Positive Deviance/Hearth: A Resource Guide for Sustainably PPositiveositive DevianceDeviance /Hearth/Hearth Rehabilitating Malnourished Children Positive Deviance/Hearth is a successful home-based & neighborhood-based nutrition program for children who are at risk for malnutrition in developing countries. It has enabled hundreds of communities to reduce their levels of childhood malnutrition and to prevent malnutrition years after the program’s completion. The “positive deviance” approach is used to find uncommon, beneficial practices by mothers or caretakers of well-nourished children from impoverished families. Once identified, ways are sought to spread these practices and behaviours to others in the community with malnourished children. A “Hearth” is the setting of the nutrition education and rehabilitation part of the program. Suggesting a family around a fireplace or kitchen, Hearths are carried out in home settings where caretakers and volunteers prepare “positive deviant foods”. They practice beneficial childcare behaviors and feed malnourished children with extra energy-rich/calorie-dense supplemental meals. Sprinkled with helpful field examples, useful tools and ideas, this guide explains step by step how to: ♥ identify at-risk children AA RResourceesource GuideGuide ♥ conduct a Positive Deviance Inquiry forfor SustainablySustainably RRehabilitatingehabilitating ♥ conduct Hearth sessions and ♥ set up a monitoring and evaluation system MalnourishedMalnourished ChildrenChildren CORE Incorporated 220 I Street, NE Suite 270 Washington DC 20002 (USA) telephone (202) 608-1830 / fax (202) 543-0121 Child Survival Collaborations and Resources Group www.coregroup.org Nutrition Working Group February 2003 The CORE Group he Child Survival Collaborations and Resources Group (The CORE T Group) is a membership association of more than 35 U.S. Private Voluntary Organizations that work together to promote and improve primary health care programs for women and children and the communities in which they live. The CORE Group’s mission is to strengthen local capacity on a global scale to measurably improve the health and well being of children and women in developing countries through collaborative NGO action and learning. Collectively, its member organizations work in over 140 countries, supporting health and development programs. This publication was made possible by support through the Office of Private and Voluntary Cooperation of the United States Agency for International Development (USAID) under cooperative agreement FAO-A-00-98-00030. This publication does not necessarily represent the views or opinion of USAID. It may be reproduced if credit is properly given. Recommended Citation utrition Working Group, Child Survival Collaborations and Resources NGroup (CORE), Positive Deviance / Hearth: A Resource Guide for Sustainably Rehabilitating Malnourished Children, Washington, D.C: December 2002. Abstract PD/HEARTH Positive Deviance/Hearth Nutrition Program is a home-based and A neighborhood-based nutrition program for children who are at risk A HOME & for protein-energy malnutrition in developing countries. The program NEIGHBORHOOD- uses the “positive deviance” approach to identify those behaviors BASED practiced by the mothers or caretakers of well-nourished children from PROGRAM poor families and to transfer such positive practices to others in the community with malnourished children. The “Hearth” or home is the location for the nutrition education and rehabilitation sessions. This resource guide explains in detail how to identify at-risk children, conduct a Positive Deviance Inquiry to identify positive practices, conduct Hearth sessions, and set up a monitoring and evaluation system. Specific field examples and useful tools are provided. ii / CORE Group / Citation / Abstract ACKNOWLEDGMENTS Many people contributed to the final version of this resource guide — writing chapters, providing cases, sharing experiences, reorganizing material and steps, and editing the document to make it user-friendly for field staff. This final product is a work of many committed individuals who found value in the Positive Deviance/Hearth approach and wanted to share their learning with others. We want to thank the many CORE members and partners who have shared insights on PD/Hearth through various meetings and e-mails over the past two years. While we cannot name everyone involved, we want to highlight a few of the key individuals who contributed significant amounts of their time. This final product is a onna Sillan was hired by CORE as the lead writer of the first draft of the work of many committed Dresource guide. She traveled to Myanmar to work with Monique and individuals who found Jerry Sternin and learn about their PD/Hearth work in Vietnam, Egypt, value in the PD/Hearth Myanmar and other countries. She built on this experience and her own work designing PD/Hearth programs for CORE members around the world to approach and wanted to compile in-depth information and cases on PD/Hearth. She incorporated share their learning with materials from the following sources: the original PD/Hearth field guide: others. Field Guide: Designing a Community-Based Nutrition Program Using the Hearth Model and the “Positive Deviance” Approach (1); the Masters thesis of Melissa Cribben, that field tested the original guide in Bolivia (2); Positive Deviance in Child Nutrition: A Field Manual for Use in West Africa (3); a national Hearth workshop in Guinea held in February 2000 by Africare; a Hearth Technical Advisory Group Meeting held in April 2000 by CORE and BASICS II; and a Positive Deviance Approach workshop held in November 2000 in Mali by Save the Children and BASICS. The contributions from these different sources are too extensive to reference individually in the text. Monique and Jerry Sternin elaborated the Positive Deviance approach and demonstrated its incredible power by setting up Save the Children’s Nutrition Education and Rehabilitation Program in Vietnam. They started small and brought it to scale with an approach they named “living university” and scientifically documented its success. Monique reviewed several drafts and provided invaluable information based on her extensive experience. Drs. Gretchen and Warren Berggren set up and wrote about the original Hearths (nutrition demonstration foyers) in the 60s in Haiti and are still contributing to the refinement and lessons learned of the Hearth approach while mentoring others in its use. Gretchen Berggren reviewed several drafts of the manual and both Gretchen and Warren provided excellent technical guidance. Positive Deviance/Hearth Manual / iii Dr. David Marsh wrote the chapter on Monitoring and Evaluation and contributed many of the case studies based on work by Save the Children. David’s hard work to document the success of the approach through operations research activities in several countries has significantly contributed to the uptake of both Positive Deviance and Hearth. Adventist Development and Relief Agency (ADRA), Africare, CARE, Christian Children’s Fund, Mercy Corps, Save the Children, World Relief, World Vision, and others implemented PD/Hearth in different communities around the world. The hard work of communities, Hearth volunteers and field staff made the lessons learned, cases, and exercises presented here possible. Olga Wollinka initiated the development of this document and provided valuable insight based on her World Relief experience with PD/Hearth. Lynette Walker solicited feedback from a team of reviewers and reorganized and wrote the final version of the manual. Additional reviewers provided extensive input on several drafts: Judiann McNulty (Mercy Corps), Karen LeBan (CORE), Caroline Tanner (FANTA), Valerie Flax (consultant), Hannah Gilk (Pearl S. Buck Foundation), Judy Gillens (FOCAS), and Karla Pearcy (consultant). Several copyeditors contributed to the document at its various stages: Alicia Oliver, Lucia Tiffany, Justine Landegger and Robin Steinwand. Regina Doyle designed the layout, graphic design, and illustrations. Our appreciation to the In addition to those persons mentioned, we want to express our appreciation many individuals & and gratitude to the many individuals and organizations who were not mentioned organizations who were but who have contributed immensely to the development of PD/Hearth programs around the world. Thank you. not mentioned but who have contributed With the hope that we are able to bring the practices of these extraordinary immensely to the devel- positive deviants into the norm, and learn to practice their good child caring, opment of Positive De- feeding, and health-seeking behaviors, we present to you, the implementers, viance/Hearth. this resource guide to the PD/Hearth approach. Sincerely, Judiann McNulty, Co-Chair The Nutrition Working Group Child Survival Collaborations and Resources (CORE) Group Karen LeBan, Executive Director Child Survival Collaborations and Resources (CORE) Group iv / Acknowledgements TABLE of CONTENTS ACKNOWLEDGMENTS .................................................................. iii OVERVIEW OF POSITIVE DEVIANCE / HEARTH........................... 1 OVERVIEW How to Use This Guide .................................................................................1 What is PD/Hearth? .......................................................................................1 Advantages of PD/Hearth vs. Traditional Approaches .................................6 Why is Malnutrition a Problem? ..................................................................10