The Positive DevianceThe Positive DevianceHearth Nutrition Hearth Nutrition

ModelModelMercy Laker,Mercy Laker,

Nutrition Specialist WVUNutrition Specialist WVU

The concept of PD Hearth• Positive Deviance: It is a departure, a difference, or

deviation from the norm that results in a positive outcome. It is a departure from the conventional wisdom,

• “Positive”? Looks for what is working, what people are doing right. Utilizing what resources are available, not what is needed and missing. It is asset-based, rather than needs based.

• A positive deviant is a poor member of the community who has a well-nourished child while most of their neighbors do not.

• A Hearth? It is a home kitchen, community volunteers volunteering their homes

• A Positive Deviance Inquiry (PDI) is a process of discovery that occurs before a Hearth directly informing the content to be shared during the Hearths.

Positive Deviance/Hearth - principle

The Million $ Question:Why do well nourished children exist beside malnourished children despite

living in the same conditions of poverty?

What is PD/Hearth programming model?

• in every community there are certain individuals or groups (the positive deviant) whose special practices or behaviors enable them to find a better solution to a prevalent problem than their neighbors who have access to the same resources.

• Presumes that the knowledge about ‘what works’ is available in existing individuals or entities (Solutions from within!)

• The goal of PD Hearth is to treat, sustain and prevent malnutrition

• Provides timely catch up growth for children showing growth faltering– Target: moderately malnourished children and

children at risk of malnutrition.

To reduce the prevalence of malnutrition

among children under 5

Three (3) Dimensional Approach of

Positive Deviance/Heart

h

Reduce

To build local capacity to sustain the

rehabilitation of children

To prevent future malnutrition

among all children in the communities

Process in PD Implementation

:

Social Mobilization

Information Gathering

Behavior Change

Build

Prevent

Stages in PD Hearth

• Implementation of the PD/HEARTH model progresses in five stages:

• Determining feasibility• Conducting the Positive Deviance Inquiry

(Learning from the positive deviants)• Implementing the NERS(treating malnutrition)

• Follow up and monitoring (sustaining)• Nutrition education (prevention)

Steps in a Positive Deviance/Hearth Model

8

Step 1 – Determining feasibility and Step 1 – Determining feasibility and normingnorming

• Malnutrition Prevalence in the Community

• Availability of Affordable Local Foods

• Availability of complimentary services

• Geographic Proximity of Homes• Existence of Food Aid• Emergency nutritional situation• Landless Populations or Squatter

Communities Committed leaders, village chiefs

9

Step 2 – Conducting a PDI (Learning Step 2 – Conducting a PDI (Learning from the positive deviants) from the positive deviants)

What works???

• Feeding PracticesFeeding Practices• -Caring & Hygiene Practices-Caring & Hygiene Practices- Health Care PracticesHealth Care Practices• (home management & health-seeking)(home management & health-seeking)

10

PD Inquiry is an “Ends” as well as “Means”PD Inquiry is an “Ends” as well as “Means”and and MUSTMUST be repeated in each Community be repeated in each Community

ToTo discover discover successful, successful, replicablereplicable PD behaviors PD behaviorsMeansMeans

EndsEnds

To empower community To empower community toto discover discover andand “own” “own”theirtheir own solution, own solution, based on theirbased on their own own resourcesresources

Step 3. Nut. Education Rehabilitation Sessions (NERS)

• Behavior ‘promotion and empowerment’ Learning by Doing

• Nutrition Rehabilitation + Education over 12 days + home visits

• Promotion of behaviors and practices related to Feeding, Caring, Hygiene and Health Seeking Food

CareHealth

Step 4: Follow up

Observe sustained application of PD behavior with Hearth child and siblings (qualitative).

Measure for sustained weight gain at 2 mos, at 6 mos, 12 months, etc.;

Follow the cohort over time to assure that the graduates stay onthe Road to Health and do not falter

Nutrition Education

Home visits are conducted to the Hearth participants at least once every two weeks to support the new behaviors at home.

Create community support systems (Nutrition care groups)

Support food production

Continue home visits and outreaches as usual

INTEGRATED POSITIVE DEVIANCE/HEARTH MODEL

Key Entry Points

Improved water, sanitation, gender &other interventions addressing the underlying causes of malnutrition

Improved access and availability of

nutritious foods

Increased family economy especially for food and health care

Families with currently

malnourished children

Target Groups

Context considerations for PD/Hearth

Stakeholders • Stakeholders are the

individuals, groups and institutions that stand to GAIN or LOSE from project activities

– Key actors for change (central role)

– support actors for change– Final Beneficiaries– Influential players (cultural,

religious leaders)– Information holders

Important considerations in identifying stakeholders

• Power and status• Degree of

organization• Control of resources• Decision-making

process• Power relations• Importance to the

success of the project

I’ll call urgent health

committee meeting

tomorrow!

What do you want to do about this high level of malnutrition?

Staffing

Combination of technical, critical thinking

&community mobilization skills• A Nutrition Advisor (NO level or regional level):

– PD Hearth approach: anthropometry, PD Inquiry, Energy calculation, Adult education

– Follow up, monitoring & evaluation

• Project staff (nut / health facilitator / coord) in ADP:– Anthropometry, Training, Referral of malnutrition, Training & working with

volunteers and health staff

• Community volunteers: as the backbone

PROCESS - How to Develop Competencies to implement PD/H

National Office – identifies malnutrition (>30% children in the

ADP community)

NO contacts the Regional Office (Regional Nutrition

Coordinators/Advisors)

Nutrition Center of Expertise (Nutrition Technical Advisor –

Diane Baik)

Interim process

SO

Costs of Hearth Sessions

The direct costs include:The average cost of themeals per child for the 12days is approximately 1 USD

The indirect costs include:the estimation of time spent by the mothers, community health agents, cooking equipments etc.

The total cost of Hearth is not substantial

Range $1.85 to $12.00 per recovered child

Cost per child with neighborhood level Nutrition education/rehabilitation is

less than half of cost per hospitalization for malnutrition

Advantages of using the PD Model!• Quick solutions addressing moderate malnutrition• Affordable

– Vietnam (USD2 per child)– Mongolia (USD8 per child)– Uganda (USD 1.2 PER child)

• Participatory – Community participation

• Sustainable– Communities gaining skills (cooking, feeding, hygiene

caring)• Indigenous (solutions from within!)• Based on behavior change

PDH Inversions• Trainee vs. Trainer (in a PDI the community becomes the

trainer of ours) • Best practices vs. working practices • Needs based vs. assets based (glass half empty/half full) • KAP vs. PAK • Hearth-based vs. Center-based • Poverty leads to malnutrition vs. Malnutrition leads to

poverty • Acting into new thinking vs. Thinking into new acting • Food Aid vs. food contributions from community • PDI vs. nutritional survey (KPC style) Listening vs. Speaking

Solutions from the inside vs. solutions from the outside • Outside experts knowledge vs. PD mothers knowledge

MANY THANKS MANY THANKS FOR FOR

YOUR ATTENTIONYOUR ATTENTION