Overview of Implementing Nutrition Week Procedures

Overview: 

WR has been implementing PD/Hearth in Rwanda as part of USAID- funded Child Survival Program since 2006, and Care Groups since 2001. The Innovation CSP in Nyamagabe District is combining these two methods in a further evolution of PD/Hearth called "Nutrition Weeks."  

The purpose of Nutrition Weeks is broader than rehabilitation of under-nourished children; instead all mothers of children in their first 1,000 days of life are invited to participate in the hands-on education program aimed at preventing under-nutrition. The aim is to improve the nutritional status of pregnant and lactating women, as well as children between 0-23 months old through enhanced Infant and Young Child Feeding (IYCF) practice. 

 Community Health Workers are trained and given a step-by-step guide to implementing Nutrition Weeks. Per MOH suggestion, these weeks will be held three times a year.  The Operations Research component of the Innovation CSP aims to identify the most feasible way to reduce and prevent under-nutrition in the first 1000 days of life of children in Nyamagabe District, Rwanda through formative research, and then to test the innovated intervention, namely, “Nutrition Weeks” to evaluate if the intervention is more effective than the standard CBNP (Community-based Nutrition Program), which are cooking demonstrations. 

The objective of this program is for mothers to learn about nutritious foods that they may not be giving children, optimal feeding practices and other health behaviors to prevent under-nutrition. The sessions last for 2 hours daily of hands-on practice for one week, with follow-up by specially-trained volunteers.

Reasoning for Innovation: 

The Standard Community Based Nutrition Program used in Rwanda now teaches mothers what to feed their children with cooking demonstrations. Nutrition Weeks adds a hands-on practice and discussion, also involving mothers in law and fathers on certain days.  The counseling, home visits, and other activities show the mothers how to practice these new skills. The peer support is also built in, as all the mothers in a village learn together in small groups.

Positive Deviance Inquiry (PDI): 

A series of semi-structured interviews and observations were carried in the Kaduha zone by a team of 2-3 ICSP staff using a PDI approach to acquire information about child feeding and heath care practices.  Both positive and negative deviant mothers were interviewed in order to adapt the program the community needs.  The findings from the positive and negative deviant household interviews were compared to the identified positive behaviors that could be broadly applied to the community.

Unlike a typical PDI approach this process was not repeated in every village where the intervention is being implemented. Rather, the results from the PDI was utilized to develop the Nutrition Week Curriculum.

Population/ Area:

The Nyamagabe district was chosen as a whole for the project based on government priority as well as to be able to build on the foundation of work with the CHWs that was established during EIP. The comparison and intervention groups were divided based on the hospital zones (Kigeme and Kaduha). Both hospitals were very similar; however Kaduha was chosen for intervention because it had slightly worse indicators.

Each Nutrition Week was held in the house of one of the community members. The house was chosen based on a criteria list to ensure the site would meet all the needs of a Nutrition Week.

Training/ Orientation:

There were three primary training/orientations:

1. Master Trainer Orientation
2. Training of Trainers (TOT)
3. Training of Village Nutrition Committees

Supervision of Nutrition Week

Supervision of Nutrition Weeks is performed by health staff, health facilities staff, and ICSP Staff. 

Training Religious Leaders to become change agents in a community

In collaboration with WR Kigali office, Nyamagabe District and ICSP-Tangiraneza staff, in July 2012, WR staff organized and conducted the Orientation meeting for Religious Leaders on MCH Intervention and Transformation Tree.  

Upon completion of the training, Religious Leaders committed to help their most vulnerable families. Churches involved in the training included EAR,ADEPR, Catholic, Adventist,CECA, EPR, Free Methodist (ELMR), Restoration Church, Rwanda Reformed Episcopal Church, AEBR, UEBR, Deliverance Church, and Inkurunziza.

During both the orientation meeting and the first training session 52 members from various denominations were in attendance. These members are the leaders from parishes. They were trained on Nutrition (balanced diet, kitchen garden, exclusive breastfeeding, and hygiene) and Family Planning.

The role of church representatives in the Modified Care Group is to share health messages with church members and to help mobilize members to take positive steps towards health such as: building latrines, improving kitchen gardens, etc.

This table outlines activities:

Health activities	Total
Hygiene
Improved/ New Latrines	50
Compost	14
Soap	285
Tippy-Tap	50
Nutrition/ Prevention of Undernutrition
Kitchen gardens	60
Food for malnourished children	78
Provide cow	14
Provide goat	70
Provide health insurance	30
Provide pig	4
Animal husbandry	18

Ten of the 13 Church denominations involved in this project provided physical health promotion programs in addition to health messages.

The religious leaders of the community have committed to continue this work for next quarter. The commitment for next quarter is:

To reinforce the mobilization and support of  the Kitchen Garden Project

Encourage Church members to make home visits

To reinforce mobilization for Family Planning

  Promote Hygiene (Good Latrine Projects; teaching proper animal keeping; hand washing; etc.)

Pastor Donat and Sousane checking Sousane's new kitchen garden to see if the seeds are growing. 

This is Sousane's previous kitchen garden. 

Sousane testified to the improvement of the kitchen garden and the help of her church (AEBR):
"I like my Church very much because they provided many things like rabbits, goats, 
kitchen gardens, and the message of hygiene and nutrition, as well as going to heaven."  

A vulnerable family who received a rabbit. 

Pastor Donat has a kitchen garden that the church utilizes to serve as an example to his community.
"Vegetables play an important role in human health especially in growing. 
That's why our members have to consume them in order to prevent malnutrition." 

The pastor now shows the construction of a latrine for one of his vulnerable members.
He explains that "building a latrine is not an easy task."

Pre-Nutrition Week Training for SED (Social and Economic Development), Social Affairs, and In Charge at HC (Health Center) for CHWS (Community Health Workers)

Training in the weeks leading up to Nutrition Weeks

1) Pre-Nutrition Week Training with the following MOH and Civil leaders: Social and Economic Development, Social Affairs, and In Charge of Community Health Workers at the Health Centers. 

These will be the primary teachers  for the Village Nutrition Committee. They are taught the daily activities; primary objectives; and simulations of the training sessions. 

Each teacher is given the opportunity to teach a lesson during the training and then given feedback to ensure they are effectively teaching the lessons. 

Nutrition Weeks have 7 primary objectives:

1. The importance of cooking porridge thicker, and feeding young children thicker (more calorie-dense) porridge.
2. The need to eat high-fat content and animal-source foods (eggs, organ meats, etc.). 
3. To increase the number of meals per day. 
4. Increase variety of foods given at each meal and each day. 
5. Infants must be mentally stimulated for development. 
6. Hand washing before meals for mothers and children is important to reduce diarrhea.
7. Pregnant women need an extra meal and rest. 

In addition to teaching the lessons during Nutrition Weeks, they are encouraged to take ownership of Nutrition Weeks. This is more than a World Relief project. Rather this is a community activity to help the community members better themselves. It is important that the teachers take ownership of the project and ask the community to take ownership. For PD/Hearth effectiveness this is an important concept. If the community does not take ownership the likelihood of behavior change after the completion of the Nutrition Week decreases. 

Highlights of Pre-Nutrition Week Training: 

An ICSP Staff teaches about presenting the program.
During this lesson the participants are learning how to stand; present themselves; answer questions;
and other information about present the daily lessons.  

One of the participants in the training is practicing teaching the importance of thicker porridge and infant feedings. 

Here are the notes given to the training participants: lyrics to the Nutrition Week song; a timetable to Nutrition Week; and the primary objectives. 

Here begins the lessons on the cooking demonstrations that are a vital component to Nutrition Week.
Nutrition Week is more than teaching lessons: it is important that the community members also learn the ways to cook and implement the lessons they are taught. 

During the cooking demonstrations the community learns how to make thicker porridge
as well as what ingredients should be included to eat a balanced meal. 

Practicing teaching a cooking demonstration. 

ICSP staff are available to answer any questions participants may think of
to ensure they do not have questions they cannot answer during Nutrition Weeks. 

Growth Monitoring Achievement

Celebration song for all the children that moved from under-nourished to normal level of growth monitoring.

The Value of Positive Deviance/Hearth Approaches to Public Health Practicies

Positive Deviance (PD) was created with the idea that solutions to a health problem can be found in the community and can be discovered.  PD can be “strength-based” or “asset-based” dependent on the cultural beliefs of a community.  A "positive deviant" is someone whose behavior varies from the norm in a positive direction (ie a poor mother who has a well-nourished child.) How did this mother learn how to overcome a health problem compared to her neighbors, even though they have the same risk factors.  These community members are identified through a Positive Deviant Inquiry (PDI).

Primary objectives of a PD Approach to decrease malnutrition:

To quickly identify and rehabilitate malnourished children in a community. 
To find a sustainable way to allow family to prevent a relapse in malnutrition in their children.
To prevent future malnutrition among children born into the community through behavior change.

The PD/Hearth Approach adds an additional element to this public health intervention program.  Community volunteers and givers utilize the information from the PDI to create programs/training sessions to teach community members the key PD behaviors found to be successful.

This is often a 12-day period that involves teaching healthy habits such as new cooking, feeding habits, and hygiene. The practices all derive from the PDI; however, they are often augmented by public health experts’ opinions and research done in that country or region.  Upon completion of the 12-day sessions monitoring is continued through home visits to ensure the behavior change is occurring.

This intervention ideal vastly varies from traditional intervention programs.

Questions that would be observed in Traditional Intervention:

1) What are your needs?

2) What is wrong?

3) What can we provide?

4) What is the community lacking?

5) What is missing?

Questions that would be observed in PD/Hearth Approach:

1) What are your strengths?

2) What is working?

3) What are your resources?

4) What is good in your community?

5) What can we build on?

This variance in questions leads to several advantages to a PD/Hearth Approach. It allows for a quick response because of the utilization of resources already available.

Furthermore, the project is more affordable and sustainable because families are not relying on outside sources to implement the change. Since the program is asking for community leadership there is higher participation and culturally accepted because they are taking ownership of the project.  

Steps to Implementing PD/Hearth:

1)   Decide whether PD/Hearth approach will be possible

2)   Begin mobilizing community and select a community resource person.

3)   Prepare PDI

4)   Conduct PDI

5)   Design Hearth Sessions

6)   Conduct Hearth

7)   Have follow-up home visits

8)   Repeat Hearth if needed

9)   Expand PD/Hearth to other areas

References: Positive Deviance/Hearth: A resource guide to sustainably rehabilitating malnourished children. February 2003.