Hearth Nutrition Guide for

Peace Corps Volunteers

Written by:

Amanda Palmer (PCV from Guinea)\ Manual adapted by Jackie Gannon (PCV Namibia)

Kavango Region

2011-2013

Table of Contents 1. Introduction 1.1 Hearth Concept

1.2 Quick Overv iew

1.3 Bringing Hearth to your community

1.4 Volunteer Benefits

2. Growth Monitoring and Promotion 2.1 Mobilizing the Community

2.2 Hearth: Alternative to Plumpy Nut

2.3 Community Weighing/Indiv idual Weighing

2.4 Community Weighing

3. Selecting and Training a Village Mother 3.1 Requirements

3.2 Selecting a Village Mother

3.3 Training your Village Mother

4. Selecting Hearth Children/the Initial Meeting 4.1 Identifying Eligible Hearth Children using MUAC

4.2 Negotiating with Families

4.3 Medical Screening

4.4 Contributions from Mothers

4.5 Funding

4.6 Location of Hearth

4.7 Reporting

5. Daily Activities 5.1 Logistics

5.2 Responsibilities

5.3 Food Preparation

5.4 Daily Messages

6. Closing Hearth 6.1 Closing Ceremony

6.2 Final Reporting

6.3 Follow up Hearth Check-ups

7. Recipes and Cooking Tips 7.1 Creating the Menu

7.2 Cooking Tips

7.3 Recipes

8.Growth Monitoring Handouts and Daily Lessons Handout 8.1 Weight based on Length/Height Table (2 papers)

8.2 MUAC information/measurements

8.3 BMI (based on weight/height for adults)

8.4 Handouts on breastfeeding and nutrition

1. Introduction

1.1 Hearth Concept Hearth Nutrition Model is based on the idea 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. If those “positive deviant mothers” could pass on their childcare, healthcare and feeding practices to other mothers in the community, we would see the problems of malnutrition and other childhood illnesses significantly decrease. Therefore, Hearth intervention brings together between four to ten mothers of

malnourished children that are between the ages of 6 months to 5 years over a two-week period to learn and practice these positive deviant behaviors. The group is centered around the positive deviant mother, or the “Village Nawe” who, with the help of community health agents, leads the mothers in preparing nutritious meals for their children and teaches them the importance of simple hygiene, preventative

healthcare and good nutrition. This approach was initially introduced in Haiti in the 1980s and has since been replicated in Vietnam, Bangladesh, Guinea, Tanzania and Mozambique and now Namibia! Qualitative studies

suggest that the mothers who participated in Hearth continue to practice the positive childcare, healthcare and feeding behaviors even after the work has ended. Combining Hearth and Peace Corps: The Peace Corps Public Health Plan, in accordance with

the priorities of the Namibian Ministry of Health, puts a major emphasis on activities that will help to decrease the rate of malnutrition among Namibian children. Through my results, Hearth program is one activity that has proven particularly successful in this area. The “Hearth Implementation Guide” combines information from Peace Corps Volunteers from other countries that have tested the initiative,

in the hopes that more Volunteers will begin to introduce this approach in their communities. This manual outlines the steps of Hearth process, as shown below, and describes how a volunteer can carry out these activities.

1.2 Quick Overview of the Program

PRE-HEARTH

• Weighing and using the MUAC* bands to identify malnourished children in the community. • Identify and train a Village Nawe. • Negotiate with couples to convince them that they should bring their child to Hearth program

for 12 days. • Distribute Vitamin A, Albendazole and Ferrous for Hearth children and ensure updated vaccinations at the initial Hearth introductory meeting.

*MUAC: Mid-Upper Arm Circumference, tool used to quickly determine child's nutritional status. THE ACTUAL HEARTH

• Introductory meeting is held, where mothers and their children are present along with a health worker (nurse, doctor, whatever you can get) to enforce the importance of the program and encourage

attendance and participation. • Mothers and children gather for 2 hours every morning for food preparation and health message. Village Nawe and PCV deliver the daily health messages.

• Weigh children after two weeks and report the results of the 12-day Hearth to the community. Can make it a congratulatory ceremony to provide further motivation for the women after the program ends or keep it simple by just sharing the results with the group. It is encouraged to share results with local clinic/hospital to spread the word of the program.

POST-HEARTH

• Follow-up weighing of Hearth children at 1 month, 2 months and 1 year.

• Continue growth-monitoring activities in the community. • Report results to your local health facility

1.3 Bringing Hearth to Your Community

During the first six months at site, volunteers are asked to complete an assessment of problems in their communities. Did your community questionnaire or PACA activities reveal a significant problem with malnutrition in your area? Are there an elevated number of malnutrition cases coming

into your Health Center? Have you observed poor child-feeding behaviors amongst friends or neighbors? If growth-monitoring data is available in your community, you can review that information to determine an approximate level of malnutrition. For example, you might ask your Vaccinator to help you track the nutritional status of all children coming in for vaccinations during a one-week period.

Discuss Hearth approach with your counterpart. He or she may be able to direct you to a particular district that could benefit from Hearth. Finding a Counterpart. Once you do determine that Hearth would be beneficial in your

community, it is crucial to find a dedicated member of the community with whom you can work. In general, agents from the Health Center already have too many responsibilities and probably will not be available to help with day-to-day activities. TB outreach volunteers, hospital's expert patients,Village midwives, the director of the local women’s group, teachers or peer educators are other potential

counterparts for this project. Counterparts should have a clear understanding of the requirements of Hearth. You should explain all of the Hearth steps and outline a plan of work and division of responsibilities. The work can

be very labor intensive during the pre-Hearth activities, but rarely requires more than two hours each morning during the actual Hearth. Keep the seasonal calendar in mind when you are planning your activities. Both counterparts and participants may not be able to commit two full weeks at certain times of the year. I have used my assigned counterpart for one Hearth course and also a woman active

in the school parents committee to assist with the Village Nawe training. There are options everywhere for working out the niches, if your normal 'go-to person' is not available, you can take the opportunity to work and train with someone else.

1.4 Volunteer Benefits

As Health Volunteers, we do sensibilizations, 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 a lot of the goals of Hearth are also long-term, during the two-week period there are obvious changes in the health of most of the children and the behaviors of their mothers. 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 also show changes in their behavior. For example, in the second week of my Hearth, after several mothers saw small results in their child's behavior, they became more curious about the health topics. They showed more interest in improving

other areas of not only their baby's health but their own as well. In addition to seeing some real results from our work, 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 agents at your Health Center to develop a fixed strategy for handling cases of malnutrition. Hearth may help to rejuvenate growth-monitoring activities in your community. Not only does Hearth spark new ideas for work, but it also provides you with potential counterparts. You may be able to continue working with the Village Nawe to spread the health and

nutrition messages to other audiences. Hearth mothers themselves may also be motivated to pass on what they have learned. Finally, Hearth is an excellent opportunity for cross-cultural exchange. During the weeks of

preparations and the actual two-week program, I was forced to communicate in Thimbukushu (Kavango language) with Hearth participants and my Village Nawe. This really helped my local language skills. The women also taught me about the foods that are available in my area and about their cooking techniques. It was an opportunity to work with a completely new set of women and even

recruited a very motivated mother to my woman's group. Hearth Mother plus child

Kayanga, Kavango April 2012

2. Growth Monitoring and Promotion

2.1 Mobilizing the Community Before beginning any activities, work with your counterpart to introduce the concept of Hearth to the officials in your community. The support of the headman, local clinic workers, members of the

VDC and the village elders (if you deem this demographic necessary) is helpful to the success of the program. The officials may be able to assist by sending out the message, alerting the school directors and organizing the youth. Village elders can pass the information within their families and encourage the women to participate in all of the activities from the baby weighing to Hearth itself.

My village has not benefited from growth monitoring or other nutrition-related activities in the recent past, so it was also helpful to sensibilize the community members prior to starting work. This included doing small talks to the women at my center, during village meetings, and to the school

attending children, anything to get the word out there before I actually began the Hearth course. During any of your talks it would be helpful to get someone, any local person of importance who is respected, to speak and reiterate your words. Points that can be stressed...

• Children need nutritious foods in order to grow strong and to stay healthy. ▪ It is less expensive to provide good foods to a child than to constantly treat a child who is sick because of malnutrition. • A child’s growth should be tracked on a monthly basis.

• The first 3 years of a child's life are MOST detrimental to the rest of their development • Local foods can provide sufficient nourishment to raise strong and healthy children. • All mothers, regardless of their social or economic level, can raise healthy and well-nourished children.

2.2 Hearth: Alternative to Plumpy Nut

In 1992 the Ministry of Health and UNICEF began a growth-monitoring program in Namibia and trained community health agents in rural areas. These activities were usually carried out in conjunction with vaccination days. Community health agents were provided with UNICEF balances and registers for recording the children and their information. In most areas of Namibia, various NGOs,

hospitals or PC volunteers have also worked with community health agents to implement regular growth-monitoring activities. As of now, 10 of the 13 regions in Namibia provide a nutrition program called Plumpy Nut. Plumpy Nut is a protein rich peanut butter paste given to children that are categorized as severely or moderately malnourished.

Hearth program is an alternative form to P lumpy Nut. Plumpy Nut is exported to Namibia from France and, even though it is free for those who are malnourished, it does not provide an endless supply. If you are not based at a clinic or hospital I still strongly suggest you speak with a healt h worker,

explain your goal and how Hearth can be a sustainable and effective alternative to Plumpy Nut. They will most likely be able to offer ideal resources to identify both Hearth children and a possible Village Nawe. They are helpful for advice however often have too large of a workload to be there for the actual program. From experience, health workers may be skeptical of your program at first. People I spoke to

continuously suggested the malnourished children just partake in the Plumpy Nut program. From their eyes, Plumpy Nut is an almost guaranteed way to fix the problem, on this program the children gain

weight and love the taste! However, from a Peace Corps Volunteer's perspective, we want to help people help themselves, not to rely on government food until it runs out.

There are pros and cons to both Nutrition Programs. With Hearth it is common but NOT guaranteed that a child will gain weight within the two weeks. With Plumpy Nut the child should automatically gain weight (unless there is a separate problem, which they should receive further treatment). Mothers prefer to see quick results and with Plumpy Nut, they are able to. What other

volunteers have said, and even health workers confess, are two common dilemmas in regards to Plumpy Nut. One is that mothers stop coming without being discharged; they don't have transport money, it's too far of a walk or maybe they don't like to be seen going to the clinic that often. Whatever the case is, that child is lost track of and his/her nutrition suffers. The other problem comes when the

nurse tries to counteract the first problem, they give out 2 weeks supply (or more!) of the fortified food in one visit. More often than not, that mother returns home to her other kids and distributes the food evenly throughout the family. All the children are satisfied that night. However, the nutritional status of the child that was meant for again, suffers. Hearth is a sustainable, although not guaranteed weight gain,

to provide the mother with the knowledge and new information about how to better care for all of her children.

2.3 Community Weighing/ Individual Weighing (for identifying children for the program)

When this was tried in West Africa, the volunteers were big on community weighing. With this they suggest having one specific location and everyone coming to you. This is done by getting the word out there, work the network! Ask the primary school director to organize his students to bring their

younger brothers and sisters. Talk to neighbors, host families, anyone that can pass on the word to children they think are suffering. Request that all mothers come with the child’s Passport. Best to have the one spot be well known and in the central space. A central spot will also draw attention from the rest of the village, and encourage them to check out the commotion. Possible locations for weighing are;

under the main tree in the village, by the market, you could do it at the hospital if that has high traffic, along the main road...wherever you see fit. The first two times I conducted Hearth I took the more subtle approach. My counterpart, Village

Nawe and I walked around to all the homesteads with our MUAC bands. At each homestead we asked them to direct us to more homesteads with more young children. We did this until we attained 7-9 mothers with malnourished babies. This approach takes longer but in a village environment I found it easy and comfortable. I was pleasantly surprised by the mother's willingness to participate and their

humility to accept help. Another reason this takes slightly longer is because with each mother you have to briefly explain the program (then we invite them to the initial weigh in day where we, in depth, explain the program). This approach also requires a lot of walking. Within 2-3 days we identified those babies that were in the moderately malnourished category.

With each section I will try to adapt this guide towards a town. The main reason I think Hearth in a village is more receptive is because of the lack of activity. The women I choose did not have jobs, their many responsibilities come from their fields and their children, but other than that they can take

the time for 2 hours every single day. In town it is harder to identify women (because they have gates, doors, less access in general). I would go straight to the hospital/clinic; find out which women were once in the nutrition program but stopped going prior to being discharged, find repeat mothers (there may be a problem at home that can be further looked into), or put up fliers. You could make Hearth

less of a 2 week weight gain challenge, since it may be the case that the women are not available every single day, and more of a nutritional once per week cooking class. Find a schedule that works best for

them. You could even set up a “Cooking Corner” sort of thing in your clinic once a week. All the benefits of this program would still be present; forming relationships, practicing the language, and of course passing on the new recipes and knowledge!

2.4 Community Weighing Approach and Organizing an Opening Ceremony (You can skip this if you plan on doing individual identifying)

I did not attempt to do a Community Opening Ceremony and a Community Weighing, here is the process taken from volunteer's experience in West Africa:

The opening ceremony of Hearth is essential to the project’s success. As the mothers were told when they volunteered to participate, Hearth is a project for the community and not just the participating children. Therefore, all of the community shares in the opening day to encourage the

children’s success in Hearth. You should also invite representatives from NGOs, local officials, village elders, and the husbands of Hearth women. This is a significant motivating factor for the mothers. If she sees that all the community and invitees have come to support the project, she will also take the work seriously.

In addition to motivating Hearth women, the ceremony also provides a forum for the discussion of health and nutrition. We stressed Hearth themes during the opening speeches. We also asked the Village Nawe to direct her daily lesson to the whole audience. Therefore, even mothers who were not

part of Hearth learned the first day’s recipe and health message. Some of those women became interested in the program and came to one or more days of Hearth preparations to assist. Make sure that this is a community-led event. We went to the District President one week in

advance to discuss the idea with him and he agreed to take responsibility for mobilizing the community. He asked the local youth director to clean up the market area and set up hangars under which the mothers would prepare and the invitees would be seated. He found a local disk jockey who was willing to donate his time and equipment; we only had to provide gasoline to run the generator. Finally, he

called on the traditional dancers to bring out their masks and costumes and take part in the opening ceremony. The opening ceremony requires a lot of organization and a lot of work. Do not expect to do all

of this work on your own. Several days prior to the opening day, we held a meeting at our Health Center to divide up the responsibilities among all of the Health Center staff. Two agents took responsibility for the celebratory meal. They purchased all of the ingredients, prepared the meal, and brought plates and spoons from their homes on which to serve the invitees. One agent was responsible

for preparing the location. He visited the site to decide the best location for the ceremony, worked with the youth to cut wood and construct a hangar (to shade the invitees and the mothers) and rented a car to transport Health Center chairs to the site. I worked with the community counterpart to organize the Village Nawe and the women for the opening day. We had addit ional people on hand for the opening

ceremony, including the village midwife, the peer educators and the primary school teachers, to assist with any last-minute problems.

3. Selecting and Training a Village Nawe

3.1 Requirements for a Village Nawe

The Village Nawe, or the positive deviant mother, is a woman from the community who has

healthy, well-nourished children despite living off less. During the two weeks of Hearth, and likely after wards, the Village Nawe will serve as a point of reference in the community for positive child feeding and health practices. Therefore, the woman that you choose should be representative of your

community. The Village Nawe should be in the same economic group as the other mothers; she should not be the wife of a principal or doctor. She should not have an education level beyond that of the other mothers. She and her husband should be originally from the community.

As a role model for healthy living, the Village Nawe’s children should all be healthy and well nourished. They should be completely vaccinated (ideally). The Village Nawe must have the passport for her child. She should understand the importance of prenatal care and have respected her monthly prenatal visits. Her children should be reasonably spaced and she should have an understanding of

family planning. Her home should be clean and she should practice good hygiene in her food preparation and in general. Although it is difficult to find one mother who excels in all areas, the Village Nawe should possess the ma jority of these characteristics.

3.2 Selecting and Negotiating with the Village Nawe

You or your community counterpart may already know some women in the village who could serve as Village Nawe. Conduct a house visit with each of these mothers, focusing on the questions

below. If possible, try to choose a woman who is outgoing and a leader. This will greatly facilitate her role with Hearth mothers. If your community has multiple tribes, it is helpful to identify a woman who speaks the local languages of all of the participating mothers. In general, the Village Nawe should be well respected by all of Hearth participants.

Once you have selected an appropriate Village Nawe, explain the full expectations of the program. As a new community health work, she must be willing to commit approximately two and a half weeks of her time to training and the implementation of Hearth. Two or three days of training are

conducted at the Village Nawe’s home and she meets with you and your counterpart each morning to review the daily health messages. During the program the Village Nawe is responsible for organizing Hearth women, preparing and teaching the recipes, and delivering health messages. If the Village Nawe agrees to participate, it is crucial to seek the support of her husband, to make sure he is on board with

the time she will be spending away from the house for 2 hours every day. Here are some things to keep in mind/observe when selecting a mother. (My Village Nawe did not have all of the characteristics listed below; overall pick someone based on their work ethic, character, likability and reputation!)

GENERAL OBSERVATIONS: • Where does the mother get water for drinking and cooking? • Does she keep her cooking area clean? • Is there a latrine available?

• Are all of the children in good health and have decent hygiene? ASK TO SEE THE CHILD’S PASSPORT: • Did the mother respect the prenatal care schedule?

• Is the child completely vaccinated? • Has the child or its siblings suffered from any serious illnesses? • How many children does she have or want to have? Are they spaced appropriately apart? • Does the mother practice family planning?

ASK ABOUT WHAT THE CHILD ATE IN THE LAST 24 HOURS: • Which food and drinks did the child eat? How much? How often? • Did the child eat everything that he or she was given?

• Does the child eat anything between meals?

3.3 Training the Village Nawe

Training for the Village Nawe varies depending on her availability and how quickly she is able to learn. In some cases, the Village Nawe can be trained in the evenings after she has finished her work for the day. Therefore, the training is limited to only one or two hours per night and may take several

days to complete. Our Village Nawe was available during the day, so we were able to complete the training in two morning sessions. It may be that there is too much information to fit into just 2 morning sessions, as was the case with our Village Nawe. So, in addition to the 2 morning trainings, we briefly went over each session before the program began each day to review. The training focused on three

themes: good healthcare practices, good feeding practices, and good childcare practices. Here is quick look at what the program will look at (I will attach my in detail program at the end of the program. BUT PLEASE, feel free to adjust the program to what problems exist in your community, ask the women what they want to learn!)

GOOD HEALTHCARE PRACTICES • The Passport is the child’s identity card and should be carefully guarded. This booklet includes all key aspects of preventative care (prenatal care, vaccinations, safe childbirth, growth monitoring).

• Children who suffer from diarrhea should be given oral rehydration salts to prevent dehydration. These can be purchased or easily prepared with water, sugar and salt. • Only give the child medication that has been prescribed by a doctor. (Learn about local, traditional medicine used to determine if some of them are harmless or should be brought up in the

program to alert them of the virulent effects.) GOOD FEEDING PRACTICES

• Breast milk is the ideal food for infants and should be given exclusively for the first six months. At six months the mother should begin to feed child other foods. She should continue to breastfeed her child for two years, even if the mother or the child is sick. • Humans need a variety of foods from each of the three food groups in order to grow strong and

healthy. • Young children should be given food four to six times per day. They should be given a separate bowl from other children. • Mothers can make a nutritious porridge for their children by combining:

1) a cereal or tubercle, plus 2) a construction food, plus 2) oil and/or sugar. GOOD CHILDCARE PRACTICES • Practice good hygiene in food preparation: wash hands (with soap and water) before cooking

and after going to the bathroom; wash fruits, vegetables, etc.; keep the cooking area swept clean; cover food when you are not working with it to prevent flies; throw garbage far away from cooking area. • Practice good hygiene: wash yourself and your child everyday; keep fingernails short and clean. • Do not leave children unattended. If the mother cannot supervise her child, she should find an

older child who can actively watch her infant. Encourage older siblings to play with and develop a close relationship with their younger siblings.

• Use latrine and encourage children to do the same (sometimes not realistic in the village, so don't dwell on this) • Cook with and drink pump water only (again, sometimes not possible, so just do the best that

you can with educating this...maybe really only encourage this when the child is sick or while he/she is young)

4. Selecting Hearth Children and the Initial Meeting

4.1 Identifying Eligible Children with MUAC

When you are finding babies that can qualify, you can either look at the child's Weight for Age chart from their passport or use your MUAC bands. Most passports I saw did not have any information in the Weight for Age chart. That is fine; it is faster and easier to go by the MUAC of the child anyway.

All children falling into the yellow (moderate) and red (severe) zones on the MUAC bands can qualify. It is not until the program actually begins when they are further measured and their exact nutritional status, determined based on Weight for Height. In general, Hearth should target children in the yellow zone, or moderately malnourished, as it is possible to rehabilitate these children during the two-week period. We chose to include yellow zone children even if they did not have a Passport; we accepted the

mother’s estimate of the child’s age. In some cases it may also be appropriate to include children falling in the green zone, or well-nourished cases. This was the case for one child on the very bottom of the green band because she had been fluctuating from yellow to green over the past year. She would easily become malnourished by diarrhea or malaria (for this I had the cutoff be 13 cm MUAC).

Among the list of moderately malnourished children, Hearth generally focuses on children between the ages of nine to 36 months. This age range is dependent on the types of food that you will be preparing (see Section 6.2). I have had babies between 6-9 months and that is also fine, as the

mothers will benefit from learning the recipes and good healthcare practices even if their young child is not able to eat every recipe. You may decide to include children older than 36 months but keep in mind that they will need more food to gain weight.

Red Zone Cases. Severally malnourished children are very difficult to rehabilitate solely through Hearth to their goal weight, even though I have seen children in the red zone gain weight through the program, often it is not close to enough to put them in the healthy category. If you choose to have them participate in your program it should be coupled with the Plumpy Nut National initiate. In

this case the child will not be solely eating Hearth food and would not be counted in your results, but it is still important to teach the mother the recipes for after her child stops the Plumpy Nut program. You can either have them do Hearth first to see how successful it is for the severely malnourished baby and immediately after the weighing bring them to the hospital to start Plumpy Nut, because it is detrimental

to their development if they continue living at such a low nourishment intake.

4.2 Negotiating with Families

After identifying the participants in person, we called for a group meeting and asked the mothers to bring their spouses. This is easier than doing individual meetings with each mother and her family. We discussed the nutritional status of the children, the concept of Hearth, and the requirements for the two weeks of participation. In a group setting the women felt less pressured to accept the

program and also it was helpful to bring up adaptations and work out a schedule with everyone together.

Each mother was aware that they all would be contributing the same amount as each other. Lastly, the group forum was advantageous to present malnutrition not as a personal issue, but rather as a community problem, to avoid offending mothers. I strongly suggest having a nurse or health care

worker present for the introductory meeting to stress the importance of child nutrition! Points to be stressed at the meeting:

• They were selected because their child falls into the category of mild malnutrition. • There are no medicines to cure malnutrition. Only a nutritious diet and simple protection against diarrhea diseases will help in the child’s rehabilitation. • Hearth requires 12 days of participation for approximately two hours each morning. The

mother should come with her child to assist in the food preparation. The child will eat at Hearth and then bring some food home. • There are expenditures for ingredients, we are either asking for a small fee or contribut ion for some ingredients from your field.

• Weight gain is not immediate or guaranteed, but mothers should not become discouraged if it takes a little time for their child’s appetite to increase or if the child does not like a certain recipe. • Participation in Hearth is not forced. If the mother has any reservations, she should not feel pressured to say yes.

**We had two mothers very motivated to join the program once they heard about it from their friends. We included these individuals regardless of the nutr itional status of their children. They were all highly motivated and served to encourage other mothers throughout Hearth.

**It may be wise to have one or two mothers on an alternative list, in case a mother drops from the program. They may find it is more commitment then they have time for or they are unwilling to contribute ingredients or money to the program (more on that later).

4.3 Medical Screening Prior to Hearth opening, all of the selected children should be evaluated by a health agent. We invited the nurse from clinic in a neighboring village to conduct this check-up and distribute the

medication. All medication should be donated from your local clinic/hospital (at least for all those regions where the government nutrition initiative exists). If possible you can get each child a proper check up from a nurse, but this is not necessary if you do not have access or affiliation with a clinic. If a child is found significantly ill, this will affect how the child gains weight. Therefore it will alter your

results but if the mother is still motivated to learn and participate have her be part of the program (just explain the realistic chance of her child gaining weight until he is healthier). The medical screening was conducted three days before the opening ceremony. In this manner,

children could recover from any reactions to the vaccination (e.g., fever) and the albendazole was given a chance to work. In addition, we were concerned that mothers would attribute any catch-up growth to the administration of the medication rather than Hearth itself. For one of the Hearths, I was not able to space the medicine distribution and the start of the program but it still worked out okay. The

nurse/health agent will be able to explain the medication given for malnourished children but here is a quick breakdown... • Vitamin A- the red 200.00 AU tablets for over one year and blue 100.00 AU tablets for under 1 year but older than 6 months. Cut top off and squeeze liquid into child's mouth. If child has teeth, easier

to give child tablet. • Albandozal- This is a de-worming medicine. If the child does have worms they will find 'tiny

white snakes' in their stool. This is normal.Dosage-100 mg for children over 6 months to 2 years. 400 mg for children over 2 years old.

The next two are not always given, please double check with your health care agent, it is prescribed on a case by case basis… • Amoxicillin- This is an antibiotic. You dissolve up to the line on the bottle with clean, distilled water then shake. The mothers take this home with them to give their child 1 spoonful 3 times per day

for 5 days. A possible side affect is diarrhea. This is why it is helpful to distribute medicine a few days before Hearth begins. • Ferrous- This boosts hemoglobin. The dosage is 1 spoonful 2 times per day for 7 days. There are no side effects, only possibly darker stool.

4.4 Contributions from the Mothers

This initial meeting is also the place to discuss contributions for the program. The first time I

conducted the program I ended up footing most of the ingredients, as I was very unsure the success of the program and felt bad having each woman bring their precious eggs for everyone. The second program I was much more confident in the program and more adamant about contributions. Each woman was instructed to bring her own porridge (pounded or store bought) that would last the entire 2

weeks. This was accepted by all. The other contribution was either giving ten dollars per mother/child pair OR donating one ingredient for the day's recipe (ex: all the mangoes for that day). This system worked out well. However, even with the contributions I still ended up spending about 50 dollars for various items; salt, soap, sugar, cooking oil and peanut butter (not locally available).

In addition to this each woman was expected to assist in fetching water for the group and providing firewood. They brought their own buckets for fetching. This system working well, as the work was pretty evenly divided the whole 2 weeks. The women also all brought their own plate/bowl

for them and their child. I provided the big pot, the ladles, the washing basin, cups, etc. For a town, where contributions may work a different way, you could suggest that instead of one person bringing a separate ingredient, rather they could pool their money and nominate one

woman per day to purchase all of the necessary ingredients. This responsibility could be given to the woman who would be hosting Hearth on that day.

4.5 Getting Funding

Hearth program is very inexpensive and the money for those few expenses should ideally come from the community itself. You can adjust the contributions to your specific situation. As mentioned earlier I had each women contribute something to the program, this helped ensure her participation as

well I believe. When Hearth was conducted in West Africa the PCVs sought out outside funding. Their opening and closing ceremonies were the very large events that received donations from other health agents and the local municipalities. The benefit to having these ceremonies is that they were motivating factors for the mothers, as the whole community was aware that their child was part of Hearth and

interested in his or her progress.

4.6 Deciding on the Location of Hearth

At the initial meeting we discussed the logistics of Hearth with all of the participating mothers and the Village Nawe. There are two options for the main cooking/meeting spot. One is to rotate the

activities from one woman’s home to the next throughout the two-week period. The other is to hold a fixed spot for the program. Both has its advantages and disadvantages. I found that when we rotated cooking spots it allowed us to interact with the fathers, as some of them were home during the

preparation time. In addition, several neighbors were able to benefit from the health messages and the recipes as we passed from family to family. This also distributes the labor or collecting the firewood and fetching water for cooking. If most of the women have taps or electricity, and therefore pay water and electric fees, this approach may be better so no one feels more onerous than the others. If you

prefer to have one fixed spot, whether it be at your home of the home of the Village Nawe, you should still distribute the work of firewood and water and have the women help set up daily. (I found the fixed approach to be easier with logistics and we wasted less time each day with set up, as the fixed spot was my own home and cooking area).

4.7 Reporting Charting the babies’ information can either be done at the initial meeting with the mothers OR

the first official day you meet for the program. For each child the following should be recorded • Height (cm) • Age • Medicine Received

• MUAC (cm) • Starting Weight (kg) • Goal Weight (kg). This is according to the Weight for Height Handout 4.6 • Standard Deviation. This is according to the Weight for Height Handout 4.6

• notes of physical appearance, initial impressions, behaviors, etc It is also a good opportunity to weigh the mothers to see their own nutritional status. Let them know ahead of time that 2 weeks is normally not enough time for an adult to gain weight. I did,

however, have one very undernourished mother gain 3 kg during the program. For the mothers the same reporting is done, except replace Standard Deviation with BMI—this is based on weight and height (handout attached). I was able to borrow a scale from the nearby hospital, this is ideal for the mothers and any children that are able to stand on their own. For those still very young I borrowed a

handing scale. We just hung it from a tree, the babies hate it but it gives precise results.

5. Daily Activities

5.1 Logistics

We met at the specified household for approximately two hours each morning to prepare the

food. Upon arrival, all of the mothers and children washed their hands prior to starting work. The Village Nawe then explained the recipe and divided up jobs between the different mothers; someone is in charge of making the fire, another for preparing the porridge and the others prepare the added ingredient. While the recipe was cooking and then sitting to cool, the Village Nawe delivered her health

chat (average time 30-45 min) and the women were given an opportunity to ask questions. The Village Nawe then served the porridge to each of the mothers and the children were fed. When all of the children were finished eating (we also would cook enough for the mothers to have some too), the mothers washed all of the bowls and spoons and the Village Nawe divided up what was left of the

porridge for each of the mothers to take home for their child. The program is meant for each child to be able to take home some of the food for another meal that day, so plan for that.

5.2 Responsibilities It is essential to develop a clear division of labor from the first day of Hearth. Below are the

responsibilities of all of the parties involved. Hearth Mothers: host one day of Hearth (if you are switching spots each day); arrive on time each morning with child; assist in the preparation of the daily recipe; listen to the daily health message; feed

child and assist in the clean-up activities; bring child to the Health Center immediately if he or she becomes ill during Hearth.

*all of us PCVs know how “Nam Time” operates, so instead of waiting hours until all the mothers arrive I created an initiative for the most punctual mother to receive a treat at the end of the program. I kept track with an attendance board with their picture. Worked great. End prize was something simple (bag of beans or lotion or candles...).

Village Nawe: assist host mothers in setting up the cooking site; measure ingredients and teach mothers the daily recipe; deliver daily health message; divide daily recipe among all of the participants; provide

encouragement to mothers who seem to lack motivation; act as a leader for all of the women. Counterpart: serve as a translator between PCV and the Village Nawe; keep local officials informed of the progress of Hearth; refer sick Hearth children to the Health Center for consultation and ensure that

have received treatment; assist Village Nawe with certain daily messages; *My counterpart was unavailable most days during the program. As long as the Village Nawe is committed the program it should work fine and as long as there is not a language barrier.

PCV: overall management of Hearth (charting children’s weights, attendance records, reporting progress to the Health Center); designing daily health messages and passing them on to the Village Nawe; selecting recipes and teaching them to the Village Nawe; possibly pr oviding daily snacks for Hearth children

*I only provided small snacks the first few days when the babies were the most hungry. Tell the mothers not to fill their babies up on fat cakes prior to the program...we want them to eat our protein rich protein not oily fat. You can also provide some crayons and paper for those old enough...

5.3 Food Preparation

Theoretically, Hearth recipes are based on the 24-hour diet recall of the Village Nawe and the market survey. With that information NGO Field Agents determine several recipes made from locally available and inexpensive ingredients that will provide a high calorie (>700 kcal) and protein (28-30 grams) count. This process is somewhat labor intensive. For the purposes of volunteers, Appendix A of

this manual includes a collection of recipes from previous Hearth interventions in Namibia. You can select between four to six recipes to prepare over the course of the two weeks, based on what is available in your market at that time.

In addition to teaching the recipes themselves, the Village Nawe should explain the components of a nutritious porridge. In this manner the women will be able to experiment with other ingredients to make new recipes. A nutritious porridge can be prepared with any combination of: 1) a cereal or tubercle, plus 2) a construction food, plus 2) oil and/or sugar.

pumpkin porridge

5.4 Daily Messages The daily Hearth messages should be short, simple, motivating and achievable. Although the

Village Nawe is responsible for delivering the messages, your counterpart should be available to provide more detailed information. For example, the Village Nawe may discuss the reasons for family planning, while the counterpart can provide more detail on each method and how they can be attained. Daily messages should be reviewed with the Village Nawe on the morning before they are to be

delivered to ensure that the information is complete and correct. Below is the schedule of messages that we laid out for our Hearth, however, we were not able to cover all of these items. Days 1-2: Hygiene. These are the activities that we will practice every day throughout Hearth. Keep the

cooking area clean. Wash your hands before preparation of meals and after using the toilet. Wash your hands and your child’s hands before and after eating. Keep all food covered when not working with it in order to protect it from contamination by flies.

Days 3-4: Breastfeeding. Breast milk is the best food for the child. It helps to protect the child against disease and fosters a strong relationship between the mother and baby. During the first 4 to 6 months, children should be exclusively breastfed. From four to six months, in addition to breast milk, we need to

give children additional food. We can start by giving them soft porridge and gradually give them a thicker mix, such as a puree of vegetables. Soft porridge without any additional nutrients, such as milk and sugar, does not provide any significant nutritional value. Continue breastfeeding until two years.

Day 5: Good Foods. 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 community. We can make a “colored bowl” of these good foods, representing a healthier, more varied, more colorful meal (with greens, eggs, bits of fish/meat, beans)

than the typical, less nutritious, monotonous meal (soft porridge). Day 6: Good Childcare. Children need people to take care of them, feed them, play with them, and guide them. Good childcare will help the child grow healthy, bright and able to love people. This

includes supervision of young children at all times, mother gives advice to secondary caretaker, father helps to care for the children, older siblings lay with the child. Days 7-8: Good Healthcare. Prevention: We can prevent diseases from affecting children by: 1)

keeping the house, the children’s bodies, and their food clean; 2) taking children for immunizations to prevent serious diseases; 3) weighing young children regularly to detect nutrition problems at an early stage. All of these preventative measures are tracked with the child’s Passport. Treatment: If the child does become ill, bring him or her to the Health Center for timely treatment. Do not self-treat a young

child with drugs from the market. Management of diarrheal diseases with ORS, continued feeding foods and fluids and supplemental feeding after illness. Days 9-10: Safe Motherhood. Discuss the importance of prenatal care: monthly visits to the Health

Center. Stress the use of the Passport in tracking prenatal care. This will eventually become the child’s identity card. In order to guarantee the health of each child, the health of the mother, and the well being of the family, child spacing is essential. Discuss the family planning methods available in the community, their costs, and how to attain them. We also did a session on Natural Family Planning

which mothers were very interested in, but this did not catch on post Hearth. This is a good day to have a guest speaker come, if a nurse is available nearby.

Day 11: Care of Child at Home. Families can continue to maintain and improve their children’s health at home by using the good foods, good childcare and good healthcare practices that they have learned from the Village Nawe. This is the last day with a message, so it should serve as a review day for all of

the previous messages.

6. Closing Hearth

6.1 Closing Ceremony The closing ceremony of Hearth is generally held on the twelfth day. You may choose not to

prepare a recipe on that day. We chose to eat the yogurt recipe, as it is prepared the day before. We weighed all of the children and reported their weight changes. Decide with your counterpart and Hearth mothers whether or not you want to conduct the final weighing in public as part of the official ceremony, or in private.

If you choose a public closing ceremony, as done in West Africa: All of the preparations for the closing were the same as for the opening ceremony. The location, the list of invitees, and the effort put forth by the health agents to mobilize the community were all kept unchanged. Our Health Center

Director opened the ceremony by reporting the overall weight change since the opening day. His address was followed by speeches from the village elders and the other invitees. All of the speakers encouraged the mothers to continue with the work that they had started during Hearth.

Regardless of which closing ceremony you choose, stress that the two-weeks of Hearth preparations were not sufficient to “cure” a child of malnutrition; it is the changes in healthcare, childcare and feeding practices learned during the program that would guarantee the health of their children. Encourage the Hearth mothers to share the recipes and information with other women in the

community. Have a group discussion of the changes seen over the two weeks, besides just weight gain. I found it helpful to have a short survey to see if something we did just really didn’t work.

6.2 Final Reporting

As you may have assumed, for the closing day of Hearth you weigh each baby and compare the ending weight to the starting weight. Another way to report weight results is to do percent gained per body weight, this is easier for comparison reasons. This can be done on the spot for the mothers

knowledge but most likely can just be done for reporting purposes to the clinic or even Peace Corps. You take the amount kg gained and divide it by the original weight of the baby. From my results , the percent weight gained ranged from 1.1% weight gained to 26% weight gained. Even if babies do not gain significant (or any) weight during the two weeks, encourage the mothers to continue with the

recipes. I have had two babies that did not gain any sort of significant weight during the program but showed promising results after 2 months. Just to give you an idea of some results, here are some taken. Some are the best, some are the worst and others I found to be average (comparative to the other results )

Age of Child Starting Weight Ending Weight Weight Gained % Weight Gained

1 yr, 8 months 9.1 kg 9.1 kg 0 0.00%

2 yrs, 1 month 5.5 kg 6.9 kg 1.4 kg 26.00%

8 months 6.4 kg 6.6 kg 0.2 kg 3.00%

7 months 4.8 kg 5.8 kg 1.0 kg 20.00%

2 years 6.6 kg 7.3 kg 0.7 kg 10.60%

6.3 Follow-up with Hearth Children Hearth intervention should not end with the closing ceremony. Ideally, the Village Nawe with the PCV will visit each of the mothers in the months following the closing to see if they are still

practicing what they learned during the project. The community counterpart should also actively follow-up with Hearth families. In addition to these informal meetings, the children’s weights should be tracked on a regular basis. One month following the closing ceremony and again two months after the closing, the children should be weighed and their weight compared with that of the opening day. The

technical success of Hearth is dependent on these activities. If, after two months, the child has adequate or catch-up growth (see chart below), Hearth has been successful. From experience, the Hearth follow ups turn into social work situations. Prepare yourself and

your Village Nawe for this. Problems arise with disagreements between the father not seeing the need for special attention for the Hearth child, or the mother has lost her motivation, etc. During a Hearth follow up, measure everything again, just as the first time. Ask about any sicknesses. Ask which recipes she has found successful and which ones fell flat. Unfortunately, depending on the season, I hae done

multiple Hearth follow ups where the baby has lost weight. This is discouranging for the PCV and of course, the mother. This is where you can do some further digging to find out the major problems and what can be done to help. Overall, make the mother feel supported by you and the Village Nawe, while at the same time setting the bar high and making her see where her responsibilities as a mother lies.

1 Month Post Hearth Weighing

>400 gram weight gain Catch-up Growth

200-399 gram weight gain Adequate Growth

< 200 gram Growth Failure

2 Month Post-Hearth Weighing

>700 gram weight gain Catch-up Growth

200-699 gram weight gain Adequate Growth

<200 grams Growth Failure

7. Recipes and Cooking Tips

7.1 Creating the Menu

This is a major part of the program and can vary significantly from the North of Namibia to the South. It can also vary depending if you are in a village or a town and how available or regularly

people go food shopping. The Hearth program should probably be attempted after you are already 6 months at site, so you have a good feel for how activities and shopping trips are run and you are more comfortable with your surroundings. At this time you should have some sort of idea of what recipes a re realistic and which ones will never catch on. But obviously locals will know better so, ask around!

For many Namibians porridge is the staple food. This is pretty standard for the North and the South, this is where to begin. Hearth program is designed around adding local, attainable, protein-rich

ingredients directly into the porridge. The first step is finding out what the average woman has access to, what does she have money to afford? Most likely if malnutrition is present then there is not much a surplus of money or food. For a town it may not be locally grown ingredients used but you can work to introduce some recipes that maybe could convince some mothers to buy different foods-peanut butter

instead of cool drinks; eggs instead of ketchup. Encourage women to make smarter, healthier decisions for the monthly food shopping trips. In the Northern regions, more locally grown foods can be used in recipes; mangoes, pumpkin, papayas, cabbage, spinach, bananas, beans, etc. In the South, where all you can see is sand, it may be harder to find home grown foods. As PCV's in Namibia know, it is very hard

to generalize with certain things, as sites can significantly vary from one region to another. The first time you are doing this in your community, alter this program for however it can work for you and your site.

If you are in a town where most people around you buy food, you can conduct a Market Survey.

The intention of the market survey is to determine what foods are available locally and at what prices. As part of the training, you could visit the market with the Village Nawe to see which foods were available in that season and in the local market. Estimate the costs of certain recipes and she can judge which recipes would be most appropriate based on their affordability. She can say which ingredients

are too expensive and therefore unrealistic for the mothers to buy after the program. The Village Nawe can also be able to identify sources of certain ingredients that are normally not sold in the market. For example, many towns in Central Namibia have farms on the outskirts, some of Hearth mothers could come from farming families and the Village Nawe can convince them to donate a food item for a new

recipe.

7.2 Hearth Cooking Tips

Hard Porridge: If you add dry powder directly to boiling water, your porridge will be lumpy. Add a small amount of cool water to the measured powder and stir to the consistency of a thick soup prior to adding to boiling water.

Soft Porridge: cooked almost the same way as hard (regular) porridge but you add oil and cook for less time. It will come out to look more like grits. If adding sugar, don’t add until the end or else it will just cook out.

[If you are purchasing porridge (instead of having the mothers contribute) about a 5 kg bag will feed 7 mothers plus babies for 5 days. This accounts for each eating during the program and enough food to also take home for a second meal. So possibly 10 kg bag for the whole program...this is NOT exact though)]

Sugar: Be as stint as possible with the oil and sugar and do not bother adding until the end since it will just cook out if added while still on the fire.

Adding in: When adding the added nutritious ingredient do it very close to the end as to not cook the nutrients out!

7.3 Hearth Recipes !!

1. Egg Porridge: ingredients: eggs (1 per mother/child pair, porridge, oil, soup packet)

one egg provides 12.6 grams of protein Bring pot of water to boil. Mix together the porridge and water to form a thick consistency before adding it to the boiling water (this is to make a smoother porridge and not completely necessary and

there are no exact measurements with porridge). While that is cooking...Separate the yolk of the egg (with about 1 egg per child/mother) and set the white aside. Whip the egg yolk(s) until frothy and add to the porridge. Stir in and let it cook about 5 minutes (very short time!). Use the separated egg whites in a soup for the relish (looks gross but comes out very good!) Can also make this by making soft

porridge but for the program show them how the egg white can also be utilized.

2. Beans and Porridge:

Ingredients: beans (1 bag at 500 g will feed approximately 6 babies and 6 mothers), oil, porridge 1 cup of beans provides 16 grams of protein

Let beans soak overnight in 1 liter of water. Put the beans and their water on to boil and allow to cook until they are soft enough to mush up (can take 2-4 hours), adding water as necessary. Using the same water beans were soaked in keeps some of the nutrients in. When the beans are fully cooked add enough water and a little oil to puree them using a wooden whisk. In a separate pot cook the porridge

as normal. Add in the mashed beans when the porridge is close to finishing. This combination should have the consistency of paste. You can also just use the mashed beans as a side, similar to a relish. (If you prefer you can add a little soup packet for flavor). While cooking the beans make sure in the 2

nd or

3rd

hour that they do not burn. Try not to use too much oil, as to not take away from the nutritional

value. With this recipe encourage the mothers to feed their babies more bean than porridge so they do not fill up on just porridge. 3. Banana and Peanut Butter Porridge:

Ingredients: bananas (about 1 banana per mother/child pa ir), peanut butter (about 500 g per 6 mothers and babies), oil, sugar *this is especially good for diarrhea and the kids love it!

Bring a pot of water to boil. Add a little water to the porridge powder to make a think consistency before adding it to the boiling water. You are cooking this as a soft porridge (not hard!). While that is cooking...Mash together the bananas. Add 1 tablespoon of vegetable oil (per 2-3 bananas) to form a

paste. Add this mixture plus the peanut butter to the porridge and cook for approximately 5 minutes. Do not let it cook for too long! Remove from fire and allow to cool. 4. Mango Porridge:

Ingredients: mangoes (1 mango per 2-3 mother/child pair), porridge, sugar, oil Bring a pot of water to boil. Add a little water to the porridge powder to make a think soup to add to the

boiling water. You are cooking this as a soft porridge (not hard!) so put a little oil in the water before adding in the porridge mixture. While that is cooking...Mash together the mangoes. Add 1 tablespoon

of vegetable oil (per 2-3 mangoes) to form a paste. Add this mixture right as the porridge is ready to take off the fire. Remove from fire and allow to cool. Add sugar to taste.

5. Pumpkin Porridge: Ingredients: pumpkin (~ ½ of a large pumpkin is plenty for 7 mothers and 7 babies), sugar, oil, porridge

Bring a pot of water to boil. Add a little water to the porridge powder to make a think consistency before adding to the boiling water. You are cooking this as a soft porridge (not hard!) so put a little o il in the water before adding in the porridge mixture. Separately, put a pot on the fire for the pumpkin pieces. Once the pumpkin pieces are soft enough to mash, add a little oil and a approximately 8

spoonfuls of sugar and one spoonful of salt. Add this pumpkin mixture right as the porridge is ready to take off the fire. Remove from fire and allow to cool. This one is SO GOOD! 6. Yogurt:

1 serving of yogurt provides 11 grams of protein (11 out of the 13 needed for the day). GREAT for diarrhea! 1. Warm milk in a large saucepan over a gentle heat, stirring constantly to prevent burning the

milk 2. Keep the milk on heat until it starts to boil, then remove immediately. 3. Allow the milk to cool until the point you can comfortably put a [clean] finger in the milk for a count of 10 before it becomes uncomfortably hot (can switch to a different saucepan/bowl to have the

milk cool faster) 4. Whisk one half cup of plain yogurt (with active cultures!) per liter of milk into the hot milk until it is combined completely. I have tried using a flavored yogurt and it did not come out as well.. 5. Transfer milk to a large glass or plastic bowl and cover it with a plastic (plastic bag will work).

If the bowl has its own cover use that. 6. Wrap the bowl of milk in a few dish clothes (or towel, shawl, wool blanket) while keeping the top just with the plastic cover, and leave in the direct sun. 7. Let it sit in the sun, undisturbed, for 5-8 hours. After 5 hours check to see if the mixture is thick,

creamy and slightly sour. If not, check again every hour until it reaches the desired consistency. The yogurt will grow more acidic over time, let it culture longer for a tangier end result. 8. Chill your freshly made yogurt if refrigerator (if available) overnight. A yellow film may form on top of the yogurt, this is safe and very healthy to eat.

9. Before eating add a little sugar, vanilla, cinnamon, fruit, whatever! 10. Save a small cupful of yogurt to then reuse for the next bath, store bought started yogurt is

only necessary the first time. For every batch after the first you can reuse the bacteria (good for

about 5-6 batches after the first until the bacteria is no longer 'active')

**if you are using cow's milk that is fine, just don’t get knocked over while milking and make sure to pick out the hairs :)

**I got about 1-2 liters of milk to then combine it with ½-1 cup of yogurt. Note that this recipe will only feed the babies as there is not enough for the mothers, but it makes plenty for the babies. I have made this multiple times and sometimes if it is a little too cloudy that day it comes out liquidy, but it was still good just didn’t look like traditional yogurt. Encourage the mothers to save a bit of their

yogurt to make future batches if that interests them. (I found that the babies LOVED this one but the recipe itself did not get replicated by any of the mothers).

7. Cabbage and Porridge:

Ingredients: cabbage, oil, porridge This cabbage will be used as a relish, so make hard porridge as instructed in previous recipes. The cabbage should be chopped into small pieces and cook for about 40 minutes, with water and some oil.

We had about 15 leaves for the group and that was enough (it was $10 worth). 8. Papaya Porridge: See mango porridge and follow instructions. Number of papayas depends on the size, maybe 1 medium

sized on 2 mother/child pairs. 9. Sweet Potato Porridge: See mango porridge and follow instructions. About 1 medium sweet potato per mother/child pair.

8.Growth Monitoring Handouts and Daily Lessons Handout

8.1 Weight for Length/Height Table (2 papers)

8.2 MUAC information, measurements

BMI for adults (based on weight and height

8.3 Handout on Breastfeeding and Nutrition

8.3 Handout on Breastfeeding and Nutrition