Hearth Nutrition Guide

a community-based approach to nutritional rehabilitation and behavior change

Peace Corps

Acknowledgements

Peace Corps, particularly in West Africa, has been fortunate to have a significant “diffusion of innovation” of the Positive Deviance/Hearth Nutrition program, and, to a large extent this diffusion can be attributed to the originalPeace Corps PD/Hearth Nutrition guide written by Amanda Palmer who served as Volunteer in Guinea (2000-2002). In 2008, Ariel Wagner, and other Peace Corps Volunteers serving in Mali updated and significantly enhanced the guide based on Peace Corps’s experience with PD/Hearth implementation.

In 2010, the Office of Programming and Training Support (OPATS) took the Peace Corps manuals from Guinea and Mali and developed this more generic Positive Deviance/Hearth guide that can be used as a resource to continue to support the work of Volunteers and their community members in implementing this important community based nutrition program.

The Peace Corps is immensely grateful to Dr. Judiann McNulty, Co-Chair of the CORE group’s Nutrition Technical Working group, who provided considerable technical feedback on ways to improve this Guide. The Peace Corps has drawn considerably upon technical resources developed by the CORE Groups’ Nutrition Working Group, including the Positive Deviance/Hearth:A Resource Guide for Sustainably Rehabilitating Malnourished Children. The Peace Corps wishes to thank the CORE group and other partners for their technical guidance on PD/Hearth implementation.

Peace Corps staff and Volunteers to thank include;

Mali: Associate Peace Corps Directors (APCDs):Cheryl Turner and Dr. Claudine Adou-Lath

Volunteers: Stacey Coulson, Jodie Bargeron, Liz Little, Chamonix Roberts, Katie MacDonald, Cathleen Prata and Rachel Emmick.

Burkina Faso: APCD-Dr. Claude Millogo

Volunteers: Jonathan Schultz and Morgan Cole

Guinea: APCDs-Agnieszka Sykes and Catherine Kling

Volunteers: Amanda Palmer, Julie Viner and Cathleen Prata.

ACRONYMS

Associate Peace Corps Director (APCD)

Frequency, Amount, Density and Utilization. FADU

Focus Group Discussion (FGD)

Infant and Young Child Nutrition (IYCN)

Non-governmental Organization (NGO)

Oral Rehydration Salts (ORS)

Monitoring and Evaluation (M & E)

Participatory Analysis for Community Development (PACA)

Peace Corps Partnership Program (PCPP)

Positive Deviance Inquiry (PDI)

Positive Deviance (PD)

Peace Corps Volunteers (PCV)

Small Project Assistance(SPA)

Table of Contents

I. Introduction to Hearth Page Number

The PD/Hearth Concept…………………………………………………………………………..6

Objectives of Hearth……………………………………………………………………………….6

Hearth and Behavior Change………………………………………………………………………6

Traditional vs. PD/Hearth Approach………………………….....………………………………..7

How Hearth fits into a Volunteer’s service…………………………………………………………7

Child and Family Health Benefits…………………………………………………………………..8

Funding…………………………………………………………………………………………….8

II. Hearth Program

Basic Hearth Steps/Elements……………………………………………………………………..8

Decide whether PD/Hearth is feasible in your community………………………………………..9

Identifying a counterpart and other resource people………………………………………………10

Community Mobilization………………………………………………………………………….10

Selecting Positive Deviant Families……………………………………………………………..…10

Community Assessment Tools……………………………………………………………………11

The Positive Deviance Inquiry (PDI)……………..……………..……………..…………12

Focus Group Discussions………………………………………………………………....12

Market Survey……………………………………………………………………………..12

Hearth questionnaire……………………………………………………………………...12

Leading Sessions: Selecting and Training Volunteer Mothers……………………………………...12

The Volunteer Mother Model……………………………………………………………..12

The Participant-Led Model………………………………………………………………..13

Negotiating with the Volunteer Mother…………………………………………………...13

Training Volunteer Mothers…………………………………………………………..…...14

Selecting Hearth Children…………………………………………………………………………14

Identifying Eligible Children………………………………………………………………14

Participation of Severely Malnourished (Red) Children……………………………………15

Negotiating with Families / How to Invite Mothers to Participate………………………...16

Health CareScreening……………………………..………………………………………………17

Preliminary Meeting with Hearth Mothers………………………………………………………...17

III. Designing Your Hearth

When to hold your Hearth?...... 17

Recipe selection………………………………………………………………………………….18

Selecting Animations (with sample schedules)…………………………………………….….…..19

Finding Animators……………………………………….……………………………………....20

Where to hold your Hearth sessions?...... 20

Supply list…………………………………………………..……………………………….……21

Sample Hearth Preparation Timeline……………………………………………………………..21

IV. Conducting Hearth Sessions

Daily Logistics: Set Up, Food Preparation and Animation………………………………………..22

V. Household Follow Up and Monitoring & Evaluation

Household Follow Up: Supporting New Behaviors through Home Visits……………………...23

Monitoring and Evaluation………………………………….………………………………….24

VI. Troubleshooting…………………………………………………………………………….25

VII. Conclusion……………………….……………………………………………………..…..26

VIII. Further Resources……………………………………………………………..…………....27

IX. Appendices

Positive Deviance Inquiry Forms:

Appendix A: Conducting a Wealth Ranking…………………………………….………………..28

Appendix B: Healthy behaviors that may be observed during the PDI……….……………….....29

Appendix C: Sample Questionnaire with Caretaker: ……………………..………………………30

Appendix D: 24-hour diet recall…………………………………………………………….……32

Appendix E: Observation Form…………….……………………………………………………33

Appendix F: Focus Group Discussion Guide……………………………………………………36

Appendix G: Market Survey…………………….………………………………………………..37

Appendix H: Hearth Preparation Worksheet…………………………………………….……….39

Monitoring and Evaluation Forms:

Appendix I: Monthly Weighing Form…………………………………………………………....44

Appendix J: Hearth Program Form(Participant list, Weights-Day 1, 12, Month 1 & Month 2)....45

Appendix K: Hearth Attendance………………………………………………..………………47

Appendix L: Qualitative Reporting Form……………………………………………………...... 48

Hearth Recipe Forms:

Appendix M: Creating a Recipe: How to Determine Calorie and Protein Content…….………..…49

Appendix N: Planning Menus and Guidance……………………………………………………...50

Appendix O: Food Composition Table (from Catholic Relief Services-Mali)……………………..52

Appendix P: Food Composition Table for Mali….…………………………………...... ………..56

Appendix Q: Peace Corps Guinea, Mali and Burkina Faso recipes………..……..…….………….58

I.Introduction

The PD/Hearth Concept

The original concept of the Positive Deviance (PD)/Hearth Nutrition Model was introduced in the 1980s in Haiti and has since been replicated in countries as various as Vietnam, Bangladesh, Tanzania, Mozambique, and Guinea. In contrast to traditional nutrition interventions which “tend to look for problems in the community that need to be solved, the PD/Hearth approach looks for the positive behaviors and strengths that exist in the community and can be built upon.”[1] It posits that despite poverty, there are local practices, knowledge, and resources that can be exploited to promote positive health practices. Even in the poorest communities, some mothers are still able to raise healthy, well-nourished children “positive deviants”. If the feeding and hygiene practices of theirmothers could be passed on to other mothers in the community, we would see the problems of malnutrition and other childhood illnesses significantly decrease. Moreover, since the solutions focused on in PD/Hearth come from within the community, the behaviors that the Hearth sessions emphasize are far more sustainable that solutions brought in from outside.

In practice, the PD/Hearth intervention brings together between six to ten mothers of malnourished children over a twelve day period to learn and practice the healthy nutrition behaviors. Led by one or more Volunteer Mothers from the community, the Hearth group prepares a nutrient dense meal using affordable, local foods and discusses a health issue of concern to the women and their children every day. At the end of the program, most children have begun gaining weight and often exhibit improvements in mood and energy. Furthermore, qualitative studies suggest that the mothers continue to practice the healthy behaviors learned in the Hearth even after the program has come to a close.

Peace Corps, Hearth, and Behavior Change

The Hearth, due to its’ group social support nature and actual applications of behaviors, offers a unique opportunity to affect behavior change. The Peace Corps defines “development” in terms of its greatest resource: people—helping people develop their capacity to improve their own lives. By working within a human capacity-building framework, the focus of Volunteers’ work is strengthening the capacity of men, women, and youth to actively participate in their own development. This capacity building approach empowers local people to be their own decision-makers and develop the skills and ultimately behaviors needed to improve their lives.As a Peace Corps Volunteer, you may have indentified infant and young child nutrition as an area to focus on based on your community assessment and formative research. Understanding the determinants of behavior is important in designing sound behavior change activities related to Infant and Young Child Nutrition (IYCN) and specifically the Hearth approach. The most influential determinants playing out in designing sustained behavior change related to Hearth are; 1) perceived social norms (is this acceptable among my peers/supported by my peers), perceived positive consequences (nutrition meals are important to my child’s health) self-efficacy (belief that one can is cable of preparing nutritious recipes, etc) and access (nutritious foods available locally).

When focusing on very specific behaviors, Volunteers should carry out the formative research in order to develop a “behavior change framework”[2] that includes 1) the behavior to be focused on, 2) the priority and influencing groups, 3) determinants 4) external considerations, and 5) activities. For example, the Volunteercan identify the Hearth as one of the key activity related to a behavior change month strategy to address IYCN.

What is particularly appealing about the PD/Hearth approach is that it leverages locally available resources and existing behaviors which increase the changes of the behaviors being sustained.

Traditional vs. PD/Hearth Approach[3]

Traditional Approach / PD/Hearth Approach
What are your needs? / What are your strengths?
What is wrong? / What is working here?
What can we provide? / What are your resources?
What is lacking in the community? / What is good in your community?
What is missing here? / What can we build on?
Adapting the Model: Conducting Hearth in Peace Corps Projects

As noted above, the PD/Hearth program has been conducted in a variety of countries and cultures around the world. The Hearth program was originally adapted by Peace Corps/Guinea in 2000 and then spread to Peace Corps/Mali in 2005 and more recently in Peace Corps/Burkina Faso in 2008. While this manual will provide you with a framework and guidelines for setting up and implementing a Hearth project in your community, it is important to keep in mind that there is no one, right way to do a Hearth. Rather, “local adaptation is a must,” and creativity in the implementation of this project is always helpful.[4] What works in one cultural context may not necessarily work in another, and it is important to keep an open mind and think outside the box when designing, conducting, and following up any PD/Hearth project.While adaptations are necessary, it is critical to follow the essential PD/Hearth elements in order for the program to be successful.

Moreover, it may also be helpful to think more in terms of Positive Deviant Families than Positive Deviant Mothers as the actions of the father and other key family members can play equally critical roles in the health and upbringing of the child. Just as the most motivated woman can have a difficult time feeding her children well if she has an unsupportive husband or mother-in-law, a woman whose husband is supportive and proactive about his children’s health is far more likely to be able keep them healthy and well-fed.

The Goals of PD/Hearth

Positive Deviance/Hearth is a community-based approach to address malnutrition with three inextricably linked goals:

1. Rehabilitate malnourished children.

2. Enable families to sustain the rehabilitation of these children at home on their own.

3. Prevent malnutrition among the community’s other children, current and future.

How Hearth Fits into a Volunteer’s Service

Hearth can help give a volunteer’s service direction. The first three months of service is generally spent focused on language, learning the dynamics of your community, and building relationships. Hearth can help you in this process. Your involvement in this project will help you to better understand local cultural practices impacting child health, identify valuable work counterparts, and help you to demonstrate your professional skills. As soon as you feel comfortable, you can begin by doing small health education sessions, leading up to doing full Hearth sessions. After the first Hearth, you can conduct subsequent Hearths at your site, as well as in neighboring villages. You may choose to conduct trainings on Hearth with local health volunteers in order to expand the program and establish it in areas where Peace Corps Volunteers are not currently working. Combining a Hearth project with the establishment of a Health Committee is also a good idea.

Child and Family Health Benefits

As Health Volunteers, we do animations, teach classes and train counterparts with the hope that the people in our community will eventually recognize how simple changes in behavior can have a significant effect on their health. However, these changes are difficult to measure and we rarely see any tangible results in our two years of service. Although many Hearth goals are also long-term, during the two-week period of the Hearth itself, the health of the children and behaviors of the mothers can undergo obvious changes. Some children show changes in weight, particularly in the face and arms. Others become more open and playful, cry less, or have a marked increase in appetite. When their mothers recognize these changes in their children, they often make changes in their behavior, for instance, improving the quality of their food preparation for their children.

In addition to seeing some real results from our work, the Hearth can be a starting point for several other activities. Women’s groups, neighbors, friends, and market women may ask to learn some of the Hearth recipes. You may work with your midwife or the staff at your health facility to improve their response and treatment of cases of malnutrition. The Hearth may help to rejuvenate growth-monitoring activities in your community. Not only does the Hearth spark new ideas for work, but it also provides you with potential counterparts. You may be able to continue working with the Volunteer Hearth Mothers to spread the health and nutrition messages to other audiences. The Hearth mothers themselves may also be motivated to pass on what they have learned.

Funding

Through donations and community contributions, it is possible to do a Hearth project with spending little to no money. Your community should be able to provide you with all or most of your materials. Sometimes, however, small a small amount of funds are necessary to cover certain expenses Contributions from Non-governmental Organizations (NGOs) may make extras possible, such as a party for the women at the end of the project. Health centers are often happy to provide services for de-worming and may even be willing to provide a free medical consultation to all participants prior to the Hearth. Other funding sources for the Hearth include Small Project Assistance (SPA) and Peace Corps Partnership (PCPP).

II. The Hearth Program

Basic Hearth Steps/Elements

Pre-Hearth

  • Determine whether PD/Hearth is a feasible in your community.
  • Weighing to identify malnourished children in the community.
  • Mobilize and inform the community, health agents and community leaders about the Hearth approach.
  • Carry out the Positive Deviant Inquiry & assessments/surveys to the extent possible.
  • Identify Positive Deviant practices and behaviors to be emphasized.
  • Identify meals to be prepared.For adequate nutritional rehabilitation, a Hearth recipe should contain 600-800 Kilocalories and 25-27 grams of protein. For areas challenged by food insecurity, recipes can have as little as 500-600 Kilocalories and 18-20 grams of protein. Also, key vitamins such be included for a completely nutritious meal: Vitamin A 400-500 RE (RE=retinal equivalent), Iron 10mg, Zinc 3-5 mg, and Vitamin C 15-25mg.
  • Identify and train the individual(s) who will be leading the Hearth sessions (e.g. your counterpart or a Volunteer Mother).
  • Negotiate with mothers and their families to convince them to participate in the Hearth.
  • Have the health center distribute Vitamin A and the de-worming medicine for Hearth children and ensure updated vaccinations.
  • Meet with participants to decide daily logistics, including what materials and ingredients (or money) they will need to contribute.

The Actual Hearth

  • Weigh children on the opening and closing days of the Hearth. You may also want to weigh children at the halfway point to gauge their progress.
  • Mothers and children gather for approximately 1-2 hours every day for food preparation. During this time, a health education session is organized which includes a conversation and questions/answers.
  • On the final day of the Hearth, explain the importance of continuing the healthy behaviors learned in the Hearth. Inform them of plans for follow-up.

Post-Hearth

  • Follow-up weighing of Hearth children at 1 month, 2 months, and 1 year.
  • Household follow up to reinforce practices and behaviors learned at least twice a week.
  • Continue growth-monitoring activities in the community.
  • Share results with your APCD, counterparts, community, etc. The Peace Corps had developed Hearth Monitoring and Evaluation forms for the Hearth.

Decide whether the PD/Hearth approach is feasible in your community

Although PD/Hearth is a flexible program that can be adapted to almost any community, it is important to consider the project’s feasibility in your area before beginning. Some important aspects to consider are:

Levels of malnutrition: Did your baseline survey, Participatory Appraisal for Community Action (PACA) activities, or growth monitoring data from baby weighings reveal a significant problem with nutrition in your area? Is a nutrition project a priority as compared against other local needs?

Availability of affordable local foods: To implement a Hearth project in your community, you should be able to make at least one recipe from local ingredients, including at least one starch (energy), one protein (construction), oil/shea butter, and ideally one fruit or vegetable (protection).

Existence of food aid or other nutrition programs: What other nutrition programs already exist in your area? Will a Hearth compete with, complement, or enhance these programs? If food aid is available, will women be willing to participate in a program that requires contributing the ingredients themselves? Is there any positive and sustainable way to integrate the food aid into the Hearth?

Community commitment: A Hearth is most successful if the community is actively involved and interested in the program’s success. Do local leaders support the project goals? Do women and volunteers have the time needed to implement the program successfully?

Identifying a counterpart and other resource people