive deviance?
Positive deviance in nutrition describes young children who grow and develop adequately in poor
families and communities, where a high number children are malnourished and frequently ill.
They are positive deviant children, and they live in positive deviant families. These families
have developed culturally appropriate positive deviant practices that enable them to succeed in
nourishing and caring for their children in spite of poverty and an often high risk environment.
These families are uniquely able to provide solutions to malnutrition to other poor families in their
communities.
The concept of learning from positive deviant families crept into the literature early in the interna-
tional nutrition movement, in the mid-1960s, with calls to pay a great deal more attention to those
individuals who are apparently healthy while consuming diets which seem to us to be restricted
(Mark Hegsted, 1967), "to study successful mothers" (Joe Wray, 1972), and to identify village
women who can cope and manage to rear healthy and active children (Peter Greaves, 1979)
applying "maternal technology" (Leonardo Mata, 1980). By 1982, Maria Alvarez had published
a half dozen studies from poor neighborhoods in Chile on mother-child interactions and home
environments related to good nutrition of infants. I believe Gretchen Berggren first came up with
the term "Positive Deviance" in the mid-1980's.
Our first book, Positive Deviance in Child Nutrition (Zeitlin, Mansour and Ghassemi, 1990),
reviewed more than 180 studies of caring behaviors and social and cultural networks that protect
the nutritional status of poor children and mothers. In the following years the various teams on the
project (Aina, Agiobu-Kemmer, Ahmed, Annunziata, Armstrong, Babatunde, Beiser, Bonilla, Brown,
Chomitz, Colletta, Ebam, Engle, Garman, Gershoff, Ghassemi, Guldan, Klein, Kramer,
Lamontagne, Mansour, Megawangi, Morales, Peterson, Rogers, Satoto, Seireg, Setiloane,
Sockalingam, Weld) published more of the same, showing that women's education, a happy
mood, and most measures of loving, attentive and patient parenting are linked to good nutrition.
Positive deviant children tended to live in cohesive, supportive and well-spaced families. These
families tended to live in supportive communities with good social services.
Positive deviant infants are breast fed. The diets of older positive deviants are richer in animal
foods, such as milk, fish or meat, in fruit and vegetables, and in day-to-day variety than the diets
of malnourished children. Their food, water, and play environments are cleaner and safer. Their
health care is better.
With such numbingly obvious findings, why did you fail to produce a simple manual?
In technical terms, the findings were significant, but the effect sizes were small. Academic
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
3
colleagues were suspicious of "soft" measures of attitudes and behavior. The ways in which
different cultures express attentiveness, cohesiveness, good diets, and so on are different. In the
quest for scientific respectability, we relied on sample sizes and analysis methods that were too
big and complicated to package in a field manual.
It wasn't always obvious. Positive deviance is one positive layer in a stack of negative adaptations
to poverty and food insecurity. Other adaptations include high death and malnutrition rates.
Population "fatigue" diminishes survival to the number of people the food supply can support.
Malnutrition "adapts" children into small adults who survive on less food. Negative care allows
unaffordable children to die without blaming their parents. Subsistence agriculture depends on
child labor. Negative feeding and care practices entwined with adaptations of this nature are the
primary targets of nutrition education and growth-monitoring in developing countries.
Positive deviance is the evolutionary vitality at the top of the stack - the spark of flame that
flickers into good growth and health, on top of the cinders, a backdrop of practices that damper
the fire so it doesn't go out. This complicated overlay does reduce statistical effect size. It does
mean that researchers don't always find good practices that can simply be taught to the whole
community.
If a behavior is adaptive because it helps children to survive in spite of conditions that increase
mortality, the first need may be to change those conditions. After the change, behaviors that
protected children may hold them back. For example, constant carrying on the mother's back
protects undernourished children in unsanitary, unsafe environments. But it slows the develop-
ment of well nourished children in safe clean environments.
Then, if it's hard to find positive deviance, how does this simple Manual come up with the
answers? And, is it true that the Positive Deviance Investigation in the Manual visits a total
sample size of only six families?
Yes, it's true and cleverly done.
First, six is about as many households as a village team can analyze comfortably and discuss
meaningfully.
Second, the manual uses a positive deviance approach to design a community-based "Hearth"
model. But this doesn't depend on positive deviance practices alone. It is based on decades of
experience in rehabilitating children and educating their mothers using scientifically valid, field
tested methods.
Third, the guide validates the six family investigation with a qualitative assessment of positive and
negative deviance factors conducted by a panel of local experts. This assessment is based on the
results of a literature review, a situation analysis, a nutrition survey, a series of focus groups, and a
community analysis of the causes of malnutrition. Where results from the six families differ from
the expert assessment, the team finds out why and modifies the results accordingly.
Fourth, the positive deviance approach mobilizes the community. The search for and discovery of
positive deviance is a dramatic device that leads the community back to the source of its inherent
wisdom and evolutionary vitality, and restores to the community the power of taking control of its
nutrition problems.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
4
As Jerry Sternin put it, the positive deviance approach is "evolution times two." It takes the
evolving edge of good nutritional change, not just static practices, but good change. Instead of
waiting a generation for the fit to survive, it applies this evolutionary advance immediately, in a
manner that speeds the capacity of the population to move forward.
M
a
ri
a
n F. Z
e
itlin
,
CoDirector, the Yoff EcoCommunity Program
Centre de Ressource pour I'Emergence Sociale Participative
(CRESP) Yoff-Dakar, Senegal
Visiting Professor, The Tufts University School of Nutrition Science and Policy
December 1998
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
5
FOREWORD
The use of the positive deviance approach has enabled communities in Vietnam and elsewhere
to take responsibility for sustainably rehabilitating tens of thousands of seriously malnourished chil-
dren. Equally significant, the approach has changed the conventional wisdom in communities
regarding feeding, caring, and health-seeking behavior, thus benefitting generations of children
to come.
This field guide is to a large degree the work of Monique Sternin, who pioneered the positive
deviance approach to nutrition in Vietnam over a six-year period. She has spent the past year writ-
ing and testing the guide in Mozambique, Egypt, Nepal, Bhutan and Cambodia with the hope of
making the approach accessible to those concerned with the problem of malnutrition in other
countries throughout the world.
Obviously, knowledge is never complete, and this manual, perhaps more than others, is a "work in
progress." Nonetheless, we feel that enough experience has accrued to justify broader application,
even as we study and refine the model in various contexts. There is only one "Monique," so the
manual is a strategy to bring her and other's insights to scale. We eagerly await your reactions,
reflections, and experience in programming and in research as we move forward together.
David R. Marsh, MD, MPH
Senior Child Survival Specialist/Epidemiologist
Health, Population and Nutrition Unit
International Programs
Save the Children
54 Wilton Road
Westport, CT 06880
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
6
T
ABLE OF CONTENTS
• Acknowledgments 9
• Glossary 10
• Introduction: Purpose of the Field Guide 11
• How to Use the Manual 12
Part I Overview Of The Hearth Nutrition Model
• Positive Deviance as the Cornerstone of the Nutrition Program 13
• Positive Deviance Approach in Nutrition 13
• The Hearth Nutrition Program's Goals Based on the
Positive Deviance Approach 14
• Components of a Hearth Nutrition Program 14
• Characteristics of a Hearth Nutrition Program 15
• Conceptual Framework for Designing a Hearth Program 19
Part II Assessing The Feasibility O f Piloting a Hearth Program
• Assessing the Prevalence of Malnutrition 20
• Availability of Local Food 21
• Availability of Mothers as Potential Volunteers in the Community 21
• Presence of Committed Leadership in the Community 22
Part III Preliminar
y
Ste
p
s: Gettin
g
Started
• Step 1: Assessing Community Organization Resources
with Local Partner 23
• Step 2: Identifying Community Health Resources
with Local Partner 23
• Step 3: Helping the Community Select Mothers to
Become Volunteers 25
• Step 4: Selecting a Local Nutrition Resource Panel 26
Part I
V
Conducting A Situation Analysis Of Malnutrition With
The Community
• Step 1: Reviewing the Health Situation of Young Children with
Local Health Staff 27
• Step 2: Carrying Out a Nutrition Baseline Survey of Young Children 27
• Step 3: Identifying Current Feeding, Caring and Health Seeking
Practices in the Community 29
• Step 4: Assessing the Nutrition Situation of Young Children
With the Community 30
Part V Conducting The Positive Deviance Inquiry
• Background Information and Definitions 33
• Process of a Positive Deviance Inquiry 33
• Outline of the Positive Deviance Inquiry 34
• The Spirit of the Positive Deviance Inquiry 34
• Selecting the PDI Team 35
• Training of the PDI Team in Conducting the PDI 35
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
7
• Household Observations and Guided Interviews 36
• Steps for Conducting a Positive Deviance Inquiry 37
• Step 1: Planning the PDI With the Community 37
• Step 2: Conducting PDI Home Visits 41
• Step 3: Selecting and Documenting Key Successful
Practices from PDI Findings 42
• Potential PDI Pitfalls and Solutions 45
• Step 4: Provide Information on PDI Findings to the Community 48
Part VI Designing A Hearth Nutrition Program With PDI
• Nutrition Education and Rehabilitation Sessions 49
• NERS Participants 49
• Identifying NERS Centers with the Help of Volunteers 49
• Setting a NERS Schedule 49
• Deciding on the NERS Daily Sessions Schedule 50
• Creating NERS Menus Incorporating the PD Foods 50
• Developing NERS Education Components 51
• Developing Strategies to Promote Behavior Change 53
Part VII Other Hearth Nutrition Program Components
• Growth Monitoring and Promotion 56
• Vital Events 58
• Community Management 59
• Monitoring and Evaluation 60
• Deworming 62
• Vitamin A Distribution 62
• Maternal and Child Health 63
Part VIII Collaboration with District Health Personnel
Advantages 65
Disadvantages 65
Appendices
• A. Regional Profiles of Positive Deviant Feeding Practices 66
• B. Characteristics of Training 69
• C. Question Guide for Focus Group Discussion on Malnutrition 70
• D. Situation Analysis Results (Nepal) 71
• E-1. Examples of Good Feeding, Caring, Care-Seeking Behaviors 72
• E-2. Examples of Poor Feeding, Caring, Care-Seeking Behaviors 73
• F. Standard Curriculum for Training of Trainers 74
• G-1. Observation Check-list During a PDI 77
• G-2. PDI Observation Recording Form 77
• H. Question Guide for Caretaker Interview during
Positive Deviant Inquiry 79
• I. Case Study Narrative (Mozambique) 81
• J. NERS Curriculum 82
• K. Qualitative Hearth Program Impact (Nepal) 84
Recommended Reading 85
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
8
ACKNOWLEDGEMENTS
To begin at the beginning, this field guide would never have come to pass if it were not for the
people in the field who took the concept of Positive Deviance, gave it life and form, and translated
it into action.
To the "Positive Deviants" in the villages, who taught us what no expert ever could: how it really
can be done. We thank you and salute your wisdom!
The positive deviance approach to the hearth model is the result of the hard work of a dedicated
and committed cadre of grass-roots development workers who sweated in the tropical sun; soaked
in torrential downpours; itched with mosquito and fly bites; ached from carrying scales, pots and
pans; dozed after meetings with villagers long into the night; grinned from ear to ear when growth
monitoring results showed continuing decreases in malnutrition; and cried when a third degree
malnourished child could not be saved. To you all, the PD pioneers in Vietnam (Hien, Tuan and
Lang) and at the Schweitzer Hospital in Haiti, first and foremost, our deepest gratitude.
Next, to those of you who later took the model, changed it, improved it, made it your own and
provided valuable feedback for the Field Guide: Save the Children Japan (particularly Anirudra
Sharma) and Save the Children Norway, both in Nepal; AFRICARE in Tanzania; Save the Children
US in Mozambique, Egypt, Nepal and Bhutan; and CARE in Cambodia, many thanks.
For those of you who read the earlier drafts of the guide book, provided sound counsel and feed-
back and attended the round-table in Washington (Liane Adams, Leslie Archer, Kirk Dearden,
Victoria Graham, Don Graybill, Marcia Griffiths, Marguerite Joseph, Charles Llewellyn; David Oot,
Ellen Piwoz, Victoria Quinn, Donna Sillin, Dirk Schroeder, and Eric Swedberg), our debt of gratitude
for your role in the evolution of the final product. Thanks too to Tamer Kirolos who helped format the
book.
To Bart Burkhalter and the BASICS Project, without whose support, moral as well as financial, the
field guide would not have been possible, our sincere thanks, To co-author and friend, David
Marsh who shepherded, prodded, encouraged and was attending mid-wife at the delivery, our
heartfelt appreciation and gratitude.
And finally, a special thanks to Marian Zeitlin whose pioneer work served as the catalyst for the
Positive Deviance-Hearth-Nutrition model, and to Gretchen Berggren, who with her husband
Warren, created the Haiti Hearth model, introduced us to the concept, and provided wise counsel
and support in Vietnam during the early days of our nutrition forays, a great debt of gratitude.
Monique Stemin,
MA Cairo
,
1998
Jerry Stemin, MA
Field Office Director,
Egypt Cairo, 1998
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
9
GLOSSAR
Y
CBO Community-based Organization (Egypt)
CDA Community Development Association (Nepal)
DHS District health services
EPI Expanded Programme for Immunization
GMP Growth Monitoring and Promotion
HV Health Volunteers
IMCI Intgrated Management of Childhood Illness
INGO International Non-Governmental Organization
KAP Knowledge Attitude Practices
LBW Low Birth Weight
ND Negative Deviant
MCH Maternal and Child Health
MOH Ministry of Health
NERP Nutrition Education and Rehabilitation Program
NERS Nutrition Education and Rehabilitation Session
NGO Non-Government Organization
PD Positive Deviant
PDI Positive Deviance Inquiry
PEM Protein Energy Malnutrition
RB Redd Barna (Save the Children, Norway)
SCJ Save the Children, Japan
SC/US Save the Children, USA
TBA Traditional Birth Attendant
TOT Training of Trainers
VHC Village Health Committee
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
10
INTRODUCTION
Purpose Of The Hearth Field Guide
For Whom?
This guide is intended for trainers, program officers and managers from NGOs and INGOs or MOH
district teams or other organizations working at the grass-roots level, in partnership with the
community or through community-based organizations. It has been developed to assist you in
designing a community-based Nutrition Education and Rehabilitation Program in collaboration with
the communities you serve.
What?
More specifically this guide will help you to:
• Assess the feasibility of the nutrition program in the proposed context
• Conduct a Situation Analysis of malnutrition with the community
• Carry out a Positive Deviance Inquiry with the community
• Design a community-based Nutrition Program using Positive Deviance
Inquiry findings
Why?
Malnutrition is the result of many interrelated factors such as poverty, insufficient household food
security, inadequate health services, poor maternal and child care practices, and inadequate
water and sanitation. For communities with a high prevalence of malnutrition, it may take years or
even decades before all of these factors can be addressed. Because today's malnourished chil-
dren cannot wait, grass-roots development workers need to address their plight today in collabo-
ration with the community.
The Hearth Nutrition Model based on the Positive Deviance approach provides encouraging
answers to this question.
How?
Based on the Positive Deviance approach, communities and their development partners have
been able to sustainably reduce malnutrition among their young children through a Nutrition
Education and Rehabilitation Program in Haiti, Vietnam and Nepal. Similar programs are currently
being implemented in Bangladesh, and Mozambique. Moreover, nutritional researchers have
found "positive deviant profiles" in every region (Appendix A).
Example: In Vietnam, the Hearth Nutrition Program has achieved a reduction of 2nd and
3rd degree malnutrition by 80% among tens of thousands of malnourished children under
3 years of age. Moreover the caretakers were able to sustain the enhanced nutritional
status of these children as long as two years beyond their participation in the pro-
gram. Of greater significance are the findings that younger siblings of these children
and other children in the community who were born after the NERP program ended,
enjoyed the same enhanced nutritional status as did the NERP participants.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
11
HOW TO USE THIS MANUAL
DESCRIPTION OF CHAPTERS
Part I provides a brief overview of the use of the Positive Deviance approach which will be
developed in detail in part V. It also covers the characteristics of the hearth nutrition model.
Part II deals briefly with the feasibility of piloting a Heath Nutrition Program based on your local
context.
Part III outlines standard steps required to initiate a community-based Hearth Program with a
focus on assessing and utilizing community resources and developing community "ownership."
(If you are integrating the nutrition component within the context of other existing community-
based projects, you may proceed directly to part V, "Conducting the Positive Deviance Inquiry.")
Part IV gives guidelines for assessing the health situation of young children in the proposed
hearth community, including instructions for carrying out a nutrition survey and setting of program
goals.
Part V focuses on positive deviance, providing background and definitions, as well as the steps
required for carrying out the Positive Deviance Inquiry.
Part VI describes designing the Hearth Program based on the findings from the Positive
Deviance Inquiry. It covers issues such as choosing menus, creating education messages, and
promoting behavioral change.
Part VII describes other standard components of the Hearth Programs, such as growth monitor-
ing and promotion, recording vital events and community management of the program. Other
optional hearth components, such as deworming, Vitamin A distribution and Maternal and Child
Health programs are also covered.
Part VIII explores the role of District Health Services in the Hearth Program, focusing on
advantages and disadvantages.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
12
Overview Of The Hearth Nutrition Model
PART I - OVERVIEW OF THE HEARTH NUTRITION
MODEL
Positive Deviance As The Cornerstone Of The Nutrition Pro
g
ram
Positive deviance is a develop-
ment approach that is based on
the premise that solutions to
community problems already
exist within the community.
The positive deviance approach
thus differs from traditional
"needs based" or problem-solv-
ing approaches in that it does
not focus primarily on identifica-
tion of needs and the external
inputs necessary to meet those
needs or solve problems.
Instead it seeks to identify and
optimize existing resources and
solutions within the community to solve community problems.
Through a Positive Deviance Inquiry (PDI), program staff and their community partners
identify the unique practices of some community members that set them apart from others
within the same communit
y
, and allow them to co
p
e more successfull
y
within the same
Based on identification of these successful practices, program staff and their community partners
develop strategies to enable all members of the community not only to learn about these prac-
tices, but also to act upon them.
Positive Deviance Approach In Nutrition
The term "Positive Deviance," has been defined as "adaptive responses for satisfactory child
growth under harsh economic circumstances such as food scarcity, while 'Negative Deviance' is
described as "the failure of children to grow satisfactorily, even under good economic conditions."
(
Zeitlin, Ghassemi and Mansour, 1990
)
Berrggren and Burkhalter note in the introduction to The Hearth Nutrition Model, (Wollinka et
al. 1996
)
:
Positive Deviance is a key concept in all of the Hearths. The concept is put to two different
uses in the Hearth Programs. The first and most prominently heralded use is as a method
for discovering affordable and nourishing local foods that mothers can give to their chil-
dren. In Vietnam the answer was shrimp and other high-protein food from the paddies,
essentially free for the taking; in Haiti it was a mixture of beans, vegetables and grains.
The second use of positive deviance is as a communication method to convince mothers
of malnourished children that an affordable solution exists. The meals mothers cook and
feed to the children (during the Nutrition Education and Rehabilitation sessions of the
Hearth) are based upon information gathered in their own communities from mothers of
well-nourished children, the positive-deviant mothers.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
13
Overview Of The Hearth Nutrition Model
The "Positive Deviance" approach as used in the Hearth Nutrition Program, identifies poor
families who have well-nourished children. These well-nourished children are called "Positive
Deviant Children" (PD children) and their families "Positive Deviant Families" (PD families). They
are the living proof that it is possible today in the community for a very poor family to have a
well-nourished child before economic improvements occur or clean water and sanitation are
accessible to all.
Through a Positive Deviance Inquiry, villagers together with the program staff identify the Positive
Deviant Families' special and demonstrably successful current feeding, caring and health-
seeking practices which enable them to "out perform" their neighbors whose children are mal-
nourished but who share the same resource base.
Based on the Positive Deviance Inquiry findings (i.e., successful feeding, caring and health seek-
ing behaviors of PD families), the villagers and the program staff plan a Hearth Nutrition Program
featuring "Nutrition Education and Rehabilitation Sessions" (NERS) to address the problems of
malnutrition in their community today.
The Hearth Nutrition Program's Goal Based On The Positive Deviance Approach
All nutrition programs based on the hearth model share the common overall goal of sustainably
rehabilitating malnourished children as well as preventing malnutrition in young children in the
community through the discovery and promotion of existing successful child feeding, caring and
health-seekin
g
behaviors.
Goals
• To rehabilitate identified malnourished children in the community
• To enable their families to sustain the rehabilitation of these children at
home on their own
• To prevent malnutrition in future children born in the communit
y
Components Of A Hearth Nutrition Program
1- At the neighborhood level
Each month caretakers of identified malnourished children are invited to participate in Nutrition
Education and Rehabilitation Sessions (NERS) for a duration of 12 days. They are assisted by
neighborhood volunteer mothers (Health Volunteers). On a daily basis these Health Volunteers
supervise caretakers preparing and cooking an energy-rich, calorie-dense meal which they feed to
their malnourished children. As the price of admission, and as the key strategy to provide practice
in new, improved feeding habits, caretakers are required to make a daily contribution of the specif-
ic positive deviant food identified in their community through the Positive Deviance Inquiry.
2- At the community level
All young children in the community participate in the Growth Monitoring and Promotion (GMP)
program on a monthly or every other month basis. The Village Health Committee (VHC) also
meets monthly or every other month to review the NERS (results, problems and solutions) and
review vital events (deaths, births and migration). Most Hearth Nutrition Programs also include a
special protocol for malnourished children who fail to gain weight, including referral for treatment
to local or district health facilities.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
14
Overview Of The Hearth Nutrition Model
The Hearth Nutrition Program may include additional health interventions for all young children in
the community, such as periodic distribution of Vitamin A per MOH policy or bi-annual deworming,
preferably at the GMP session.
In some countries, Hearth Nutrition Programs are established and implemented within the context
of other programs, such as Safe Motherhood, Early Childhood Development and Water and
Sanitation programs.
Main Components Of A Hearth Nutrition Program
Identification of successful behaviors among positive deviant families through a
Positive Deviance Inquiry
Monthly or every other month weighing of all children in the target group through a
Growth Monitoring and Promotion (GMP) activity
Monthly Nutrition Education and Rehabilitation Sessions (NERS) for identified mal-
nourished children and their caretakers in local kitchens
Community management of the Hearth Nutrition Program through monthly or every
other month meeting of the Village Health Committee (VHC)
Vital events monitoring
Characteristics Of A Hearth Nutrition Program
1-Use of adult learning principles
One of the most distinctive characteristics of the hearth model is its conscious use and depend-
ence upon adult learning and behavioral change theory to achieve program objectives. It has
been widely demonstrated that groups directly involved in the decision-making process regard-
ing a specific issue are much more likely to change their attitudes and behaviors than those
who were simply informed about how their behavior should change. Alinsky (1972) Hochbaum
(1960) and Lewin (1958) all noted that change requires an "unfreezing" of currently held percep-
tions. The Positive Deviance approach involves the community in the discovery of successful
alternatives, (i.e., an unfreezing of currently held perceptions) regarding the conventional
wisdom about child feeding, and care practices.
It is the Community Health Volunteers and Village Health Committee which analyze findings from
the Positive Deviance Inquiry (positive deviant foods, care and health seeking behaviors which
enable some poor families in the community to have well- nourished children) and design strate-
gies to make those practices accessible to other families through the Hearth Nutrition Education
and Rehabilitation Sessions.
Knowles (1980) posited that the adult learner brings to the learning situation considerable life
experience, learns best by doing and requires a safe, accepting and interactive approach to
learning.
The positive deviance approach at the core of the Hearth Program is based on the belief that
"answers to community problems already exist in the community." It is the positive deviants' "life
experience," (i.e., demonstrably successful behaviors and practices) discovered through the
Positive Deviance Inquiry, which forms the basis for the Nutrition Education and Rehabilitation
Sessions (NERS).
The NERS provides a safe, accepting environment in which mothers can practice new behav-
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
15
Overview Of The Hearth Nutrition Model
iors and "learn by doing." The Health Volunteers learn to be interactive in their approach and
elicit cultural metaphors and stories from the mothers to reinforce new habits learned at the
NERS. Rather than "teaching" mothers what to feed their children, the mother's mandatory "daily
contribution," (a handful of the PD food) provides them with the opportunity to actually practice
preparing and feeding their children the new food.
Similarly, other positive deviance caring practices (i.e., hand and face washing before meals,
hygienic food preparation, active feeding of children) are not only discussed at the daily sessions,
but also are practiced. At the end of a two week NERS, mothers have internalized the new feed-
ing and caring practices and continue them naturally at home. Perhaps Mark Twain best captured
the objective of the NERS when he said, "Education isn't teaching people to know what they don't
know. It is teaching them to behave as they don't behave."
2- Implementation framework
A nutrition program based on the hearth nutrition model can be implemented over a one or two
year period in two distinct phases:
Phase 1 is the active nutrition rehabilitation period with the NERS as the main activity.
Based on experience in hundreds of program communities, it takes 6 months to 12 months to
complete the rehabilitation of most malnourished children in the community, at which time the
Nutrition Education and Rehabilitation Session (NERS) activity is discontinued. On average it
takes 2 to 3 NERS for a child to gain sufficient weight to go from below <3 standard deviations
(or < -3 Z scores) to above<2 standard deviations (or < 2 Z scores).
Phase 2 is the Prevention of Malnutrition Phase: other components of the NERP continue such as
the GMP program, Vitamin A distribution and deworming; and new activities are introduced or
emphasized, such as Health Volunteers' home visits.
Note: The Maternal and Child Health component can be introduced (or integrated if already ongo-
ing in the community) in either phase 1, (SCJ NERP implementation model in Nepal) or in phase
2 (SC/US NERP implementation model in Vietnam).
Comparison of NERP Implementation Plans
Implementation SCJ Nepal SC/US Vietnam
Phase 1 GMP GMP
(12 months) NERS NERS
Vital events monitoring Vital events monitoring
MCH Program Vitamin A and Deworming
Community Management of NERP
Phase 2 GMP GMP
Vital events Vital events
SC/J 12 months MCH Program MCH Program
SC/US 24 months Community Management of NERP
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
16
Overview Of The Hearth Nutrition Model
3- Measurability of impact on nutritional status of young children
The community monitors the nutritional status of all NERS participants during the rehabilitation
phase (Phase 1) and during the Prevention of Malnutrition Phase (Phase 2), up to 24 months
beyond their participation in the NERS, through the community-wide GMP program.
This monthly or every other month activity carried out one to two years beyond the active rehabili-
tation phase enables the community to measure the sustainability of the program impact on
targeted malnourished children.
4- Sustainability
The program sustainability is ensured by the identification of solutions to nutrition problems based
on existing resources accessible to all community members. Involvement of local community lead-
ers and local women volunteers also reinforce the sustainability of the impact of the program.
5- Community participation and ownership of program
The Hearth Program encourages full community participation in assessing local resources, and in
designing and taking part in the program. All relevant groups in the community gain full ownership
of the program through the following processes:
Mobilization to cant' out household registrations and GMP sessions
Identification of practices which affect positively or negatively the nutritional
well-being of their children
Discovery of community-based solutions through the Positive Deviance Inquiry
Elaboration of community-based strategies to solve community problems
Involvement in the program as volunteers, parents of malnourished children, or
Village Health Committee members
6- Establishment of a network of women volunteers at the hamlet level
Volunteers play a critical role in carrying out the main nutrition activities including:
Supervision of regular GMP sessions
Management and facilitation of the NERS
Home visiting (counseling caretakers, sick children, pregnant women
and post-partum mothers)
Monitoring attendance and recording results of NERS
7- Focus on behavior change
The NERS focuses on changing or promoting new behavio
r
rather than transferring knowl-
edge. The program success is measured by what people do rather than what people know.
Changing or promoting new behavior in the caretakers of malnourished children is achieved
through the following learner-centered strategies:
Involving the caretakers in modeling the good practices, i.e., "learning by
doing" in a NERS
Requiring the caretakers to make daily contribution of foods that have
been identified as positive deviant foods to the NERS sessions
Using peer support to encourage new habits
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
17
Overview Of The Hearth Nutrition Model
These strategies enable caretakers of young children to:
Gain the confidence necessary to embrace a new habit through direct and
repeated practice
Take responsibility for the rehabilitation of their malnourished child through their
daily food contribution
Continue to practice the new habits at home because they see positive changes in
the malnourished child's physical appearance and behavior usually within 2 NERS
(2 months).
8- Design training
To carry out the program successfully, managers need to invest time and effort in drafting and
implementing various training components. For example, the proficient implementation of a GMP
program requires 3 trainings interspersed during the first 6 months of implementation. The NERS
activity requires at least 3 trainings within 3 months of startup. Each training is carefully drafted to
include reviews of acquired skills, improvements when needed, and acquisition of new skills
(Appendix B).
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
18
Overview Of The Hearth Nutrition Model
Conceptual Framework for Designing a Hearth Program
Identification of Local Resources
• Village Health Committee
• Health Volunteers
• Formal and Non-formal Health Resources
Situational Analysis Of Malnutrition in Children
• Baseline Nutrition Survey
• Focus Group Discussions
• Settin
g
-u
p
Pro
g
ram Goals
Positive Deviance Inquiry
• Identification of Successful Feeding,
• Carin
g
and Health Seekin
g
Practices
Design Of A NERS Based On PDI Findings
• NERS Menu and Messages
• Positive Deviance Food Contribution
• NERS Protocols
• Integration with Other Existing Programs
Hearth Components
• Counseling Caretakers
• GMP Program
• NERS (Phase 1 only)
• Vital Events Monitoring
• Community Management of NERS
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
19
Assessing the Feasibility of Piloting a Hearth Program
PART II - ASSESSING THE FEASIBILIT
Y
OF PILOTING A
HEARTH PROGRAM
To realize the full benefit from the Hearth Program a proposed site needs to meet the following
criteria.
Minimum criteria for site selection
Prevalence of PEM malnutrition among young children of at least 30%
Availability of affordable local foods
Availability of mothers as potential volunteers in the community
Presence of committed leadership in the community
Assessing The Prevalence Of Malnutrition In The Area
Operational definition of malnutrition:
Underweight (weight for age) is a composite measure of stunting and wasting. It has been
chosen as the measurement of PEM malnutrition in the NERP because it is the easiest to
obtain and the most widely used indicator for malnutrition at the grassroots level and on
MOH "Road to Health" growth monitoring cards.
Locate and Review existing information on the prevalence of malnutrition in young
children (under 2, under 3 or under 5) in the area through the following sources:
Information Location
Demographic & Health Surveys (DHS) District Health Department, MOH
District Health Department or other
Nutritional surveys sources (UNICEF, MOH Nutrition
Department)
GMP program data DHS or local health posts, local CBOs
or NGOs
KAP surveys regarding child nutrition MOH, INGOs
Fertility rate Provincial or District MCH Department
Child mortality rate Provincial or District MCH Department
EPI coverage rate Provincial or District MCH Department
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
20
Assessing the Feasibility of Piloting a Hearth Program
Scenario 1:
If you plan to pilot a Hearth Program in communities where you are already involved in devel-
opment projects, and have access to recent (less than a year old) nutritional surveys from other
communities in the same district indicating a malnutrition rate (weight for age) of at least 30% in
the area, you do not need to carry out a sample nutrition survey at this stage.
Scenario 2:
If you need to select one or two villages within an impact area for piloting the Hearth Program,
conduct a sample survey of the nutritional status of children under age 3 or 5 years in several
villages to determine the malnutrition rate (weight for age) and to choose the most appropriate
localities for the pilot program, after reviewing all the other criteria.
Note: Generally, an underweight rate of around 30% (weight for age) of the surveyed age group
justifies the human and financial investment required to successfully carry out the Hearth Program.
However, in a site with high population density where the underweight rate is less than 30%, but
the absolute number of malnourished children is more than 100, the program may also be justi-
fied.
Besides high malnutrition rate, localities suitable for NERP are marginal poor rural communities
with high fertility and high child mortality rates.
Availability Of Local Food
Carry out an informal market survey. Visit local shops and small markets to inventory food avail-
ability and price. Interview the shopkeeper and find out who buys the food and ask about food
availability (seasonal or year-round, constant or sporadic).
Assess availability of home-grown food. Walk through the village and document the presence of
home gardens and their produce (including fruit trees), and interview villagers to establish the
cu
r
rent availabilit
y
of sta
p
le food.
Unlike relief feeding programs which only aim to rehabilitate children, the NERS aims to rehabili-
tate and SUSTAIN the enhanced nutritional status of malnourished children through the use of
locally available food. For this reason it would be extremely difficult to carry out the program in
areas where there are prolonged (more than 3 months) periods of household food insecurity.
Availability Of Mothers As Potential Volunteers In The Community
The program relies on the presence of mothers as volunteers to teach or provide peer support to
caretakers of malnourished children. Therefore, the presence of women in the community who are
willing to give some of their time for community activities is critical. More specific criteria are pre-
sented below.
Identify existing grass-roots level women's associations or clubs and discuss the topic of volun-
teerism with them. Assess their interest, willingness and availability to be potential "volunteers."
Identify existing community-based, government female health workers or volunteers.
Note: Because many women "volunteers" are poor, some Hearth Programs provide them with a
small stipend to compensate for lost income resulting from their volunteer activities.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
21
A
ssessin
g
the Feasibilit
y
of Pilotin
g
a Hearth Pro
g
ram
Presence Of Committed Leadership In The Community
During meetings and conversation with community leaders including, but not limited to, govern-
ment and religious leaders, school directors and local NGO personnel, look for statements of gen-
uine concern for the children's health situation in the community as well as the expressed desire to
improve it. The implementation of the program relies on the commitment and participation of the
leadership which would be difficult to elicit if they do not perceive malnutrition to be a problem in
their community.
Because the Hearth Program requires the participation of many people (caretakers of malnour-
ished children, women volunteers, teachers) in community-wide activities such as Growth
Monitoring and Promotion program and Nutrition Education and Rehabilitation Session, it is critical
that the leaders of the community (religious and/or secular) give their full support to the program.
Their support will be critical in the areas of community mobilization, decision-making and arbitra-
tion.
Note: Among the criteria listed above, the prevalence of malnutrition should assume a very high
priority among the criteria in your selection process. The NERP is designed for communities
with high levels of malnutrition in young children.
Example of decision making criteria
Main Criteria YES NO Comments
Prevalence of malnutrition
around 30% of < 36 month X
old children in the area.
Availability of local foods X Seasonal variety
Availability of mothers as Seasonal unavailability
potential volunteers X due to workload (planting
and harvest); low literacy
Presence of committed
leadership in the community X Especially the local CDA*
*Community Development Agency
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
22
Preliminary Steps: Getting Started
PART III - PRELIMINARY STEPS: GETTING STARTED
Now that you have selected your pilot sites, remember that the success of this program will
depend on a strong partnership between you and the community.
Tips to build
g
ood partnership with the communit
y
Before each visit to the community
Share with other team members the purpose of the visit(s) to the community.
Develop a short presentation about the purpose of each visit.
Practice your presentation with your team, and improve your presentation based on
feedback from your team.
Review with team members the information you are trying to collect, as well as the tools
you may use to collect the information (assessment forms, questionnaire, check lists).
Inform the village leader or community chief of date and time of your visit to discuss the
program.
During each visit to the community
Try always to meet and greet even briefly the leaders or the village chief
Discuss the purpose of your visit and what activities you would like to do and why.
Make arrangements for next visits: whom you need to meet, date and time.
Step 1 and 2 (below) may require multiple visits to the community.
Step 1: Assessing Community Organizational Resources With Your Local Partner
Meet with the village leaders and other key community members to discuss the following topics:
1. The health situation in the community, especially children under five years of age
2. The creation of a Village Health Committee if no such organization exists, or an
expansion of another existing village committee to include new members,
particularly women volunteers. The role of such a committee would be:
a) To manage and coordinate health activities at the local level
b) To set criteria and select and supervise women volunteers
c) To collaborate with the agency implementing the Hearth Program and with
appropriate district health personnel
Key community members include:
Hamlet leaders or chiefs
Teachers
Members of the formal health sector (if any)
Members of the informal health sector (traditional healers, TBAs, local medicine
vendor)
Religious leaders, tribal or caste leaders
Local groups, clubs, associations involving women, and NGOs
Individuals recognized by the community as opinion leaders, decision-makers,
and local "heroes"
Ste
p
2: Identif
y
in
g
Communit
y
Health Resources With Your Local Partne
r
Identifying private, non-formal and public health sector resources is critical to the success of the
Hearth Program, initially as a source of needed information and later for provision of services. For
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
23
Preliminary Steps: Getting Started
example, children who are identified at GMP sessions as 3rd degree malnourished will need to be
referred to the local health post. Decisions regarding universal deworming, protocols for Vitamin A
distribution, and appropriate content and reinforcement of health messages at NERS, all require
close linka
g
es with communit
y
health
p
roviders.
Example from Vietnam
Type of health providers in each village:
Commune Health Center TBAs Traditional Drug Retired Health
Healers Vendors Providers
Ngoc Linh 3 Midwives
Pop. <3428 Assistant Doctor 3 6 2 7
Head of Health Center
Tan Dan 3 Midwives
Pop. <3232 Assistant Doctor 1 0 3 3
Head of Health Center
1-Private and non-formal health sector resources
Identify the individuals involved in the non-formal health sector, especially the Traditional Birth
Attendants(TBA), traditional healers and drug vendors. These individuals are in many instances
the only health resource available to local people, and are often the first consulted by caretakers
when their child falls ill. The villagers often trust and respect traditional healers who also maintain
and shape the caretakers' health-seeking practices.
Meet with them separately and ascertain the number of sick children they treat per month and for
what ailment.
Make sure to use local dialect terms when referring to illnesses as names sometimes vary from
re
g
ion to re
g
ion, or district to district, or even villa
g
e to villa
g
e.
Who # Activities/treatments or ailments # Children/ # Clients/
month month
TBAs
Traditional
healers
Retired health
personnel
Others:
(drug vendors,
quacks)
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
24
Preliminary Steps: Getting Started
2- Public health sector resources (if available)
Meet with public health staff at the health facility. After introductions and explanation of the
purpose of visit, assess the human and infrastructure resources.
Identify each health worker's job and work schedule, extension activities, if any, and the type of
currently available services and health activities for children and women (for example, EPI includ-
ing tetanus vaccination for pregnant women, IMCI, Vitamin A distribution campaigns, deworming
campaigns).
3- Public health sector services
Existing health services Yes No Schedule Comments
Immunization
First Aid
Curative care
Health education
Environment sanitation
Antenatal care
Deliveries
Malaria treatment
MCH services
Family Planning
GMP
IMCI
Visit the health facility (including latrines) and assess cleanliness and availability of clean water
and soap. Do a quick inventory of essential medical equipment, supplies and medicines (such as
working refrigerator, syringes, needles, and common life-saving medicines [cotrimoxazole,
Fansidar, for example]).
Step 3: Helpin
g
The Communit
y
Select Mothers To Become Volunteers
Once the Village Health Committee (VHC) has been organized, meet with its members to carry
out the following activities:
Make a map of the community. The purpose of this activity is two-fold: to identify all households,
especially those at the periphery, and to guide the selection of volunteers who can serve all corners
of the community.
Select candidate volunteers from all neighborhoods to ensure better coverage. Health Volunteers
must be selected from each hamlet or neighborhood, or any unit which forms a homogenous com-
munity. They are responsible for up to 60 households. If a hamlet has more than 70 households, 2
Health Volunteers may be needed.
Describe tasks that Health Volunteers will be trained to perform. These include, but are not limited to:
• Weighing children and plotting their weight on growth chart
• Buying food (optional) and preparing it according to the set menu
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
25
Preliminary Steps: Getting Started
• Supervising caretakers in processing food, cooking meals and feeding their children
at NERS
• Teaching simple messages to mothers or other caretakers of malnourished children •
Keeping records (children's attendance, progress, food purchase)
• Reporting to the Village Health Committee
Develop criteria for selection of women volunteers with the Village Health Committee. Be cautious
about selecting volunteers who are close relatives of village leaders, unless they are qualified.
Criteria for selection vary from country to country but usually include:
• Willing to work as a volunteer
• Married woman with children living in the hamlet
• Respected and trusted by the community
• Can read and write (preferably 3 to 6 years of schooling)
• Eager to learn, open to new ideas
Exam
p
le: Criteria for HV selection: Save the Children
,
Ja
p
an
(
Ne
p
al
)
• Female, between 18 to 40 years of age
• Able to speak local dialect fluently
• At least 8 years of schooling
• From same Village Development Committee (VDC)
• Willing to work as a volunteer with a small stipend
• Accepted by the community
• Married and from a disadvantaged community/neighborhood
• Priority for selection given to trained government health volunteers
Step 4: Selecting a Local Nutrition Resource Panel
Marian Zeitlin suggests creating a Local Nutrition Resource Panel to strengthen the validity of the
Positive Deviance Inquiry without increasing the size of the sample. Once the community volun-
teers have been selected, invite two or more experienced local professionals (local clinic doctors
and/or wise grandmothers) to form the panel. Select health/nutrition workers, professionals or edu-
cated older women who are themselves positive deviants in that they already understand many of
the nutrition problems of their community and the ways in which poor positive deviant families suc-
cessfully cope. The purpose of the panel is to enhance the quality and validity of the Positive
Deviance Inquiry, described in Section V.
The Panel will be "silent participants" during the focus group meetings, and discussions with vol-
unteers and Village Health Committee on causes of malnutrition in the community (described in
Section IV). Their "silence" during these meetings will not only enable them to be excellent, active
listeners and recorders, but also will not interfere with the process of community discovery, central
to the positive deviance approach: learning from community members (positive deviants) to solve
nutrition problems with resources already existing in the community. The panel's role is detailed in
Part VI, Step 4 and Part V, Step 1.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
26
Conducting a Situation Analysis of Malnutrition with the Community
PART IV - CONDUCTING A SITUATION ANALYSIS OF
MALNUTRITION WITH THE COMMUNITY
Step 1: Reviewin
g
The Health Situation Of Youn
g
Children With Local Health Staf
f
Discuss and Identify the most frequent illnesses among young children treated at the health
center which usually include those listed below (request to look at the treatment registry).
• Diarrhea
• Acute Respiratory Illnesses (ARI)
• Worms in young children
• Other common childhood diseases in the community (measles, malaria, tuberculosis,
hepatitis, anemia, Vitamin A deficiency-night blindness)
Review EPI activity schedule and coverage (Coverage rates are rarely available at the village
level since the activity is usually carried out by the district EPI mobile team, and data kept at the
district EPI and epidemiology department.).
Identify levels and causes of under-5 child mortality. Seek both the "medical cause" (i.e.,
diagnosis) and the "system cause" (i.e., late care-seeking, unavailable or low quality care).
Create community "case histories" which document actual deaths of children under 5.
Identify usage of health facility by the community by reviewing the attendance log for the past
week or past month. This information will give you an idea of the villagers' confidence in the public
health workers and, to some extent, an indication of the perceived quality of care.
Discuss the prevalence of malnutrition and perceived causes of malnutrition in young children.
Step 2: Carrying Out A Nutrition Baseline Survey Of Young Children
A. Preliminary steps:
Because the Hearth Program is a resource-based program, you will want, to the extent possible,
to use survey tools which are already available and being used in the district or nationally.
The growth chart:
Select the most widely used weight for age growth chart in the country or the one currently in use
in the district. The most frequently used is the MOH/UNICEF growth chart. It will enable you to
compare survey results with those of the district at large.
Use scales that are available in the country and easy to use (UNICEF digital scales or Salter
scales). Remember to order enough scales to cover your needs for the whole pilot phase.
B. Before the survey, at community level:
Select the target group in collaboration with the VHC and in some cases the District Health
Department. Malnutrition rates are usually the highest among children 6 to 24 months of age with
consequences that persist throughout life, hence you must include at a minimum all children
under 2 years of age in any nutrition intervention. Other considerations for determining the target
group are:
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
27
Conducting a Situation Analysis of Malnutrition with the Community
• Total number of children in a given age group in the hamlet
• Ratio of number of children per volunteer
• The target group set up by the MOH guidelines for GMP
• Integration with other existing health activities in the community (EPI, PHC)
• Community capacity to implement the program
Example: Target age groups in current Hearth Programs include: children 12 months to 59
months (Haiti), 6 months to 23 months (Bangladesh), under 36 months (Vietnam, Mozambique),
under 60 months (Nepal).
Identify all children in the target group. This can be done in different ways. The best way is to
conduct a household registration of all families in the community. Another way is to register all
families with children in the target group.
Enlist and train or retrain local health workers and/or Health Volunteers in weighing children, plot-
ting and interpreting the growth chart, with particular emphasis on techniques to determine date of
birth. The training curriculum, which is exactly the same as used for the GMP, should also include
training in interpersonal skills and counseling to provide appropriate feedback to the family on the
current nutritional status of the child.
Explain to the community leaders the purpose of the nutritional survey and get their consent and
cooperation.
Identify and agree with community leaders on the number of weighing sites to ensure that ALL
children in target group will be weighed.
Create a roster of the children to be weighed with proper identification and addresses i.e., loca-
tion of housing. The roster will also include each individual child's nutritional status i.e., normal,
mild, moderate or severe based on the growth chart and birth ranking as well. This list is very
important, as it will enable the community and its partners to identify positive deviant children for
the Positive Deviance Inquiry.
Name of Village: _______________________
Name of Hamlet or Cluster: _______________________
Name of Local Chief or Leader: _______________________
Name of HV or weigher: _______________________
Date of weighing: _______________________
Child's Father's/ Birth F/M DOB Age Weight Nutritional Comments
Name Mother's Rank M/Y in mths Status
Name
1.
2.
3.
4.
5.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
28
Conducting a Situation Analysis of Malnutrition with the Community
C. During the survey:
Involve community members in the nutrition survey itself, especially health volunteers. If commu-
nity members are unable to do the actual weighing and plotting, they can mobilize their neighbors
and provide logistical support at the weighing sites.
Copy the necessary information on each child in the roster book at each weighing site.
Ensure that each family is informed of their child's current nutritional status on the spot (after plot-
ting the weight on the growth chart).
Include (optional) 1 or 2 questions for caretakers, during the survey, on diarrhea prevalence,
breast-feeding or complementary feeding as a baseline (Example: Has your child had an episode
of diarrhea in the last 2 weeks? i.e., 3 or more loose stools per day).
D. After the survey:
Tabulate results for each hamlet or neighborhood (sometimes called cluster) from the roster, using
the coding for level of malnutrition used in the growth chart (i.e., Vietnam - A, B, C, D categories;
Nepal- green, yellow, orange and red).
Name of Village: Tuy Loc
District: Hau Loc
Province: Thanh Hoa
Date of survey: January 1996
Name Total # # of Normal 1st degree 2nd degree 3rd degree Total
Hamlet children children (A)* (B)* (C)* (D)* B,C,D
(Cluster) < 3 weighed # % # % # % # % # %
Hamlet 1 48 48 17 36 11 23 18 38 2 1 31 65
Hamlet 1 59 58
Hamlet 1 37 37
Etc.
Total 372 369 128 35 110 30 126 34 5 1 241 65
*A > -2 Z; *B> -3Z and < -2Z; *C> -4Z and < -3Z; *D< -4Z
Step 3: Identifying Current Feeding Caring and Health Seeking Practices In The
Community
Identifying current practices in the community serves two purposes. First, it will enable you to
understand the "norm" or "conventional wisdom" regarding caring, feeding and health-seeking
practices in the community. When you cant' out the Positive Deviance Inquiry, it will enable you to
identify those behaviors or practices the positive deviants demonstrate which are different from
the norm. Secondly, it will also serve as a qualitative baseline against which you can later docu-
ment changes in feeding, caring and health-seeking practices as a result of the program.
Carry out focus group discussions to identify norms regarding child feeding, child care and child
health care in the community.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
29
Conducting a Situation Analysis of Malnutrition with the Community
Topics to explore in focus group discussion with mothers include:
• Breast-feeding practices
• Complementary feeding practices
• Workload
• Child caring
Topics to explore in focus group discussions with mothers and other caretakers as
your cultural context dictates:
• Beliefs regarding child-rearing
• Perception of causes of malnutrition in children
• Health-seeking practices in the community
Review and adapt the sample questionnaires (see Appendix C) on malnutrition to your cultural
and local context.
Keep a record of what you have learned about the local feeding, caring and health-seeking cus-
toms and beliefs.
Tips for facilitating group discussion:
• Choose an informal setting
• Create a congenial atmosphere
• Respect the group's ideas, beliefs and values
• Listen carefully and show interest in participants'
responses or exchange
• Encourage everyone to participate in the discussion
• Be observant and notice participants' level of comfort or discomfort
• Ensure that every one can voice their ideas or opinion
(See Appendix D: Results of Situation Analysis conducted in Nepal by SCJ)
Step 4: Assessing The Nutrition Situation Of Young Children With The Community
The community needs to acknowledge the nutrition problem and understand its causes in order to
identif
y
solutions from within the communit
y
to address it. Therefore:
Organize a meeting with the Village Health Committee and the Health Volunteers and outline the
purpose of the meeting:
• To explain what malnutrition is
• To report the results of the community's nutrition survey of young children
• To identify causes of malnutrition in the community
• To review the objectives for a nutrition program
Explain to participants the 3 conventional grades of malnutrition: mild, moderate and severe, with
visual aids (pictures, real children from the village, the growth chart).
Describe physical and behavioral symptoms of malnutrition in the young child. Highlight the fact
that mild malnutrition often does not have visible symptoms and that regular weighing or growth
monitoring is the only way to establish the nutritional status and growth pattern of the child, i.e.,
normal, faltering or malnourished.
Explain both the short-term and long-term adverse effects of malnutrition on young children.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
30
Conducting a Situation Analysis of Malnutrition with the Community
Report on the nutritional status of the children weighed during the most recent nutrition survey
using the 3 grades of malnutrition, indicating how many children are well-nourished, and how
man
y
suffer from mild, moderate and severe malnutrition.
Explore causes of malnutrition with the VHC and HVs from the information gathered during focus
group discussions with different groups. Help the VHC and HVs focus on current factors and prac-
tices that contribute to malnutrition in their young children. See examples of good and bad feeding,
caring and health seeking practices in the following section on Positive Deviance Inquiry.
After completing the community assessment, have the Nutrition Resource Panel meet to draft their
version of the forms (below), based on their own experience and additional information they may
have learned during their participation in focus group sessions and meeting with volunteers and
Village Health Committee. These will be used later as a cross-check against the findings from the
Positive and Non-Positive Deviance Inquiry described in Part V.
Qualitative Assessment of Successful Practices of Poor Families with
Well-Nourished Children (Appendices E-1 and E-2)
Good Feeding Good Caring Good Health Seeking
Practices Practices Practices
Qualitative Assessment of Poor or Harmful practices of
Poor Families with Malnourished Children
Poor Feeding Poor Caring Poor Health Seeking
Practices Practices Practices
Set up program goal with the VHC and HVs and make sure they actively endorse them.
Designing a Community-Based Nutrition Progr g the Hearth Model and th sitive Deviance Approach
31
am Usin e Po
Conducting a Situation Analysis of Malnutrition with the Community
Example of program goal from Nepal (SCJ):
• To rehabilitate children under 3 suffering from moderate and severe malnutrition
(weight for age, standard Gomez classification)
• To maintain the enhanced nutritional status of these children at home after
rehabilitation
• To prevent malnutrition in young children
Example of program goal from Vietnam (SC US):
• To rehabilitate identified malnourished children in the community
• To enable their families to sustain the rehabilitation of these children at home
• To prevent malnutrition in young children in the community
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
32
Conducting the Positive Deviance Inquiry
PART V - CONDUCTING THE POSITIVE DEVIANCE
INQUIRY
Background Information
The positive deviance approach in nutrition enables the caretakers of malnourished children to
rehabilitate them by adopting identified successful behaviors which poor families with well-
nourished children are practicing today in their community. These successful behaviors or
practices are identified through a Positive Deviance Inquiry.
Definitions for Positive Deviance Inquiry:
Positive Deviant Child (PD child): well-nourished child who belongs to a poor or very poor house-
hold. (Definitions of poverty are extremely relative and vary from community to community,
hence the term "poor" or "very poor" is used as defined by the local community.)
Positive Deviant Family (PD family): poor or very poor family which has a well-nourished child.
Non-Positive Deviant Child (NPD child): malnourished child from a poor family in the same
neighborhood as the PD family.
Non-Positive Deviant Family (NPD family): poor family with a malnourished child who
lives in the same neighborhood as the PD family.
Positive Deviance Inquiry (PDI): an assessment to identify the successful feeding, caring and
health-seeking practices of some poor families with well- nourished children.
PDI team: selected staff from the NGO, sometimes District Health Service staff.
Positive Deviant Behavior. a successful behavior or practice displayed by PD families which is
unique or not normally practiced by the majority of caretakers in that community, which
contributes to kee
p
in
g
the
y
oun
g
child health
y
.
Positive Deviant foods (PD food): nutritious foods that poor or very poor families feed their
children, which are not traditionally or normally fed to young children in the community.
By using these operative definitions the implementers are able to identify successful child
feeding, caring and health seeking practices which are accessible to almost ALL members
of the community, including the very poor.
Process Of The Positive Deviance Inquiry
Identify poor families with well-nourished children (PD families).
Compare these PD families with equally poor neighboring families with malnourished children (NPD
families).
Discover the successful feeding, caring and health-seeking practices which are likely to
enable the PD families to have well-nourished children.
Identify harmful practices or lack of good practices among NPD that are likely to contribute to
their children's malnutrition.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
33
Conducting the Positive Deviance Inquiry
Choose from the successful practices those that are accessible today to all members of the
community.
Use these practices as the basis for designing a Hearth Nutrition Program.
Note: In some Hearth Nutrition Programs, the Positive Deviance Inquiry compares practices
among PD families with families with higher socio-economic standard who have a malnour-
ished child (Negative Deviant families). The purpose of choosing Negative Deviant families for
the PDI is to demonstrate to community members that wealth does not necessarily guarantee
good child nutrition. For purposes of clarity and simplicity the PDI described below compares PD
families with NPD families.
Outline of the Positive Deviance Inquiry
The PDI is conducted in a village by
trained staff from the implementing
organization (the district health serv-
ices, the local partner agency or
NGO) with the participation of the
Village Health Committee members,
Health Volunteers and local members
of the formal and informal health sec-
tor. The PDI consists of home visits
to identified PD families and NPD
families. During the home visits, the
PDI team conducts a guided inter-
view with family members and makes
various observations. Ideally, home
visits occur at mealtime to observe
feeding and caring interactions
between the child and the mother, as well as with other family members.
The Spirit of the Positive Deviance Inquiry
The PDI often requires a transformation on the part of the PDI team members, demanding differ-
ent skills and attitudes than they may be used to. This change is often difficult for health providers
who are educated and confident in their knowledge. They may believe they "know the answers" to
community nutrition problems and can readily provide solutions to villagers. (For tips on ways to
remedy this potential pitfall, read chapter 1 in "Helping Health Workers Learn" by David Werner
and Bill Bower).
The PDI, however, requires team members to relinquish their knowledge and professional status
as TEACHERS to become LEARNERS, willing to learn from people who are poor and illiterate.
They must move from a position of power and control to a position of humility, embracing the
belief that there is indigenous wisdom in community people as well as unique coping skills which
ensure their survival in very difficult situations. The PDI is not a quantitative scientific study, but a
qualitative search for hidden solutions,"a treasure hunt" to discover or uncover unique and suc-
cessful ways by which individuals manage at the edge.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
34
Conducting the Positive Deviance Inquiry
Selection of the PDI team
The outcome of the PDI depends almost entirely on the ability of the PDI team to DISCOVER the
"successful special behaviors" of some local poor families. Therefore the selection of the PDI team
requires special attention. Lessons learned from failed PDIs point to certain necessary characteris-
tics in the individuals to be involved in the PDI. Team members do not need to be chosen exclu-
sively from the health sector. On the contrary, experience proves that staff from other disciplines,
like water and sanitation workers or agriculture extensionists, are often better suited to participate
in the PDI because of their knowledge of the local people, their openness and willingness to learn
from them.
Criteria for selection of staff to participate in the PDI
• Experience in working with communities
• Good communication skills
• Fluency in the local language
• Flexibility and open-mindedness
• Willingness to learn from non-specialists
• Demonstrated respect for local people
• Interested in child feeding, caring and healthseeking issues at the community level
Participation of District Health personnel
Although desirable in the design stage of the program, participation of district health personnel in
the PDI may jeopardize its outcome as their contact and experience with communities is often
very limited.
Training of the PDI team in conducting the PDI
Because the PDI is at the center of a Hearth Program design, it is essential that the PDI team be
well trained and prepared. On average, a training for the PDI will take 2 days. In designing the
PDI training, include the following two components.
1. The identification of household practices which contribute to or compromise good nutritional sta-
tus of local children. These often include practices of which the PDI team members may be
unaware, or whose contribution to the well-being of young children they may greatly underesti-
mate. Hence, an objective of the training is to enable the PDI team members to discover these
practices and their significance. The training activity consists of having trainees interview parents
of well-nourished children as well as parents of malnourished children in their neighborhood with-
out telling them what to look for (blind interview). This process enables them to discover by them-
selves what behaviors affect positively or negatively the young child's health.
2. The acquisition of good observation and interview skills with special emphasis on probing and
active listening skills through practice of role plays. (See Appendix F, Standard Curriculum for the
Trainin
g
of Trainers.
)
Tips for working with the community
• Develop trust among the community.
• Be flexible.
• Allow yourself and others to experiment.
• Celebrate mistakes for the opportunity they provide for learning.
• Do not take information at face value. Pursue the facts as they are, not as
people would wish them to be.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
35
Conducting the Positive Deviance Inquiry
• Deal with reality. Concentrate on what is, not on what should be.
• Be realistic in your expectations.
The Methods Used To Carry Out The PDI: Household Observations and Guided Interview
A combination of questions and observation techniques during home visits will enable you to iden-
tify the families' feeding, caring and health- seeking practices.
Observation
Direct observation is the most useful way to gather information on specific practices used by
Positive Deviant and Non-Positive Deviant families, particularly if home visits occur during meal-
time. Good observation allows you to assess whether knowledge of a good hygiene habit (like
washing hands before eating) is actually practiced. Observations will confirm or contradict what
the people say during the interview.
Observing is not a passive activity but involves all our senses, i.e., seeing, hearing, touch-
ing, tasting and smelling. Observations should include sites like the families' living and cooking
quarters, activities like cooking, interactions like a mother feeding a young child, situations like
a child refusin
g
to eat.
Before conducting the PDI, develop an observation check list according to your cultural and local
context with the PDI team. (See a sample Standard Observation check-list in Appendix G-1.)
(Optional) Design your own observation worksheet form to note specific practices or behavior, like
active feeding or hygiene practices. (See a sample of recording observation form in Appendix G-2.)
Guidelines to develop good observation skills
Have a clear objective for your observation.
Prepare a checklist of what you want to observe.
Share the checklist with the other participants and encourage input.
Be specific in your observations, i.e., the child ate 3 spoonfuls of the porridge.
Look critically (a covered water container, a well-kept home garden).
Note people's general demeanor, moods, and other non-verbal communication.
Guided Interview:
The purpose of the guided interview is to learn from the selected PD and NPD families, present
practices which affect the well-being of their children. Hence, the guided interview is a critical tool
on which the successful outcome of the PDI depends.
The guided interview takes place during home visits and involves direct questioning and open-
ended discussion with mothers, other child caretakers and present family members in their
homes. The guided interview is conducted by one interviewer, with another person recording the
answers in a notebook. The same questionnaire is used to interview PD and NPD families, or if
included, in the PDI Negative Deviant families.
The interview is based on a five-part question guide (Appendix H):
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
36
Conducting the Positive Deviance Inquiry
I Background information on the child and family
II Child feeding practices
III Child caring practices
IV Health-seeking practices
V Questions to other family members
Adapt the standard questionnaire to fit your local cultural context.
Design Part V of the questionnaire (questions to other family members):
Decide whom to interview besides the mother according to cultural norms. Select topics relevant
to the person interviewed. For mother-in-law/grandmothers, inquire about introduction of com-
plementary feeding, what foods are good for young children, what foods are not good, role in
deciding child's diet, home treatment of the sick child, and diet of the sick child, for example. For
fathers, ask about their role in child raising and feeding, and seeking help when the child is sick,
for example.
Examples:
• In Nepal, the mother-in-law decides on the menu for the daily
meals for all family members.
• In Mozambique, the maternal uncle of a young child is the most
im
p
ortant
p
erson after the mother.
It is highly recommended that the PDI team practice the questionnaire a few times beforehand to
be thoroughly familiar and comfortable with the questions, the communication skills of probing and
active listenin
g,
and the recordin
g
p
rocess.
Summary of the Steps For Conducting A Positive Deviance Inquiry
Step 1: Planning the PDI with the community
Activity 1:
Introduce Positive Deviance Review nutrition survey results.
to the community. Review the short term & long term effects of
malnutrition.
Review the program goals.
Identify the presence of Positive Deviant children.
Explain the purpose of visiting PD families.
Identify PD children & select 4 PD families from the
baseline survey roster.
Identify NPD children and select 4 NPD families from
the baseline survey roster.
Activity 2:
Review the participants' tasks Create home visit teams (4 people per team on average).
to conduct the PDI. Review the observation checklist and guided
questionnaire with participants.
Explain the trainers' tasks (interviewing and reporting).
Explain the participants' tasks.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
37
Conductin
g
the Positive Deviance In
q
uir
y
Decide on number of home visits per team per day
Activity 3: (usually 2 visits per day).
Review logistics for home visits. Schedule home visit (at meal time if possible).
Ask selected families' permission to visit them.
Ste
p
2: Conductin
g
the PDl/home visits of PD and ND families
Activity 1: Carry out the interview and record information
Conduct family interviews gathered through observations and questionnaire.
at home. Allow flexibility in time frame,
minimum 3 hours per visit.
Step 3: Selecting and documenting key successful practices from the PDI findings
Activity 1:
Compile the information on PD Compile information on each family on flip charts
and ND families. following the model matrix used for recording
information during the PDI.
Activity 2:
Select key practices from PD Identify PD nutritious foods, "good foods," and the PD
families that are accessible families' successful feeding, caring and health-seeking
to all caretakers in the practices.
community today.
Activity 3:
Summarize composite findings Make a matrix with 3 columns, summarizing the key
for successful practices as successful feeding (Good Food), caring (Good Care)
well as poor or harmful and health-seeking (Good Health) behaviors found
practices. in the community.
Write positive deviant and negative deviant case
studies as illustrations.
Activity 4:
Provide information on the Illustrate findings with a poster for the community.
results of the PDI to Investigate ways to communicate findings to
the community. the community.
Design a sample menu using PD foods with the VHC.
STEP 1: PLANNING THE PDI IN THE COMMUNITY
Note: In all interactions with villagers, PDI is simply called "Home visits to poor families with well-
nourished children." Similarly Positive Deviant children are referred to as "well-nourished children
from poor families," and Non Positive Deviant children as "malnourished children from poor fami-
lies." (If Negative Deviant children are included in the PDI they should be identified as "malnour-
ished children from better off families".)
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
38
Conducting the Positive Deviance Inquiry
The content of this section can either be included at the meeting in the community where the
nutritional situation of young children is assessed, (see page 19) or conducted in a separate,
subse
q
uent meetin
g
.
A. Introduce Positive Deviance to the VHC and Health Volunteers
At the meeting with the VHC members and Health Volunteers, review the following:
• The results of the nutrition survey
• The number and percentage of children who are malnourished
• The short- and long-term effects of malnutrition
• The objectives of the Hearth Nutrition Program
Identify Positive Deviant children in the community. Highlight the fact that there are a certain
percentage of well-nourished children in the locality. Ask VHC members and Health
Volunteers to look at the roster of children weighed during the survey and determine if any of
the well-nourished children come from very poor households. If "YES," highlight the
discovery that according to their survey, it is possible today for a poor family to have a
well-nourished child.
Sample dialogue between Trainer (T) and VHC members (V) to introduce the
Positive Deviance Inquiry
T: Why are we here?
V: To discuss ways to make our malnourished children healthy.
T: Let's look at the results of the nutrition survey. How many malnourished children
do you have?
V: Two hundred or 40% malnourished children.
T: How many well-nourished children do you have in your community?
V: Three hundred or 60% well-nourished children.
T: Now let's look at the list of children who are well-nourished. Are there any
well nourished children who come from a poor or very poor family?
V: Yes!
T: (With great surprise) You mean, it is possible for a very poor villager to have a
well-nourished child today in your community?
V: Yes!
T: Then, let's go and visit them to discover what they are doing to have a
well-nourished child despite their poverty. Then we can learn from them how to
solve our malnutrition problem using solutions that are already here in the
community. Let's go and find out what are the special good food and feeding
practices, the good child care, and the good health care practices they use
which contribute to their child being well-nourished.
The importance of the "discovery" that there are some well-nourished children
among the very poor families in the community cannot be stressed enough! Since
the entire program, including NERS menus and mothers' contributions, will be based
on the successful behaviors or practices identified during the PDI, it is critical that
the community understands its significance.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
39
Conducting the Positive Deviance Inquiry
Explain the purpose of the home visits to the participants: (1) to discover the successful feeding
practices (good food and feeding practices); the successful child caring practices (good child
care); and the successful health seeking practices (good health care) that enable some poor
families identified in the survey to have well-nourished children, and (2) to discover the harmful
practices or lack of good feeding, caring and health-seeking practices that contribute to malnutri-
tion in other children from the same poor neighborhood.
Identification of PD and NPD families
First, have the VHC look for all the well-nourished children on the baseline survey results roster.
Then ask them to circle or underline the name of those well-nourished children who belong to a
poor or very poor neighborhood according to local poverty criteria. (See example of poverty crite-
ria below.) Then request the VHC to identify NPD children living in the same neighborhood.
Selection of PD families and NPD families for the PDI
Review the common selection criteria for PD and NPD children and families with VHC.
Common Criteria for selection of PD and NPD families:
• The child must belong to the target age group (6-23, 6-35 or 6-59).
• The child must belong to a family with a minimum of 2 children.
• The 6 families should be representative of geographical (lowlands, coastal or highlands
areas) occupational (farmer, fishermen, tradesmen) and social (tribe, castes) groups
living in the village.
• The family with the PD child should have no severely malnourished children.
• The family of the PD child should have no severe or untypical social or health problems.
• The PD or ND children must be well at the time of the visit.
• The PD child should not be a very big baby who is losing weight now.
• The ND child should not be a very small low birthweight baby who is growing well now.
• The PD child should not have a food begging or scavenging personality.
Review additional considerations to select NPD children. Through brief interview with present
caretakers, ensure that the assessed malnourished status is not due to low birth weight (LBW) or
premature birth, physical or mental handicap.
Sort out children and families accordingly, then have the VHC select 4 PD and 4 NPD families
accordingly.
If Nutrition Resource Panel members can unobtrusively make informal home visits to the families
selected, they may identify conditions missed by the volunteers or VCH which could invalidate the
information potentially obtained from these families. In this case another family which meets the
criteria should be selected by the HVs and VCH.
(Optional) Use of wealth ranking to identify and select PD and NPD families.
Ask villagers to make a list of poverty indicators according to their village standard, such as type of
housing, occupation, ownership of land, possession of consumer goods.
Example: In Vietnam, Quang Xuong district, lowland farming area, poverty was defined as fol-
lows:
• Number of months per year the family went without rice (minimum 2 months)
• Mud house with straw roof
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
40
Conducting the Positive Deviance Inquiry
• No kitchen building
• Mud courtyard
• Sharing source of water with other families
B. Review the tasks to conduct PDI (home visits)
Participation of villagers
Form teams of 3 to 4 people to visit individual families. For example, in addition to the 2 members
of the PDI team, request the presence of 2 VHC members who know the neighborhood well and
can guide you to the families.
Review the purpose of home visits and explain the tools used to carry out the PDI. Review the
observation check list and
q
uestionnaire with the extended PDI team
(
s
)
.
Decide jointly individual members' roles. The 2 member PDI team conducts the guided interview
with the family and takes notes. All the team members observe the setting and the interaction
between members of family, listen to the interview and help the communication between the inter-
viewer and the family members when necessary.
C. Review logistics for home visits
Whenever possible, each team should complete 2 home visits, preferably with a PD family and a
NPD neighboring family.
Allow time for VHC members to meet the selected families to explain the purpose of the home
visit and secure their permission to be visited. It should be made clear to the families that they do
not need to prepare for the visit. Should the timing of the visit be unsuitable for the family, an
alternative date should be considered. In some cultural contexts it may be extremely difficult to
secure permission for a visit to the PD family since it may bring them some trouble (evil eye). In
such cases it will be necessary to find culturally acceptable ways to gather the necessary informa-
tion from PD families. For example, Health Volunteers may not publicly distinguish between PD
and NPD families, but rather keep those classifications private. They would then approach PD
families and merely say, "We are visiting several families in the community to learn about nutrition
and wonder if you would be willing to talk with us."
Plan to conduct the home visits around meal times.
Consider distance to household or between households to visit.
Allow a minimum of three hours for each family visit.
STEP 2: CONDUCTING PDI (HOME VISITS) AMONG PD AND ND FAMILIES
Establishing a friendly relationship with the family is key to the whole PDI process of the home
visit. It facilitates the interview and will enable the mother and/or other family members to relax
and respond more completely and accurately.
Tips for participants during PDI
• Be polite and respectful at all times.
• Follow a culturally acceptable time frame for introductions and getting acquainted.
• State very clearly the purpose of your visit.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
41
Conducting the Positive Deviance Inquiry
• Remember that you are there to learn and not to preach or teach.
• Avoid criticism or displays of dismay, annoyance and disapproval.
• Avoid similar signs of approval.
Conducting the guided interview of the family
The guided interview is usually conducted in the home compound. Specific topics such as hygiene
around food preparation and cooking are best discussed in the kitchen area so that the actual
utensils and methods used to process and serve the food can be observed. It also facilitates the
conversation and enables the interviewer to compare reported practices with observed behavior.
Remember to use probes (secondary questions) as a way to get more specific information after
the initial response to a question, or repeat the respondent's last phrase.
Example of dialogue using probe
Question: What food do you give your child in addition to breast milk?
Answer: Many foods
Probe question: What are they?
Answer: The usual foods, like rice and vegetables
Probe Question: Vegetables?
Answer: Yes, you know, like mustard greens or spinach
Avoid going through the entire interview all at once. Rather, focus on each part at well spaced
times during the 3 hour visit unless the caretakers are very busy. Encourage the caretaker or the
mother to go on with the business at hand and continue the conversation while they work. It will
make your interview more natural and congenial.
Guidelines for guided interview
• Make sure you ask all the questions to every family you visit.
• Involve caretakers other than the mother in the interview.
• When the answer to a specific question is vague, seek clarification by
rephrasing the question.
• When you are not sure you have understood the interviewee's statement,
summarize by saying, "Let me repeat. If I understand correctly..." Or
request confirmation: "Do I hear you say..."
• Use "situational questioning" to elicit more accuracy in the responses to your
questions. Example: ask about feeding practices while the mother is feeding the child;
ask about the food the child eats when the caretaker is cooking or processing food or
while talking in the cooking area.
• Avoid leading questions and practice active listening.
STEP 3: SELECTING AND DOCUMENTING KEY SUCCESSFUL PRACTICES FROM PDI FINDINGS
This is a critical step for planning the Hearth Nutrition Program. The information gathered on exist-
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
42
Conducting the Positive Deviance Inquiry
ing successful feeding, caring and health-seeking practices in the community will be used as
the basis for the nutrition program, enabling the families of malnourished children to sustain-
ably rehabilitate them.
A. Recording the information on each PD and NPD family:
After the visits to families have been completed, each team meets to compile information gath-
ered from the interview and observation of each family.
Have each team create a matrix with 4 columns on paper and fill in the specific information they
gathered from their notes on observations and questionnaire worksheets.
Model Matrix to Compile Information on Each Family Visited
Family # 1 Feeding Practices Care Practices Health Seeking
Information Practices
• Name of child • Breast-feeding • Active feeding • # diarrhea*
• Age of child schedule • Food hygiene episode in the
• Nutritional • Special good food • Body hygiene last 15 days
status • Frequency of • Feeding hygiene • Home treatment
• Birth order of feeding • Child supervision of child with diarrhea
child • Quantity & care • Feeding the sick
• Breast-feeding • Complementary • Family members' child &providing
status foods relationship with extra food & fluids
• Caretakers' • Content of last meal child during recovery
period
names • Snack foods • Caring behaviors • Breast-feeding
• Family • Feeding behavior • Others during child's illness
occupation • Other observations • Identification of signs
• Description of of sickness
household • Seeking help for
garden, animals, treatment of sick child
cooking & eating • Vaccinations
place • Others
* Diarrhea: 3 or more loose stools in a day
B. Consolidating individual teams' PDI findings:
Prepare two summary flip-charts with 4 columns: one for all PD families, the other for the NPD
families (or negative deviant families if they are included in the PDI).
Ask each team to present the findings on their home visits on the summary flip chart. Use one
summary flip chart for all PD families' profiles. Encourage the reporter to make a lively account of
each family visited, in a story telling fashion, with detailed observations. (See example from
Vietnam below.
)
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
43
Conducting the Positive Deviance Inquiry
Summary table of PDI findings in 3 PD families from Cau Loc commune, Hau Loc district,
Than Hoa province, Vietnam.
Household Good Foods Good Child Care Good Health Care
Good Feeding
• Linh, M, 24 months • 4 meals a day • Father and grand • Complete vaccination
• 3rd child • shrimps, fish or crabs, mother look after the • Deworming once a
• Mother is dead vegetables and fruits child, teach him to year
• Channel A • Cook food in talk, walk and play • The child is taken to
rendered pig's fat health post timely
when sick
• Hien, F, 8 months, • Breast milk • Mother is main • Deworming every
• 4th child • Shrimps or fish and caretaker 8 months
• Channel A sauropus (green • Child is clean
vegetables) • Mother wash hands
• 3 meals a day before eating
• Quyen, M, 6 months • Breast milk main food • First 3 months mother • Vaccination on track
• 4th child, • Exclusive Breast- only caretaker, now • Use of traditional
• Channel A feeding for 5 months grandmother and medicine for small
• Complementary food older sister illnesses
now (broth with pig's • Love and care by all
bone) members of family
C. Selecting key practices from PD families
Identify and circle in the second column, "feeding practices," the foods which PD families feed
their children, i.e., foods which are not normally fed to young children in this community, also
called PD food or "good food."
Identify and circle in the third column, "caring practices" that are practiced by PD families and
accessible to all.
Repeat the same in the fourth column for good health seeking practices.
Criteria for selecting key good practices
• Accessible to all caretakers of the community today
• Unique or different from the norm; not part of the conventional wisdom
• Replicable
Note: Some successful practices may be "True But Useless" (TBU) because they cannot be
acted upon today by all members of the community. Example: use of medicine to treat the
sick child because an uncle works at the district hospital and has access to free medicines.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
44
Conducting the Positive Deviance Inquiry
Identify and acknowledge the poor practices or lack of good practices among the NPD families
that contribute to their child's malnutrition.
D. Summarize composite PDI findings
Make a composite matrix compiling results from all PD family visits. (See example from
Mozambique and Nepal, below.)
Ask participants to name the "good foods," "good feeding," "good child care", and "good health
care" practices available in the village.
Compare with the harmful practices (or lack of good practices) among NPD families (or the
Negative Deviant families if included in inquiry.
After the participants have had the opportunity to share their findings on the composite matrix,
invite the Nutrition Resource Panel to share its matrix prepared after the community assessment.
If their findings confirm those listed, the positive deviance inquiry is likely valid. If there are major
discrepancies, you will want to probe further holding discussions with the volunteers, participants
and the panel until there is a consensus. Adjust the composite matrix accordingly.
Write one or two case studies on Positive Deviant family home visits to document your findings. (See
case study narrative, Appendix I). More importantly these stories can be used as "narrative" in the
community, since many cultures place great importance on oral histories, value and remember them.
Potential PDI Pitfalls and Solutions:
All PDI are not necessarily successful, as noted in the following scenarios:
1. No PD families can be identified in the neighborhood because of the small number of
children in the target group. It may be difficult to find PD families in neighborhoods with less
than 50 children in the target group. If the community context is similar to a nearby neighbor-
hood where the PDI has been conducted successfully, the PDI findings can be "borrowed"
from that community, provided that the community knows where findings came from.
2. No PD behavior can be identified in the selected PD family. Occasionally some PD children
may be thriving in families whose feeding, caring and healthseeking practices are not different
or more successful , or may be even worse than their NPD counterparts. This child may simply
be unusually aggressive and have the drive and coping skills to get food, no matter what.
"True, but useless!"
3. During the PDI, the NPD child is found to be malnourished because he or she suffers from
chronic diarrhea or repeated infections or secondary illnesses like malaria. If after close exami-
nation of the case during the review session, it is concluded that the child's malnutrition is not
due to any harmful household practices or due to lack of good practices, this case should be an
opportunity to stress the role of repeated infections in malnutrition and the necessity to develop
appropriate strategies to deal with this problem.
Through the interview on health-seeking behaviors, you may discover, however, that the family
treated the child with repeated self-prescribed medication or, on the contrary, did not recognize
illness or take early action. While reflecting on NPD families, this lack of good household
behavior needs to be highlighted as potential contributing factors to malnutrition, that is, unnec-
essarily severe, prolonged or mis-treated illness.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
45
Conducting the Positive Deviance Inquiry
4. The PDI is inconclusive because of the PDI team's inability to discover the PD behaviors
through observation/interview or analysis. In this case, the PDI should be repeated after the
cause of failure has been identified and appropriate measures taken. For example, retraining
the PDI team on communication skills, especially probing, or rescheduling the PDI to enable
the PDI team to observe the family during a meal, or during meal preparation.
5. The PDI fails to identify PD foods (special foods or foods that are not usually fed to young
children). In some cultural contexts it may not be the food that constitutes the Positive Deviant
behavior because every family has access to nutritious foods. The PDI, however, may reveal a
striking difference between PD and NPD families in the caring and healthseeking behaviors
(as evidenced in the SC/US nutrition program in Egypt where no PD foods were found but
where active feeding and good hygiene seemed to be the defining PD behavior).
Positive Deviance Inquiry Results Mozambique (November 1997)
Successful practices identified through home visits to Positive Deviant families
Good Feeding Practices Good Caring Practices Good Health Seeking Practices
• Porridge made of • Covered drinking • Complete vaccination
cashew, fruit, molasses water container • Purchase of medicine
& manioc flour • Wash food before with prescription only
• Use of cashew nuts or processing • Appropriate usage of ORS
peanuts in "Mathapa" • Washing hands package or homemade
(local dish) before eating equivalent for diarrhea
• Seafood • Supervision of young
• 4 kinds of leafy children at all times
vegetables • Supervision or
• 3 meals a day assistance of young
• Introduction of child at meals
complementary
feedin
g
at 5 months
Poor or harmful practices identified through home visits
to Non-Positive Deviant families
Poor Feeding Practices Poor Caring Practices Poor Health Seeking Practices
• Only 2 meals a day • No principal caretaker
• No cashew nuts • Water container
or peanuts in food not covered • No vaccination
• No vegetable in • Child not clean &
daily diet no food hygiene
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
46
Conducting the Positive Deviance Inquiry
Positive Deviance Inquiry Results Nepal
Successful practices identified through home visits to poor families with well nourished children
Good Feeding Practices Good Caring Practices Good Health Seeking Practices
• Breast-feeding up to 30 • Mother feeds the child • Child fully immunized
months herself • Cool bath when child has
• Introduction of comple- • Use of different strategies a fever
mentary feeding between to encourage eating when • Deworming
4 to 6 months the child refuses to eat • Seeking treatment of the
• Feeding the child 4 to 5
• Mother gives advice to sick child at health post
times a day secondary caretaker • Giving Jeevan Jal (ORS)
• Feeding the child many • Good body hygiene when child gets diarrhea
kinds of food, including (regular baths, cutting • Treatment of colds &
wild food (berries, snails, nails & combing hair) coughs with turmeric &
frogs) • Hand washing before ginger tea
• Feeding the child an early eating
morning snack • Water tap is clean &
drinking water covered
• Daily massage with
mustard oil
• Father helps in care of
children
Poor or harmful practices identified through home visits to Negative Deviant Families
(wealthy * families with malnourished children)
Poor Feeding Practices Poor Caring Practices Poor Health Seeking
Practices
• No complementary feeding • Lack of interest in the • No special diet for
of child over 6 months child displayed by adult sick child
despite availability of food caretakers • Mothers don't know about
in the home • Lack of body & Jeevan Jal (ORS)
• No vegetables in the diet environmental hygiene preparation
• Only rice and salt for • Mother needs mother- • Use of cow dung for the
complementary feeding for in-law's permission to treatment of pneumonia
child up to 15 months old feed the child new • Mother needs permission
foods from her parents-in-law to
take child to health post for
vaccination
• Seeking treatment only from
traditional healers
* According to community standards
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
47
Conducting the Positive Deviance Inquiry
STEP 4: PROVIDE INFORMATION ON PDI FINDINGS TO THE COMMUNITY
Have team members make a poster to illustrate the successful practices that enable even a very
poor family to have a well-nourished child.
Discuss ways for the Village Health Committee to spread the information to the community at
large, such as informing villagers at community meetings, displaying posters at the market place,
school, health center, community center, village meeting house.
Create a sample chart based on the PDI findings regarding food (PD food) with the Village Health
Committee. To illustrate the variety of food necessary to ensure adequate growth in the young
child, develop a poster on a flip chart or draw on the ground 4 squares (the 4 food groups) and
draw in the food that PD families feed their children or place in the squares the actual foods that
constitute an adequate meal. If cultural context permits, invite Positive Deviant mothers to partici-
pate in this activity.
Explain the value of each category of food in relation to child's growth, in addition to mother's
milk.
Example from Nepal (mountainous region)
Note: PD foods in bold print
Pulse or rice, maize, millet, potatoes,
Snails, frog, goat, chicken, pork, crabs, fish
Vegetables: different kinds of spinach,
green beans,onion leaves, eggplants, Ghee, oil
peas, pumpkin, onions, ginger and garlic Peanuts
Fruits: wild berries, banana, lemon,
mullberries, orange, guava, mango
Explore with the Village Health Committee the availability of food throughout the year by making a
seasonal food calendar using PRA techniques. This activity can also be carried out when creating
a NERS menu. (See next Chapter on creating NERS menus.)
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
48
Designing a Hearth Nutrition Program Based on PDI Findings
PART VI: - DESIGNING A HEARTH NUTRITION
PROGRAM BASED ON PDI FINDINGS
Once the Positive Deviant families' successful practices have been identified, the next step is to
use them to develop your Hearth Nutrition Program, which will enable the families of malnourished
children as well as other community members to ACCESS and ACT upon this new knowledge.
Nutrition Education And Rehabilitation Session (NERS)
The design of the Nutrition Education and Rehabilitation Session (NERS) component of the
Hearth Program is based on the PDI findings. The NERS provides a skill-oriented learning envi-
ronment where caretakers learn to rehabilitate their malnourished children under the supervision
and the support of trained volunteers.
NERS Participants
To choose what category of malnourished children will participate in the NERS depends on the
overall number of identified malnourished children in the community. For instance in both the
Nepal and Vietnam Hearth Programs, the large number of second and third degree malnourished
children dictated that only these children were targeted for rehabilitation. Other Hearth Programs
targeted all malnourished children in the community (i.e., Bhutan, Egypt and Mozambique).
Identifying "NERS Centers" With The Help Of Health Volunteers
Criteria for selection of the NERS center or neighborhood kitchen:
Must be easily accessible for the participants
Must have enough space to accommodate a group of 8 to 15 children and
their caretakers
Must have a source of clean water and a latrine
Must have adequate kitchen space for 3 or more women to process food and
cook a meal for 8 to 15 children
Note: The NERS center is often the home of the Health Volunteer
Setting A Nutrition Education and Rehabilitation Session Schedule
To help your community partners decide on the NERS schedule, consider with them the daily
availability of the Health Volunteers. Also remind your community partners that the NERS is
time-limited in its implementation, i.e., it is usually carried out over a 6 to 10 month period
depending on the rehabilitation rate and number of participants.
Characteristics of NERS:
The NERS are usually carried out on a monthly basis. NERS are also scheduled to follow soon
after the monthly or every other month GMP session at which time newly malnourished children
have been identified to participate in the next NERS. The timing also allows the assessment of
the current nutritional status of NERS participants, determining their eligibility to participate in
another NERS.
The NERS run for a sufficient number of consecutive days every month to initiate the child's reha-
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
49
Designing a Hearth Nutrition Program Based on PDI Findings
bilitation and to allow the caretaker to be comfortable practicing the new skills in a supportive
environment. Most Hearth Programs run the NERS for approximately 12 days per month.
As critical as the participation in the 12-day NERS, is the post-NERS period during which caretak-
ers practice the newly acquired skills at home on their own.
Example: NERS Schedule, Vietnam (12 days a month)
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
NERS* NERS NERS NERS NERS NERS Off
NERS NERS NERS NERS NERS NERS* **
** ** ** ** ** ** **
** ** ** ** ** ** **
** ** **
* Participating child is weighed
** Rehabilitation of child by caretaker at home on their own
Deciding on the NERS Daily Sessions Schedule
On average the daily NERS class lasts about 2 hours from preparation to clean up after the meal.
Caretakers of participating children usually cant' out kitchen duties on a rotating basis. The sup-
plemental feeding activity itself takes about 1/2 an hour. The daily NERS meal is an EXTRA meal
and should be scheduled halfwa
y
between other
p
lanned dail
y
meals.
Creating NERS Menus Incorporating The PD Foods
NERS menus are based on findings from the PDI and use meals which the positive deviant fami-
lies cook and feed their well-nourished children. However, because the participating children in the
NERS are malnourished, total calorie and protein intake must exceed the daily normal require-
ment. Thus each child's portion should be from 600 to 800 calories and contain 20 to 30 grams of
p
rotein.
Besides speeding up the child's recovery, this extra meal also enables the mother or other care-
taker to observe visible changes in the child within the first 2 weeks of rehabilitation. Encouraged
by these positive results, the mother is more likely to continue the rehabilitation of her child at
home on her own, increasing the frequency of feeding and the amount and variety of food she
uses in her meals.
In most Hearth Programs participating families contribute the PD foods and some fuel and the initiat-
ing NGO partner provides whatever else is required. In some programs, however, participants con-
tribute all the ingredients to the NERS meal (Mozambique, Tanzania). In these cases the participants
must be told how much of each ingredient to bring in order to ensure that each child's portion has
enough nutritional value.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
50
Designing a Hearth Nutrition Program Based on PDI Findings
Criteria for making NERS menus
• Design 3 or more menus to be repeated at least twice within each monthly NERS.
• Each menu should provide between 600 to 800 Kcal per child serving.
• Include special foods identified through the PDI and contributed every day by the
caretakers of the malnourished child.
• Use locally available food.
• Use affordable food.
• Use food rich in vitamin A and other micronutrients (fruits and vegetables).
• Use animal products and fat whenever available and affordable.
In Vietnam, the National Institute of Nutrition endorses the use of food squares to illustrate food
varieties and groups. Each big square represents a menu with its ingredients. In the example, PD
foods are in italicized bold; the Day 6 menu completely relies on PD foods.
Developing_ NERS Education Components
Although behavior change is promoted through learning by doing, other strategies can be used to
reinforce the concepts behind the new practices.
Choose the educational medium which suits best your cultural context and the concept at hand.
For example, in communist Vietnam, verbal and written messages work best given the political
culture and high literacy rates. In Nepal, visual games and songs are most effective. In Islamic
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
51
Designing a Hearth Nutrition Program Based on PDI Findings
Egypt, quotes from the Koran work best.
Each day of the NERS a new health related topic is introduced through situational discussions and
illustrated by an educational medium such as a song, an appropriate game or a message. (See
Appendix J). Topics covered include, but are not limited to: breast-feeding, variety and frequency
of feeding, complementary feeding, child caring practices, health-seeking practices and the abili-
ty of participants to keep their children healthy at home on their own by following existing success-
ful practices (PD behaviors).
If you choose messages, ensure that they are short, simple and clear, motivating and achievable.
(A good reference for messages is the UNICEF booklet, "Facts for Life".)
Messages should highlight, illustrate or summarize what caretakers have been learning by doing.
Examples of NERS topics from SC/Japan:
Day 1: Breast-feeding
Day 2: Good foods for our children
Day 3: Supplementary food
Day 4: Good childcare
Day 5: Good health care
Day 6: Care of child at home (PD behavior)
Day 7: Safe Motherhood
The following is a more detailed description of NERS topics used by Africare in Tanzania:
1. Exclusive breastfeeding for 4 - 6 months
2. Increased use of PD foods: groundnuts, beans, milk (for non-breastfed children), and
fruits and vegetables
3. Increase number of meals and snacks per day
4. Improved household feeding and body hygiene
5. Management of diarrheal disease with ORS, continued feeding foods and fluids and
supplemental feeding after illness
6. Importance of child spacing
7. Prompt care-seeking in the case of illness (malaria, diarrhea)
8. Use of impregnated mosquito net
9. Importance of active feeding and close supervision
Example of NERS messages from Vietnam:
Day 1 Message: Breast-feeding
"Breast milk is the best food for the child. It helps protect the child against disease and fosters
a strong relationship between mother and baby. Keep breast-feeding until 24 months".
Day 2 Message: Variety of Food
"We must give children under three a variety of foods three to five times a day. These foods
include the "Good Foods" which some very poor families feed their well-nourished child and
which are available in our commune. We can make a "colored bowl" of these nutritious
"Good Foods" which are..."
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
52
Designing a Hearth Nutrition Program Based on PDI Findings
Day 3 Message: Complementary Foods
"From four to six months, in addition to breast milk, we need to give children additional food.
We can start by giving them soft rice gruel and gradually give them a thicker mix of rice flour
cooked in shrimp, crab, fish or vegetable broth."
Day 4 Message: "Good Child Care"
"Children need people to take care of them, feed them, play with them and guide them. Good
child care will help the child grow healthy, bright and able to love people."
Day 5 Message: "Good Health Care"
"We can prevent diseases from affecting children by:
Keeping the house, the children's bodies, and their food clean
Taking children for immunization to prevent serious diseases
Timely bringing of sick children to the health center for treatment
Weighing young children regularly to detect malnourishment at an early stage."
Day 6 Message: Taking care of the child at home
"Families can continue to maintain and improve their children's health at home by using:
The "Good Foods" available in the commune which are...
The "Good Child Care" and "Good Health Care" they have learned from the Model Families
(PD families) such as..." (The facilitator uses the Model Family poster which was created
after the PDI in that community)
*A "colored bowl" represents a healthier, more varied, more colorful meal (with greens, egg,
bits of fish, beans) than the typical, less nutritious, monotonous meal (white rice).
Developing Strategies To Promote Behavior Change
To meet the second goal of the program, i.e., to enable the caretakers of the malnourished child
to maintain their enhanced nutritional status at home, integrate lessons learned from the PDI in
your Hearth Program to promote behavior change in both the caretakers and the community at
large in the following ways.
1- At the household level
Require the daily contribution of the PD foods by caretakers as "price of admission" to the
NERS. This mandatory daily food contribution is critical for the sustained rehabilitation of the mal-
nourished child because it enables the caretaker to change habits by adding a new, demonstra-
bly successful food to the child's diet. It is, therefore, necessary to include the purpose of this spe-
cial daily food contribution in the daily NERS protocol.
The importance of the daily contribution can not be over-emphasized. It is this feature of the
NERS which, likely accounts for its success and separates it from many traditional programs
where participants are "taught" how to feed their children. The daily contribution focuses on
"changing behavior" rather than "transferring knowledge." Of course, once the participants
have witnessed the impact of their new behavior on the enhanced nutritional status of their chil-
dren, they do internalize and "own" the new knowledge. However, the NERS reverses the tradi-
tional learning paradigm from "knowledge leads to behavior change" to "behavior change leads to
knowledge."
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
53
Designing a Hearth Nutrition Program Based on PDI Findings
If caretakers "forget" to bring their contribution they are allowed to participate that day, but if they
fail to bring their contribution the next day, they are not be allowed to participate that day. If the sit-
uation does not improve, the VHC or traditional community mediators may be asked to help solve
the problem. In some Hearth Programs all the food is contributed by participants; thus, when a
caretaker forgets to bring her food contribution, the repercussions for the group are far reaching.
Example of daily protocol in NERS for health Volunteers ( Vietnam):
• Preparation of NERS center to welcome caretakers and their malnourished children
• Collection of the PD food contribution from each caretaker
• Processing the food and cooking the meal with assistance of 2 or 3 caretakers
• Cleaning hands and faces of children before the meal
• Review the NERS objectives and discuss today's message with caretakers
(while the food is cooking: 20 to 30 minutes)
• Supervision of caretakers while feeding the children
• Supervision of cleaning up (washing children's faces and hands, cooking utensils
and bowls, mats)
• Reminding caretakers to bring their PD food contribution to the NERS the next day
and explaining why this contribution is so important
Examples of PD food contribution (Vietnam, Nepal):
Vietnam:
Lowland areas: fresh or dried river or paddy shrimp, or crabs and greens
Seaside areas: fresh or dried sea fish or shrimps and greens
Mountainous areas: groundnuts and greens
Nepal:
Mountainous areas: vegetables, wild fruits, crab or fish
Lowland areas: crabs, grains, pulses
Require the active participation of caretakers in all aspects of the NERS such as food processing,
cooking, and clean up.
Include successful feeding, caring and health-seeking practices identified during the PDI in the
NERS protocols such as:
• Washing hands before processing food, before and after eating
• Supervising the child during the meal
• Encouraging the child with poor appetite
• Demonstrating the use of the ORS package for oral rehydration
• Identification of danger signs for Diarrhea and ARI or other non-specific danger signs
Seek the commitment of the participating families to continue at home to feed the child the
meals they have learned to prepare and use during the NERS.
In cases where the caretaker of the child is an older sibling, the Health Volunteer pays home visits
to the family to ensure that the goals of the program are well understood by the parents and/or
other decision makers in the household.
Involve key family members other than the mother (fathers, mother-in-law) in the rehabilitation
process through home visits. Health Volunteers pay home visits (monthly or every other month)
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
54
Designing a Hearth Nutrition Program Based on PDI Findings
to the families of NERS participants to ensure that all the caretakers are actually continuing the
child's rehabilitation at home.
Other strategies to support behavior change in the NERS include:
• Selection of mothers with healthy children as volunteers (Bangladesh)
• A special menu on the last day of the NERS which consists of only the PD food,
(i.e., food any family in the community can afford), plus the main starch ingredient
in the local diet and some fat (Vietnam)
2- At the community level
Develop with villagers simple, multi-channel, multi-targeted messages based on the successful
nutritional habits of Positive Deviant families. In Vietnam, in some villages NERP messages have
been adapted for use in the school curriculum on health and hygiene. Other communities have
used the public address system to propagate NERS messages at health events such as EPI and
GMP sessions.
Involve decision makers and opinion leaders in the program (i.e., religious leaders, teachers, tra-
ditional healers, drug vendors) and rally their support for initiatives to promote good feeding, car-
ing and health seeking practices among their constituencies.
Promote dissemination of information on good nutritional practices at community events.
Integrate NERS concepts and messages into other community-based activities or projects such
as parenting programs (Redd Bama Nepal and SC/Japan) and Safe Motherhood (SC/US in
Vietnam, SC/Japan and Redd Barna in Nepal), agriculture (kitchen gardens), animal husbandry
and forestry programs (Bhutan).
Examples of other community-level activities and initiatives, Vietnam:
• A Nutrition Day including a competition for the Best Health Volunteer
• Participation of community men at introductory session of all HV trainings
• A "commercial" shop set up by a village family, selling low cost (5-10 US cents)
meals to community members
• Children's puppet show about "Good food, good care and good health" at
community-wide meeting
• Posters featuring food squares and PD food placed throughout the community at
meeting hall, clinic, and school
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
55
Other Hearth Nutrition Program Components
PART VII: - OTHER HEARTH NUTRITION PROGRAM
COMPONENTS
I. GROWTH MONITORING AND PROMOTION
Purpose Of The GMP Program
• To enable families to know the current nutritional status of their child and monitor
his/her growth over time.
• To identify "at risk" malnourished children for enrollment in the NERS.
• To enable the community to monitor the aggregated nutritional status of all target
group children in the community over time.
Description of the GMP program
The GMP program involves the regular weighing of young children to ensure that they are growing
normally. A GMP program may already be in place in the communities where you plan to have a
Hearth Program. It may be implemented by the district health mobile team as a joint EPI/GMP
activity or by local health providers. In general, GMP programs are difficult to implement and are
plagued with problems such as poor coverage and poor accuracy in plotting the weight on the
growth chart. Often caretakers are unwilling to make the effort to bring their children to the GMP if
no real benefit is perceived, for example, if a caretaker is told that her child is malnourished but
not given counseling or follow-up plan.
In the context of the Hearth Program, the GMP program is a community-wide activity, which
involves community mobilization and participation and provides follow-up. Health Volunteers and
other community members join the local health providers (if available) or carry out the activity by
themselves in a decentralized fashion, at neighborhood level. These trained individuals weigh the
children, assess their current nutritional status and provide immediate feedback to their caretak-
ers. Beside praising and encouraging the caretakers whose children are growing normally, the HV
counsels caretakers of children whose growth is faltering and identifies malnourished children for
immediate enrollment in the next Nutrition Education and Rehabilitation Session (NERS). Children
who are sick are referred to the local health post or the district hospital for treatment.
The Hearth Program provides an opportunity to collaborate with the District Health Department by
training or retraining health staff and allowing local community members to learn the skills to carry
out the GMP in more remote areas, hence increasing the GMP program coverage and usefulness.
The GMP Schedule
The GMP program is carried out monthly or every other month and requires the weighing of ALL
children in the target group. It is a key approach to identify malnourished children and secure their
enrollment in the NERS. If the GMP program is not currently available in the community:
Ascertain the community capacity to mobilize parents of young children for the GMP.
Consider other scheduled health activities in the community, such as EPI, to see if GMP can be
integrated with those interventions thus maximizing overall impact.
Steps To Plan The First GMP Session
Ensure that you have enough scales (100 gram calibration) and a good supply of child growth
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
56
Other Hearth Nutrition Program Components
charts, Health Volunteers, and a GMP Roster Book.
Develop the curriculum for the first GMP Training Session.
Set up a meeting with the VHC to plan the first GMP (who?, what?, where?, when?)
Update the roster of children in the target group from the baseline survey, including children born
after that date and any deaths which may have occurred.
Identify the people to be involved (local health providers, teachers, Health Volunteers). It takes a
minimum of 5 people to carry out a GMP session at each site: the local chief or leader, the Health
Volunteer, one or two trained staff (local health providers or partner NGO staff) and a community
male volunteer. The trained staff can rotate between different GMP sites over a two-day period,
enabling them to cover all sites.
Schedule and carry out the GMP training with identified individuals.
Decide on the number and location of GMP weighing sites, each with 3 stations: welcoming area,
weighing area and plotting/counseling area. If possible, weighing should be carried out at a local
neighborhood site where approximately 60-100 children could be weighed. A population of 5,000
p
eo
p
le with 400 children less than 36 months would ideall
y
re
q
uire a minimum of four GMP sites.
Mobilize the community through your community partners.
Agenda for meeting on planning the first GMP with the community
• Review the overall goals of the Hearth Program and what has been done to date
• Purpose of the GMP component of the program
• Description of the GMP program
• Inventory of manpower necessary to implement the program
• Selection of a GMP coordinator and implementers (HVs and others) at the
village level
• Schedule and logistics for first GMP training
GMP trainings
Because of the importance of this activity throughout the life of the program, GMP implementers
need to learn and maintain the basic skills needed to implement the program successfully (plotting
the weight of the child, interpreting the growth curve, counseling the caretaker, consolidating and
reporting results). Hence it is necessary to cant' out at least 3 GMP trainings over the first year of
implementation with an additional refresher training in the second year. Not only local health
providers and health volunteers, but also chiefs, leaders and others can learn to weigh and plot.
GMP Session Results
The monthly or every other month GMP session results are consolidated during a Village Health
Committee meeting to assess the current nutritional situation of all children in target group.
Note: In some settings prone to gender biases, implementers are encouraged to compile GMP
session results also by gender at least twice a year.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
57
Other Hearth Nutrition Program Components
Example from Mozambique:
Cabo (village) GMP Session (every other month
Name HV Chefe de Children Children Normal 1st 2nd 3rd Total D* M*
Zone < 3 Weighed Degree Degree Degree 2nd 3rd
# # # % # % # % # % # %
Total
Date of weighing: _________ Name of Cabo: ______________________
* D = died, M = moved out
GMP "Score Boards"
Create GMP "score boards" to enable the community to visualize the progress of the program
over time. The type of display will vary by culture and context.
Example from Vietnam
GMP 1
,
(
11/93
)
GMP 5
,
(
7/94
)
GMP 13
,
(
11/95
)
Example from Mozambique
In the SC/US Hearth Program in Nacala-a Velha, community score boards consist of wooden
sticks all of the same length. After each GMP, the proportion of well-nourished to malnourished
children is painted on the stick. Red zone for malnourished children and green zone for well-nour-
ished children. The sticks are kept at the Cabo's house (village chief).
II. VITAL EVENTS
Another component of the Hearth Program is the monitoring of vital events by the community. The
purpose of monitoring vital events is to enable villagers to have a greater awareness of what is
happening in their community and to better understand the causes of maternal and child mortality
in order to initiate activities to reduce their incidence in the the future. Some Hearth Programs
include a Safe Motherhood initiative in their second phase; others integrate a Hearth Program
with their current Safe Motherhood program.
Health Volunteers with the help of TBAs and local health providers (if any) monitor vital events
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
58
Other Hearth Nutrition Program Components
and update their family registration book accordingly. Vital events include births, deaths, particular-
ly infants and children under 5 years of age, maternal deaths, and in- and out-migration. They
report on vital events in their neighborhood to the VHC on a regular basis. In addition to reporting
the counts, volunteers tell the story behind deaths, providing valuable information on the circum-
stances and often shedding light on causes which galvanizes the community to action.
III. COMMUNITY MANAGEMENT
Using the UNICEF "Triple A" approach: Assessment, Analysis and Action, the Village Health
Committee carries out the followin
g
tasks:
1. Assessment of health events in the community
Through periodic meetings, the Village Health Committee reviews and assesses the following:
• Vital events (births, deaths, migrations)
• The current nutritional status of all children in the target group (based on the results of
the last GMP weighing)
• The current nutritional status of children participating in the NERS and number of
malnourished children who will participate in the next session (based on the results of
the last NERS and number of newly identified malnourished children from last GMP)
Individual Health Volunteers present the results of the latest NERS in their neighborhoods. The
results are aggregated to get a community-wide assessment of the progress of the NERS.
Example from Vietnam:
Results of a monthly NERS activity:
Name Hamlet Total Gained No Gain Lost Children Absences
of HV Children Weight Weight Graduated (deaths,
# illnesses)
# % # % # % # %
TotaI
2. Analysis and Action
Analysis of current NERS implementation
VHC members create a check list to monitor the status of program implementation. They discuss
problems such as the need for temporary HV replacements (funerals, wedding, sickness), poor
HV performance, and issues impacting the quality of NERS. They then identify solutions and
actions required to address the problems. These usually involve improvements in program deliv-
ery and provision of additional training.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
59
Other Hearth Nutrition Program Components
Example: Analysis and Action NERS Check List (Vietnam)
Items Analysis/Problems Solutions/Actions
Participation of caretakers
Caretakers' PD food contribution
Cooking tools, cooking
NERS menus (seasonal adjustments)
Buying food
The NERS food
The NERS messages
Counseling caretakers
Help from community members
NERS schedule (seasonal adjustment)
Health Volunteers problems
IV MONITORING AND EVALUATION
Setting up impact objectives for the Hearth Nutrition Program
Although it is very difficult to predict the rate, speed and sustainability of nutritional enhancement
of children in the community before the program even begins, it is useful to set quantitative objec-
tives against which the community and partner
NGO can later measure the efficacy of program
implementation. These objectives may prove to be unrealistically high or low and may need to be
adjusted accordingly, however, they do provide a goal towards which everyone can strive.
Example of objectives:
1. To achieve a 50 % reduction of malnutrition in the target group by the end of the
first year implementation
2. To further decrease malnutrition by 30% in the second year of implementation
3. To rehabilitate 80% of malnourished children participating in the NERS by the end
of the first year
4. To sustain the rehabilitation of 80% of the same children by the end of the second year
5. To reduce the gender gap in malnutrition by 50%
Tools:
Baseline nutritional survey
GMP session results after one and two years of implementation
Possible Impact Indicators:
1. # and % of malnourished children at baseline, after one year, after two years
2. # and % of children who participated in NERS and were rehabilitated
3. # and% of children in the target group who died in the first year
4. # and % of children in the target group who died in the second year
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
60
Other Hearth Nutrition Program Components
5. # and % of girl children who were malnourished at baseline
6. # and % of girl children who were malnourished after one year of implementation
One year after the NERS program has been discontinued:
# and % of NERS participants who remained well-nourished
# and % of NERS participants who have died
Over the life of the NERS (usually 6 to 10 months), the following indicators may apply:
# and % of malnourished children who participate in the NERS
# and % of NERS participants who "graduate" after one NERS, two NERS, three NERS
# and % of NERS participants who relapse
Example from Vietnam:
Summary results of nutritional status of all children under 3 over 1 year
Note: It is extremely important to set and monitor knowledge and especially behavioral objec-
tives intermediate to achieving impact.
Examples (Highlights of Qualitative Impact Assessment Appendix K)
1. Introduction of nutritious complementary foods in children 6-11 months of age
2. Exclusive breast feeding for about 4-6 months
3. Practice hand-washing before food handling
4. Caretaker knowledge of danger sign recognition in young children
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
61
Other Hearth Nutrition Program Components
Tools:
Focus group discussions at the beginning and end of the program can provide information regard-
ing changes in feeding, caring and health seeking behaviors. Home visits to ascertain the use of
new practices and random conversations with community members are also useful. Resources
permitting, KPC surveys can assess reported behavior, yet questions of actual behavior practice
ma
y
remain.
In addition to the 4 standard components of the Hearth Program described above, the following
interventions are often jointly carried out as well:
V. DEWORMING
Deworming can be carried out at GMP sessions for all target children (over 6 months of age) once
or twice a year following MOH recommended dosage for each age group (Vietnam) or caretakers
can be encoura
g
ed to deworm their children durin
g
the NERS-
(
Redd Barna, SC/Japan
)
.
Preparations for distribution at GMP sessions include:
• Purchase the deworming tablets. In Vietnam this distribution is subsidized by the
partner agency during the first year of program implementation and subsequently
by the local People's Committee.
• Instructions to the caretaker on how and when to give the child the single tablet
deworming medicine
• Recording the deworming date on each child's growth chart
VI. VITAMIN A DISTRIBUTION
Vitamin A is a micro-nutrient that plays an important role in vision, cell differentiation, bone growth
and especially in resistance to infection. Children between the ages of six months to 6 years are at
greatest risk of Vitamin A deficiency. Because their nutritional demands are high, their consumption
of Vitamin
A
-rich foods can be limited, and infections can deplete bod
y
reserves of this vitamin.
Deficiency also occurs when absorption and utilization of Vitamin A are compromised. Infections
and/or low consumption of fat, oils or proteins often cause this. Foods containing fat or oil are
needed b
y
the bod
y
for
p
ro
p
er absor
p
tion of Vitamin A and
p
rotein, for its
p
ro
p
er utilization.
Impact Of Vitamin A Deficiency On Children's Health
A common sign of Vitamin A deficiency is night blindness. Even sub-clinical deficiency is associat-
ed with an increased risk of infection (diarrheal disease and severe respiratory infection) and even
death. If you work in an area of high child mortality and high childhood malnutrition, if there is doc-
umented incidence of childhood blindness or "night blindness," or if the diet of young children is
low in fat or oil content, Vitamin A capsule distribution may be an appropriate component of the
nutrition program. It must, however, be consistent with the MOH policy. Vitamin A supplementa-
tion in areas of Vitamin A deficiency can reduce child mortality by 23% to 34%.
Logistics for Vitamin A Distribution
Secure MOH permission to distribute the Vitamin A.
Locate where Vitamin A capsules are available (usually at the district or provincial health depart-
ment).
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
62
Other Hearth Nutrition Program Components
Assess the quantity you need for distribution according to MOH policy.
Plan to distribute the Vitamin A capsules at GMP sessions.
Instruct health providers or HVs to follow MOH guidelines for Vitamin A dosage for each age
group.
Remind the HVs to record the distribution of Vitamin A capsule on each child's growth chart
.
VII. MATERNAL AND CHILD HEALTH
This component of the program is critical for the prevention of malnutrition in young children, espe-
cially "newbom malnutrition" or low birth weight. Because maternal health care plays an essential
role in the well-being of the fetus, newborn and infant, many Hearth Nutrition Programs include a
Safe Motherhood initiative or a Maternal and Child Health component.
This program is predicated on the fact that healthy women have healthy babies. Activities may
include: improved antenatal care, delivery and post-delivery care at home or at health facilities;
home-based counseling in maternal diet during pregnancy and after delivery; delivery prepared-
ness (identification of danger signs, reducing workload); colostrum intake and exclusive breast-
feeding promotion. Vitamin A distribution to post-partum mothers, as well as good health-seeking
practices for the infant, including vaccination and participation in the GMP program.
The program objectives can include but are not limited to:
• Providing women with access to quality prenatal care
• Ensuring cleaner and safer delivery
• Promoting good health-seeking behaviors among pregnant women, postpartum
mothers, their families and community regarding pregnancy, delivery and the post
deliver
y
p
eriod for the mother and infant.
Depending on the community capacity to cant' out the program and the availability of MCH servic-
es at the local level, a range of activities can be implemented which have direct and lasting impact
on the nutritional status of both mother and child. The Maternal and Child Health component can
be introduced from the very beginning of the NERS program as is done in Nepal or in the second
phase as in Vietnam.
Example: Nepal/SC Japan: Safe Motherhood Program (NERS phase 1)
• Situation analysis including PDI
• Training TBAs in clean delivery
• Establishing antenatal clinic
• Promoting anti-tetanus vaccination
• Promoting iron supplementation for pregnant women
• Training Community Health Facilitators in pregnancy and antenatal care, nutrition
during pregnancy, care during delivery and post-partum care
• Breast-feeding promotion
• Vitamin A distribution to post-partum mothers
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
63
Other Hearth Nutrition Program Components
Example: Vietnam/ SC/US: Healthy Mother Healthy Baby/MCH Program (NERS phase 2)
• Situation Analysis (evaluation, case studies and survey, done during NERS Phase1)
• Pregnancy Monitoring: minimum 3 prenatal check-ups with counseling, iron
supplementation and anti-tetanus vaccination
• Home-based counseling by Health Volunteers through 4 visits to women and
their families.
• Monthly review of MCH activities at the monthly Village Health Committee meeting
including: vital events (i.e., miscarriages, abortions, stillborn, live births, perinatal and
neonatal deaths, case studies of obstetric emergencies and outcomes).
• MIS for MCH activities: a monitoring system in place at both community and district
level, including a reporting flow of the MCH data from the community to the district
MCH Department and feedback to the community health post.
• MCH training at community level: (1) public health providers: prenatal care, maternal
nutrition, delivery and post-partum care, monitoring and reporting (2) TBAs and
private providers: danger signs, referral guidelines, clean delivery care and post-
partum care.
• MCH training at district level: TOT in MCH, including pregnancy monitoring,
sterilization of instruments, management and supervision skills, monitoring village
level staff and reporting.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
64
Collaboration With District Health Personnel
PART VIII: - COLLABORATION WITH DISTRICT HEALTH
PERSONNEL
Role of District Health Services
Advantages
A strong endorsement, involvement and participation by the district health office in the Hearth
Program can significantly enhance its overall impact and potential for "scaling up." As described
elsewhere in the guide, linking and integrating hearth activities such as GMP with ongoing district
activities at the village level can enhance villagers' participation and provide "value added" to both
activities. Required referrals of village children to district health facilities are usually much
smoother and more successful when district health personnel are already aware of and supportive
of the Hearth Program.
If a Maternal and Child Health/MCH component is implemented as part of the Hearth Program, the
district health services can play a vital role in training public health providers, TBAs and private
providers in clean delivery and post partum care, recognition of obstetric "danger signs," referral
guidelines, sterilization of instruments, and so on.
The district health office can in turn benefit from Health Volunteer data on children's nutritional sta-
tus and vital events as it is almost always more accurate than that collected by outsiders or from
facilities. Rosters used for the GMP can also assist EPI teams in reaching maximum coverage
during village EPI campaigns. Village data from a closely monitored MCH Hearth component can
make an invaluable contribution to district health personnel's understanding of "the reality" of
maternal and child health conditions and outcomes at the village level.
The active participation of district health personnel during the pilot phase of a Hearth Program
can be invaluable at a later stage when "scaling-up" to other communities in the district is
desired. In Vietnam, for example, the district provided trainers for Health Volunteers in new pro-
gram villages during the Hearth expansion period.
Disadvantages
There are, however, certain problems and potential pitfalls related to the participation of district
health personnel. In reality, very few of the countries in which the Hearth Program has been imple-
mented have district health personnel with either the skill, will or experience to work at the commu-
nity level. With the exception in a few countries of mobile EPI teams, district level health personnel
rarely if ever visit the village.
Another issue to consider is the inordinate power vested in "higher-ups" in many developing coun-
tries. District health personnel may often be extremely intimidating to local villagers and leaders.
Their involvement in early stages of the Hearth Program implementation (i.e., PDI, creation of the
NERS) can potentially jeopardize the adult learning approach of the model, by replacing the
desired "bottom up self-discovery and experimentation" with top down commands and orders.
Hence, it is important to decide within your local context at what point district health participation
will be most useful and to strike a balance between the potential benefits and risks inherent in that
involvement.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
65
A
pp
endices
APPENDICES
Appendix A
Regional Profiles of Positive Deviance Feeding Practices:
Supplementary Information (Zeitlin, MR 1996)
Asian Subcontinent -- Afghanistan to Nepal and Bangladesh: Cultural misunderstanding of
the child's developmental readiness to eat adult foods. Child is perceived to be physically "ready
to eat adult foods" at a later age than is justified by modern nutritional science, i.e., after the child
can walk, after back teeth have erupted, after child can feed him/herself - or not until 18-24
months. Adult meals of rice, flat breads, spicy sauces with vegetables and animal food ingredi-
ents, may be given in small tastes or not at all before this age. Breastfeeding continues past two
years. Widespread lack of soap and clean water, and poor hygiene may make long reliance on
breastmilk and late feeding of perishable foods protective.
Positive deviant feeding profiles:
Family foods and nutrient-dense animal and vegetable foods are given in adequate
quantities before the age of 15 months
• Parents have a scientifically accurate understanding of the child's maturational time-table
and nutritional needs and actually do what they say (not just lip service)
Good food and personal hygiene
Special foods given to the child:
Porridges/puddings made with cereal grain, sugar and milk, butter fat or other oil.
Soft rice cooked with dal or mung beans
Milk products: water mixed with yogurt (lassi)
Snacks and sweets: e.g. puffed rice, sweets prepared with milk, flour, sugar and oil,
• Halvahs
Fruits in season, particularly mangos and citrus
East and Southeast Asia-Burma to Korea-also Malaysia, Indonesia, Philippines:
Starches and liquids of inadequate nutrient density are given too early, e.g. sweetened rice gruel,
soft rice, clear or noodle soups, tea or soft drinks. This causes stunting and vitamin A and iron defi-
ciency. Frequent sweet and starchy snacks may fill child with empty calories and cut appetite for
meals. Unregulated sometimes toxic food additives.
Positive deviance profiles:
Exclusive breastfeeding for six months followed by sustained breastfeeding
Replacement of thin rice gruel by thick enriched gruel/soft rice and by soft adult foods
before nine months
An inexpensive food of animal origin or soya, fed in sufficient quantity to meet
micronutrient needs
Oil or fat in the diet
Fruits or green or yellow vegetables for Vitamin A and other micronutrients
• Supervised balanced and scheduled meals
Sub-Saharan Africa:
Watery maize, sorghum or millet gruels may be started too early, be force-fed, and fill the child with-
out providing adequate nutrients. Working mothers can't let the infants on their backs grow too
heavy to carry. Meal time is a teaching event-more essential for educating the child than for her
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
66
Appendices
nutrition. Food is communal property. The individual's share depends on seniority, social skills and
ability to help oneself appropriately and unobtrusively. Children learn these rules by observation
and example, particularly around the family bowl. Children below 5 may have no right to help
themselves to nutritious foods from the common bowl (W. Senegal); or they may be given tiny por-
tion sizes proportional to their low rank (W. Nigeria). Fathers permit favored 1- 3 year olds to join
their private meals. Adults and children may eat only once or twice a day. Indulgence in frequent
meals may be seen as character weakness.
Positive deviance profiles:
Gruels for infants are enriched with soy, peanut paste, niebe, cowpeas, milk, egg etc.
Former pastoral milk-drinkers keep milk products as part of child's diet
Diet contains red palm oil and seasonal fruit
Five or more meals or snacks per day:
• Child receives regular adult supervised extra meals or snacks in addition to and apart
from the main family meals, i.e., nutritious meal/snack in kitchen with mother during
food preparation; fruit or biscuits brought by father or others; eats privately with father or
with mother or both together; grandmother or auntie gives food treats.
• Parents understand the relationship between good nutrition and success in school and
that they need to discipline the child through verbal explanations rather than relying on
food distribution and other object lessons alone for moral training.
The Middle East, Mediterranean, North Africa and the Gulf States:
Ample quantities of starchy foods with sufficient fat content are offered to infants and young chil-
dren, but dietary diversity, foods of animal origin and fruits and vegetables tend to be lacking.
Hygiene often is deficient.
Positive deviance profiles:
Exclusive breastfeeding for six months followed by sustained breastfeeding
Presence of animal foods, fruits and vegetables
Clean drinking water
Good household hygiene, regular deworming
Rural Areas of Latin America:
Monotonous diet of maize and beans, rice and beans, or potatoes is bulky, fibrous and insufficient-
ly dense in micronutrients to promote good growth.
Positive deviance profile:
Presence of animal foods, fruits and vegetables
Frequent active feeding to compensate for low palatability
Urban areas of Latin America, the Caribbean, South Pacific, and Urban Poverty Zones of
Other Poor and Rich Countries: Diet heavy in cheap fatty processed convenience or "junk"
foods, fried crisps, sweets, soft drinks; low grade foods imported to the area, with few fresh or
local foods.
Positive deviance profiles:
Exclusive breastfeeding for six months (if culturally possible) followed by sustained
breastfeeding
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
67
Appendices
Home cooking, organized meal times and supervised meals
• Home or community gardens
• Concepts of home economics- planned shopping and food stocks
• Knowledge of "good foods" and ability to make wise food choices
• Fruits and vegetables
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
68
Appendices
A
ppen
di
x
B
Characteristics of Training
Training plays an important role in the Hearth Program. All training has the following characteris-
tics
Participatory: all trainings use interactive and participatory techniques
On-going, process oriented: each training follows the pattern:
1. Training...
2. Activity...
3. Feedback...
4. New training...
5. Improved activity...
6. Feedback
Example: the GMP activity requires 3 trainings over a period of 6 months
Skill oriented and practical:
1. Starting from participants' experience
2. Building on existing knowledge and skills
3. Extensive practice of newly acquired skill or reviewed skill
Community-based: all trainings take place in a community
Multi-targeted: training sessions involve different groups in the community to ensure clarity of
understanding and consistency of program goal, objectives, activities and messages.
Example: In Vietnam, hamlet leaders (predominantly male) are invited to participate in the
introductory part of all trainings.
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
69
Appendices
Appendix C
Sample Question Guide For Focus Group Discussions On Malnutrition
Note: Precede fact-finding questions with the expressions "usually" or "normally" or "in your
village," precede attitudinal questions with the expressions "in your opinion," or "according to
you."
1-Questions for mothers of young children
Breast-feeding habits:
1. When does a mother start breast-feeding after delivery?
2. What do women in your village do with the colostrum? And why?
3. Up to what age does a mother usually breast-feed a child?
On complementary feeding;
4. At what age (month) are food or liquids other than milk introduced?
5. What is the first weaning food made of? How long is it used?
6. What foods are considered healthy for young children? Why?
7. What foods do mothers avoid feeding young children? Why?
8. How many times a day do young children get fed (meals and snacks)?
9. Do people other than the family also feed the child?
10. What problems do you have feeding your young children?
11. Who decides what the child can or cannot eat in the household?
2. Questions for mothers and other caretakers of young children
On common caring practices
1. How often are young children bathed? Hands washed?
2. How much time do you spend away from your children daily?
Health-seeking practices
1. What do you feed the child when he/she is sick?
2. When a child is sick, what foods should be avoided?
3. When a child is sick, whom do you seek for help first?
4. When your children have diarrhea, what do you do?
3. Questions for caretakers. Health Volunteers and members of VHC
Common beliefs about child sickness:
1. What common diseases do children in your community suffer from?
2. What illnesses or diseases most concern parents?
3. What causes children to have diarrhea?
4. What causes young children to have worms?
5. How can we get rid of worms?
6. What makes a child malnourished?
Common health-seeking practices:
7. What are the remedies people use against common illnesses?
8. What is a common remedy for diarrhea?
9. What do parents traditionally do to protect their children from illnesses?
10. What is your opinion about the local health staff?
11. In your opinion are vaccinations good for the child? Why?
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
70
Appendix D
Example of Situation Analysis Results (Nepal)
Area Current practices
Local health services • Services: inadequate, unreliable, no referral system
Staff: unskilled and unmotivated, underpaid, constant turn-over
• Health post: lack of equipment
Feeding practices • Colostrum is not commonly fed to the newborn
• In many cases newborns are fed goat milk, and breast-feeding is established
after one week
• Low frequency of breast-feeding the infant during the day because of
mother's workload
• Late introduction of complementary feeding
• Weaning takes place early; almost all children are weaned between
9 and 12 months
• Lack of variety of food for young children; they are usually fed soup made of
pulses and left-over rice
Caring practices • Young children are not supervised during feeding
• Young children are under the care of untrained older siblings
• Young children are not supervised at all
• Poor body and food hygiene in the community at large
Health-seeking practices • Little utilization of local health facilities
• Seeking treatment of sick child by traditional healers or "quacks"
• Low vaccination coverage
• Poor utilization of ORS
• No special food during illness and no extra food during recovery
• Food taboos during illnesses
Maternal and Child Health • No antenatal care available
Low antitetanic vaccination coverage
• Untrained TBAs assist women at delivery
Use of unhygienic method to cut the umbilical cord
Husbands and mother-in-law do not help women during pregnancy and
post-partum period
High workload throughout pregnancy
• Poor maternal diet during pregnancy and after delivery; soup with molasses
for 6 days after delivery
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
71
Appendix E-1
Examples Of Good Feeding. Caring and Health-Seeking Practices
GOOD GOOD GOOD
FEEDING PRACTICES CARING PRACTICES HEALTH-SEEKING PRACTICES
• Exclusive breast feeding for about 6 • Positive and caring interaction between • Frequent breast feeding during and after
months child, caretakers and other family members child's illness
• Frequent breast feeding on demand, • Supervising the young child at all times
including night feeding, up to 24 months
• Introducing appropriate complementary • Using good hygiene around food: • Mixing and administering ORS, or
food at around 6 months washing hands before processing appropriate home-made equivalent
and handling food fluid, correctly, during episode of diarrhea
• Keeping drinking water covered
• Feeding the young child food with the • Using good hygiene around feeding the child: • Treatment of the sick child:
appropriate consistency for his age • washing child's hands and face before eating • Prompt recognition of danger signs
• Semi-solid foods around 6 months • Child does not eat food picked up • Timely seeking appropriate care when
• Soft foods 6 to 11 months from the ground the child is recognized as seriously sick*
• Finger foods/snacks around 9 months
• Food from the family pot at 12 months
• Feeding a variety of foods daily in • Using good body hygiene: • Continued feeding and increased
addition to breast milk: vegetables and • washing hands with soap after defecating, fluids during illnesses
fruits, animal products and toileting child; keeping nails short, • Increase feeding immediately after illness
keeping away from human and
animal excrement
• Feeding the infant • Active feeding: Feeding slowly • Getting the child completely immunized:
(6 to 12 months) at least 3 times and patiently • Taking infant for measles immunization
a day • Assisting the older child who feeds himself as soon as possible after the age of
• Encouraging the child with poor appetite 9 months
• Taking infant for immunization even
when sick
* Looks unwell, not playing, not eating or drinking, fast or difficult breathing, high fever, excessive vomiting, lethargic or difficulty
in waking, convulsions
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
72
Appendix E-2
Examples Of Poor Feeding. Caring and Health-Seeking Practices
POOR POOR POOR
FEEDING PRACTICES CARING PRACTICES HEALTH-SEEKING PRACTICES
• Early introduction of food or liquid • Lack of child supervision around feeding • Reduction or complete cessation of
other than breast-milk breast feeding during child's illness
• Delayed introduction of complementary • Forced feeding, lack of interaction • Cessation of breast feeding
food in the breast-fed child during feeding during maternal illness
• Poor management of child with no appetite
• Premature weaning • Poor or lack of body hygiene • Food restrictions during episodes of illness
• Traditional food restrictions in the • Poor food hygiene and unsafe • Failure to identify danger signs and
diet of young children drinking water usage delayed seeking help for treatment
of the sick child
• Food taboos related to religious beliefs • Poor hygiene around feeding: • Using harmful remedies to treat sickness
or tribal or caste customs no washing child's hands before eating
• Lack of variety in the daily diet of the • Traditional gender biases regarding feeding • Seeking and following unqualified help
young child in the treatment of the sick child
• Poor frequency of feeding • Lack of positive interaction between • In case of diarrhea, failure to use
(<2 meals a day) child and caretaker or improper use of ORT
• Not enough food at each feeding • Lack of continuous supervision of the • Restricted access to health services
young child due to traditional customs
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
73
Appendices
Appendix F
Standard Curriculum for the Training of Trainers in the Use of the Positive Deviance
Approach in designing a Nutrition Intervention Based on the Hearth Nutrition Model
(October 98)
Module 1 Learning about Malnutrition
1.1 Local language terminology of malnutrition
1.2 Types of malnutrition; signs of malnutrition
1.3 Facts about malnutrition & adverse effects of malnutrition
1.4 Causes of malnutrition (UNICEF framework); country and district specific analysis
Module 2 Orientation to Positive Deviance Approach
2.1 Analysis of needs and conventional approaches to solve malnutrition
2.2 Positive Deviance Approach: a new way to look at old problems
2.3 Positive Deviance and Nutrition; translation in local language (local proverbs)
2.4 Positive Deviance Inquiry and sustainability (investigating local ways-proverbs to
illustrate self-reliance)
2.5 Understanding and exploring the role of household behaviors (feeding, caring and
care-seeking) in health
2.6 Program design; conceptual framework
Module 3 Conducting a situation analysis of malnutrition in the community
Qualitative assessment: Assessing the traditional or normal feeding, caring
and health-seeking behaviors in the community
3.1 Purpose of qualitative assessment; relation to Positive Deviance Inquiry
3.2 Review of existing information on traditional, wide-spread practices (KAP surveys,
anthropological studies or monographs), participants' experience, etc.
3.3 Identifying the different groups for FGD (including volunteers, decision makers,
caretakers of young children)
3.4 Skills and steps to cant' out focus group discussion
3.5 Review and adaptation of FGD questions according to cultural context audience,
content
3.6 Logistics for carrying FGD; selection criteria for participants
3.7 Compiling information
3.8 Role play
Field work: Conducting Focus Group Discussions in the community
Module 4 Conducting a situation analysis of malnutrition in the community
quantitative assessment : Assessing the current nutritional status of all
target group children (baseline survey/GMP 1 )
4.1 Conceptual framework/preliminary steps (review)
4.2 Purpose, tools: scales, growth charts, roster of all children in target group,
weighing slip
4.3 How to identify month of birth, plotting and assessing current nutritional status
of child
Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach
74
Appendices
4.4 Feedback to the mother or caretaker after plotting
4.5 Organizing the weighing site (welcome/registration, weighing, plotting &
counseling stations) and role-play.
4.6 Compiling results: community profile, malnutrition rates, malnutrition by sex and by
age groups
Optional other information: prevalence of diarrhea and fever
4.7 Exploring ways to illustrate results and giving feedback to the community and
creating community score board
Module 5 Preparing for the Positive Deviance Inquiry
5.1 Review overall conceptual framework of the PD approach
5.2 Purpose of PDI
5.3 Review of feeding, caring and health-seeking behaviors
5.4 Introduction of the 2 tools to carry out PDI/home visits:
Observation & guided interview (questionnaire), adapting the tools to
local context, recording information; role-plays
5.5 Guidelines for home visits
Module 6 Introduction of PDI to the community: the steps
6.1 Step 1: Explaining malnutrition situation to community
* Sharing results of nutrition survey with community
* Explain short/long term adverse effects of malnutrition
* Reviewing the objectives of project/partnership with community
6.2 Step 2: Planning the PDI with the community
* Identify Positive Deviant children in the community
* Explain purpose of home visits (PDI); role-play
* Assist villagers to select PD and NPD families to visit, or other
neighboring families (criteria for selection, wealth ranking)
6.3 * Set up schedule of home visits with community
* Review the participants' tasks & logistics during home visits
6.4 Review agenda for visit to the communities; assignment of tasks
Field work: 1. Carry out the baseline survey in one or two communities
2. Compile results on the spot (# normal/malnourished, proportion)
3. Provide immediate feedback on nutritional status of the children in the
target group to community
4. Identify well-nourished children who belong to very poor families
5. Select PD and NPD families or other neighboring families to visit
6. Logistics
Field work: home visits to PD families and NPD families or other neighboring families
Module 7 Reporting, selecting and documenting PDI Findings
7.1 Feedback session on PDI process
7.2 Report findings for each family visited
Compile and present findings from each visit in a matrix
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75
A
pp
endices
7.3 Select & document key successful practices from the PDI findings
1. Selecting key practices
2. Summarizing findings
7.4 Provide feedback on PDI findings to the community
Illustrate findings with model poster (good foods, good care, good health)
Other ways to enable the community to learn about PDI findings
Module 8 Designing a Hearth Program using PDI findings
8.1 Facts about the adult learner
Promote behavior change by -Learning by Doing-
8.2 Schedule a rehabilitation session (how many days in a month, time of day, length
of daily sessions )
8.3 Make Menus (making a seasonal calendar), participants + food contribution
8.4 Include PDI findings in messages, protocols
8.5 Integrate PDI findings in other existing community based projects
Investigate ways to develop multi-channel, multi-targeted strategies to enhance
behavior change and promote good health-seeking behaviors in the
entire community
Module 9: Monitoring and Evaluation
Monitoring
9.1 The community management of the Hearth Program: adapting the "Triple A"
approach from UNICEF
9.2 Developing quantitatively achievable objectives and quantitative indicators of
impact with the community
9.3 GMP as a monitoring tool to measure Hearth Program progress over time
Monitoring vital events (births, deaths, migration); purpose, how
Evaluation
9.4 Quantitative evaluation Hearth Program participants, overall target population
Schedule (after 6 mths, 1 year, 2 years)
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Appendices
Appendix G-1
Sample Observation Check-list During a PDI
1. Observation of members of the household
The well-nourished or malnourished child
Primary caretaker/mother
Secondary caretaker(s)
Siblings of the child
Father
Other family members (grandmother, uncles, aunts, helpers)
2. Observation of practices
Hygiene practices around food and eating
Feeding practices (active feeding/passive feeding, supervision, and type of
feeding)
Family eating practices (eating together, priority to males)
Interaction between mother and child, or child with secondary caretaker
Other family members' interactions with the child
Personal hygiene (toileting, washing or bathing the child)
Food preparation
Water usage for drinking and washing
3. Observation of food availability
Quantity and variety of food in meal observed/other family meals
Food from the garden
Food from animal source
Storage of foods
Food preservation and food processing tools
4. Observation of household environment living quarters
(including cooking area, courtyard)
Home garden
Source of water
Latrine
A
nimals
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Appendices
Appendix G-2
Sample of a PDI Observation Recording Form:
Body and Food Hygiene Practices
Description Comment
Hygiene
Child, mother, other family members are clean
Keep child's nails short
Keep child away from animal excrement
Mother/caretaker washes hands after toileting child
Caretaker Hygiene Around Food & Water
Wash hands before processing food
Keep drinking water covered
Keep food covered before eating
Wash raw fruits and vegetables before eating them
Hygiene Around Child's Feeding
Wash child's hands and face before eating
Child does not eat food picked up off the ground
Child does not eat food touched b
y
animals
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e Po
Appendices
Appendix H
Standard Question Guide For Caretaker Interview
During PDI (Home Visits)
I- General introduction questions
How old is (name of selected child)?
How many other children do you have?
How old are they?
How many people live in this household?
II-Questions on feeding practices
Are you (still) breast-feeding this child (name)? (If no move to #9)
(If yes) how many times a day do you breast-feed your child? At night?
Do you give food to your child in addition to breast-milk? (If no move to #15)
(If yes) what food do you give your child beside breast-milk?
When did you wean your child?
How many times a day do you feed your child? How much?
What food did you feed your child yesterday in the morning, midday, in the evening?
Does your child eat from the family dish?
What do you do when your child does not want to eat?
Do other people in your neighborhood feed your child? If yes, what food?
In your opinion, what foods are not good for young children? And why?
(Ask this question to other family members such as mother-in-law, father)
III- Questions on child care practices
Who cares for the child besides you every day?
What does (this person) do for the child?
(If the secondary caretaker is present ask this question to him/her directly)
How often do you bathe the child?
How often do you wash your hands in a day? With what? For what reason?
How long do you (mother) work outside the home?
Do you take your child with you when you go outside the home?
If you leave the child at home with other caretakers, what advice do you give them?
How much time (hours) do you spend with your child every day?
IV-Questions on health-seeking practices/Diarrhea
Has your child suffered from diarrhea in the last 2 weeks?* (if no go to #26)
(If yes) How did you treat it?
What do you do when your child has diarrhea?
(If the mother or caretaker mentions ORS) How do you use it?
Do you keep ORS packets at home?
(If yes and if situation permits, ask to see the ORS packets) Can we see it?
What food and liquid do you feed your child when he/she has diarrhea?
When your child has diarrhea, what food and/or liquid do you avoid feeding him/her?
* Diarrhea: 3 or more loose stools in a day
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Appendices
ARI
Has your child had a cough associated with fast or difficult breathing in the last 2 weeks?
(If no, go to question # 34)
(If yes) How did you treat it?
Seeking treatment for the sick child
When your child is sick (ear, eye, skin infection), what do you do?
When do you take your child to the health center? To the district hospital?
Has your child been fully immunized?
(if yes ask to see the immunization card/document)
V Questions to other family members (decision-makers)(Identify whom to interview,
i.e., mother-in-law, father)
Interview with mother-in-law
According to you, at what age should a baby start taking food in addition to breast-milk?
What are good foods for young children (under 1, under 2 or 3) and why?
What foods should be avoided and why?
Interview with father
According to you, is your child healthy? Why?
How much time do you spend with this child every day?
What do you do with the child?
What do you do when your child is sick?
In your household, who decides when to get help when child is sick?
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Appendices
Appendix 1
Case Study: Sanar Abudo From Mozambique (November 1997)
Sanar Abudo is a 4-month-old infant, the youngest of 7 children. He weighed 4.3 kg at last
month's weighing session carried out by the mobile district team. His mother, Azira, is still
practicing exclusive breast feeding and indicated that she will start Sanar on complementa-
ry feeding when he is 5 months old as she did for his older siblings. Currently only the 3
youngest children live with their mother while the 4 older ones live with their grandmother
in another part of the village. The mother is single and unable to manage all 7 children her-
self. The house, surrounded by cashew trees and mango trees, consists of 1 room with an
area for cooking. It is swept and tidy. The family does not own any chickens or other
domestic animals. There is still some dried cassava in store, 3 months after harvest.
All 3 children look clean and alert. The mother reported feeding her children all kinds of
food, such as vegetables, peanuts, cashew nuts and coconut. Because she lives near the
coast, Azira goes to the beach on a daily basis to pick up seafood, such as sea snails and
small crabs. She gave us a handful of seafood as she was preparing her family lunch,
seafood cooked with vegetables. She feeds her children 3 times a day, unusual in this com-
munity where most eat only twice a day. Breakfast consists of porridge made of manioc
flour mixed with molasses made from the cashew fruit. Azira told us how she stores the
molasses to last her 4 months. She gave us some molasses to sample; it was sweet and
tasty. She showed us how she processes cashew fruit into molasses since this is the sea-
son to harvest the nuts. Most people disregard the cashew fruit because they have forgot-
ten how to process it or do not have a sieve to make it.
For dinner yesterday the mother fed her 2 older children the traditional chima (cassava flour
and water) with fish and tomatoes, and the three of them shared a mango. Like most peo-
ple in the village, she avoids feeding her children eggs, liver, ripe banana, or a certain fish
(Nguri) sharing the common belief that these foods give children diarrhea.
During meals, the oldest child eats by herself from her own plate, while Azira eats with the
3-year-old child to assist him while eating. Unlike many other village mothers who leave
their young children under the care of older siblings or neighbors, Azira insists on looking
after her children herself. When her children look sick the mother seeks help first from the
traditional healer. But when her children are seriously ill, she goes straight to the hospital.
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Appendix J
Sample Of Educational Curriculum for a 12-day NERS
DAY MAIN TOPIC CONTENT ACTIVITIES
Day 1 Breast-feeding • Breast-milk as the best food for the infant • Discussion
• Benefits of colostrum • Use of interactive
• Immediate initiation of breast-feeding after delivery visual aids (poster)
• Exclusive breast-feeding for at least 3 months, delivering the message
• Breast -feeding duration (up to 24 months)
Day 2 "Good foods" • Inventory of foods for children available in the village • Discussion
variety of food • PD foods • Use of NERS menu ingredients