Positive Deviance (PD)/Hearth

PD is based on the belief that in every community there are a few individuals and families whose particular practices enable them to have better health compared to their similarly impoverished neighbours. Hearth, suggesting a family around a fireplace or kitchen, is an implementation strategy that supports caregivers to learn and practice new health behaviours together in a safe environment (such as a home setting) and to rehabilitate their malnourished children. Participants practice positive child caring and active feeding techniques and feed malnourished children with extra energy-rich/calorie-dense supplemental meals. Two-week participation in a Hearth is common, and often contributes to rapid improvement in nutritional status for children, as well as better long-term feeding practices by caretakers at home.

PD/Hearth Programmes: Essential Elements - click here [PDF] for further details.

1. Each and every community conducts a PDI - a learning opportunity for the community, not just fact-finding for the project staff. It is meant to provide an opportunity for community members (e.g., Hearth volunteers, health staff, community leaders) to "discover" that impoverished families can have certain good practices which enable them to prevent malnutrition, and these practices can be taken up by any family with similarly scarce resources. The PDI, as described in the PD/Hearth Guide [PDF], involves both questioning the family members and making careful observations of the situation. The lists of questions given are best used as discussion guides, rather than interviews.
2. Utilise community women volunteers to conduct the Hearth sessions and the follow-up home visits. Mothers will learn best with a peer, with whom they feel comfortable and who understands local customs and conditions. Note: PD mothers are not necessarily the Hearth volunteers; in many cultures, identifying individuals or families as models or "better" will result in social rejection by their peers.
3. Prior to the Hearth sessions, de-worm all children, update immunisations, and provide needed micronutrients. Families should be referred for these services to the local health facility with which the programme is collaborating.
4. Use growth monitoring (GM) to identify newly malnourished children and monitor nutritional status of participants who have graduated from the Hearth. The GM programme must include good nutrition counselling and explanations of the child's growth for the caregivers.
5. Ensure that caregivers bring a daily contribution of food and/or materials to the Hearth sessions. One of the fundamentals of PD/Hearth is that families learn they really can afford to feed their children nutritious food. In addition, requiring contributions makes the programme non-paternalistic while also making it possible for a community to implement without outside material support.
6. Design Hearth session menus based on locally available and affordable foods.
7. The Hearth session menus must provide a special nutrient-dense meal sufficient to ensure rapid recuperation of the child. The daily menu including the snack must contain specific amounts of calories, protein, and micronutrients per child [click here and scroll down to #7 for details].
8. Have caregivers present and actively involved every day of the Hearth session. Involvement promotes ownership and active learning and builds self-confidence. Further, by learning and internalising the new practices, not only will the improved nutritional status of the participating child be sustained at home but also, malnutrition will be prevented among future children.
9. Conduct the Hearth session for 10-12 days within a 2-week period. Within 8-12 days of starting the Hearth rehabilitation (which provides the extra, nutrient-dense meal), mothers may need some guidance to recognise the changes in improved appetite and energy level, less irritability, level of alertness, etc. "This recognition of the child's improvement serves as a major motivator in the caregiver's adoption of the new feeding, caring and health practices."
10. Include follow-up visits at home for 2 weeks after the Hearth session (every 1-2 days) to ensure the average of 21 days of practice needed to change a new behaviour into a habit.
11. Actively involve the community throughout the process. Community leaders and a village health committee can provide support, such as by recruiting volunteers, conducting the PDI, assuring that eligible caregivers attend the Hearth session regularly, and encouraging other community members to support the families with malnourished children in adopting new practices. Involving the community in monitoring programme implementation and results can reportedly provide "living proof" of the effects of good nutritional inputs on malnourished children, which may raise the consciousness of community members and empower them to prevent malnutrition from within their own community.
12. Monitor and evaluate progress. At a minimum, programmes should monitor attendance, entering weight and weight at one month, and the percent of children who "graduate" after one session or after two sessions. (Many examples of indicators to monitor the quality of implementation, community support, etc. are given in the CORE PD/Hearth Guide.)
13. If a child doesn't gain weight after two 10-12 day sessions, refer the child to a health facility to check for any underlying causes of illness such as tuberculosis (TB), HIV/AIDS, or other infection. There should be a cap on the total number of sessions a caregiver can attend, as caregivers may start to become dependent on the Hearth and not be actually internalising new behaviours.
14. Limit the number of participants in each Hearth session; doing so provides a "safe" environment in which rapport can be built and all caregivers have an equal opportunity to participate in all activities. Experience has shown that Hearth sessions are most successful when limited to 10 caregivers, with 6-8 being ideal.

Children, Nutrition.

The CORE Group is a membership association of international NGOs seeking to improve the health and well-being of children and women and the communities in which they live.