pfd’s hearth program in cambodia - · pdf fileto ms. kim chadwick for her “village...

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Chhlong Field Office

PFD’s HEARTH PROGRAM IN CAMBODIA

Program Research Document

Ana Karina Lopez May, 2005
Supported by GTZ Food
Security and Nutrition Policy Support Project (FSNPSP)

PFD’s Hearth Program in Cambodia

FOREWORD

The idea to look at the hearth model and its application in Cambodia grew out of discussions between Partners for Development (PFD), Adventist Relief and Development Association (ADRA) and the GTZ Food Security and Nutrition Policy Support Project (FSNPSP). PFD initiated Hearth in Cambodia in early 2002 and since then has targeted several villages in Kratie and Koh Kong provinces with financial support of CIDA and USAID. ADRA currently also implement Hearth in Kampong Thom province, while GTZ/FSNPSP supports research on innovative activities with regard to food security and nutrition and assists with the dissemination of best practices and lessons learned. GTZ/FSNPSP provided funding to PFD to evaluate the practices and results of Hearth in the Heart villages and to produce this Hearth Program Research Document.

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As a follow-up to this study, a national workshop on the Hearth model, its adaptability to the Cambodian context and its impact on reducing malnutrition in the community is planned for late 2005 with the participation of food security and nutrition stakeholders and under the umbrella of the National Forum on Food Security and Nutrition, chaired by the Council for Agriculture and Rural Development (CARD).


ACKNOWLEDGEMENTS Without the help of many people this research could not have been possible. To begin with, a very special thanks to all Community Officers and Junior Community Officers, from the three PFD’s offices that, not only provided valuable information and worked as translators in the communities, but also were a great support making the village life easier for me. I express my gratitude, as well, to all the volunteers and members of the Health Centers that provided us accommodation and food while working in the villages; also to Ms. Kim Chadwick for her “village life training” and to Mr. Mao Chhay for teaching me how to ride a motorbike. I would thank, too, Mr. Horm Chandet, Mr. Ngoun Ly and Mr. Heng Theara for their help, facilitating and translating during the focus groups discussions. My sincere thanks to Mr. Dul Setha, Mr. Sous Sam Ol and Mr. Phal Phoeun, who, despite their busy schedules, were always available to make arrangements for my field visits, to translate and to provide information. I am very grateful to Mr. Rick Jacobson, Mr. Jonathan Garrett and, particularly, Ms. Judi Harris for their kindness, support and precious advises. Equally, thanks to Dr. Mary Mohan, for her time and the contributions to the report.

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1. ACRONYMS ....................................................................................................................... 3 2. PREFACE ........................................................................................................................... 4 3. INTRODUCTION................................................................................................................. 5

3.1. Nutrition situation in Cambodia .............................................................................. 5 3.2. Background ............................................................................................................ 6 3.3. Objectives of the research ..................................................................................... 7

4. RESEARCH METHODS..................................................................................................... 7 5. RESULTS ........................................................................................................................... 7

5.1. Program description............................................................................................... 7 5.1.1. Process to start a new Hearth Village.............................................................................7 5.1.2. Growth Monitoring Program (GMP) ................................................................................8 5.1.3. Nutrition Education and Rehabilitation Program (NERP)................................................9 5.1.4. Graduating from NERP.................................................................................................12

5.2. Focus groups results............................................................................................ 12 5.3. Qualitative analysis .............................................................................................. 13

5.3.1. Hearth impact ...............................................................................................................13 5.3.2. Present nutrition situation .............................................................................................15 5.3.3. Evolution of the nutrition situation .................................................................................16 5.3.4. Obstacles identified ......................................................................................................17

6. DISCUSSION.................................................................................................................... 18 6.1. Theory vs. practice............................................................................................... 18

6.1.1. The Positive Deviance approach ..................................................................................18 6.1.2. Conducting GMP and NERP every 2 months ...............................................................18 6.1.3. The volunteers’ role ......................................................................................................18 6.1.4. NERP food....................................................................................................................19 6.1.5. Community contribution to NERP .................................................................................19 6.1.6. Hygiene practices .........................................................................................................20 6.1.7. Practice at home...........................................................................................................20

6.2. Analysis................................................................................................................ 20 7. BEST PRACTICES........................................................................................................... 23 8. LESSONS LEARNED....................................................................................................... 24 9. RECOMMENDATIONS..................................................................................................... 24 10. CONCLUSION .................................................................................................................. 28 11. ANNEXES......................................................................................................................... 29

11.1. PFD’s working areas in Cambodia....................................................................... 29 11.2. PFD contributions for the NERP sessions ........................................................... 30

11.2.1. Chhlong (Prohout – March 2005) .............................................................................30 11.2.2. Sre Ambel (Cham Srey – February 2005) ................................................................31 11.2.3. Kratie (Chang Krang – January 2005) ......................................................................31

11.3. Focus group discussions results.......................................................................... 32 11.4. GMP results ......................................................................................................... 34 11.5. NERP results........................................................................................................ 41

11.5.1. Average weight variations sorted by area.................................................................41 11.5.2. Average percentage of graduated children sorted by village....................................41

11.6. Northeast Cambodia Child Survival Program Final Evaluation results................ 42 11.7. Nutritional value of NERP food ............................................................................ 43

11.7.1. PFD’s provided foods ...............................................................................................43 11.7.2. Nutritional value of PFD’s contributed food ..............................................................43

11.8. Nutrition guidelines............................................................................................... 44 11.8.1. Recommended Dietary Intake for children from 6 to 36 months...............................44 11.8.2. CORE’s Hearth Manual Guidelines for NERP food ..................................................44

11.9. Nutrition situation of children from 6 to 36 months in the Hearth villages............ 44 11.10. Evolution of the nutrition situation in the Hearth villages ..................................... 45 11.11. Percentage of malnourished children in the Hearth villages per month .............. 47

12. BIBLIOGRAPHY............................................................................................................... 49

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1. ACRONYMS ARI Acute Respiratory Infections

CBD Community Based Distribution

CDHS Cambodia Demographic and Health Survey

CO Community Officer

EPI Expanded Program on Immunization

GMP Growth Monitoring Program

IDA Iron Deficiency Anemia

IDD Iron Deficiencies Disorders

JCO Junior Community Officer

ND Negative Deviance

NERP Nutrition Education and Rehabilitation Program

NGO Non Governmental Organization

OD Operative District

PD Positive Deviance

PFD Partners for Development

RDA Recommended Dietary Allowance

USI Universal Salt Iodization

VADD Vitamin A Deficiency Disorders

VDC Village Development Committee

VHSG Village Health Support Group

VHV Village Health Volunteer

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2. PREFACE Hearth is a community based program where mothers, guided by volunteers, work collectively to improve the nutritional status of malnourished children of their own village. The premise is that malnutrition is a consequence of a lack of knowledge. The Hearth Model has its roots in the Nutrition Demonstration Foyers created in Haiti by Drs. Gretchen and Warren Berggren in the 1960’s. The actual model is based on the Positive Deviance (PD) approach, demonstrated by Monique and Jerry Sternin in the 1990’s when starting the Save the Children’s Education and Rehabilitation Program in Vietnam, followed by a visit to the far northwest of Cambodia in the late 1990’s. The Hearth villages are those with high prevalence of malnutrition among children between the ages of six months to three years or six months to five years. During the first phase, using the PD approach, the community provides information about the practices that allow some families to have healthy children (referred to as Positive Deviance -PD- families for this discussion), and also practices, carried out by wealthier families that do not contribute to a good nutritional status in the children (referred to as Negative Deviance -ND- families). Taking the PD families as a model, the objective of Hearth is to share the knowledge with other mothers in the community, so that they can replicate healthy behaviors and improve the children’s nutritional status. There are two main arms to the Hearth Model:

Growth Monitoring Program (GMP) and Nutrition Education and Rehabilitation Program (NERP).

During GMP all children of the selected age group, are weighed. This takes place in the Hearth villages once every two months in order to monitor the nutritional status and to identify the malnourished children with the purpose of inviting them to join NERP. NERP is alternated with GMP, every other month. It consists of 10 – 12 day sessions where mothers contribute food and cook a nutritious meal (similar to the food the PD families prepare for their children) that the kids eat as a group at the end of each session. During these sessions mothers receive education about nutrition and health related subjects (diarrhea, immunization, malaria and other subjects found relevant during the PD assessment). The aim of the model is to empower the community to address and prevent malnutrition in the area, learning from their own neighbors and working together.

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3. INTRODUCTION

3.1. Nutrition situation in Cambodia Good nutrition is essential for sound healthy development. A nation cannot attain progress if its population is not healthy enough to work. Malnutrition remains a crucial issue in Cambodia, although figures show some improvement in this area. The Cambodia Demographic and Health Survey (CDHS), conducted in 2000, reveals that the prevalence of malnutrition (underweight and stunting) among children under five years of age is around 45% as against 48% in 1996; severe underweight is 13% (14% in 1996) and severe stunting 21% (28% in 1996). Conversely, wasting is up from 13% in 1996 to 15% in 2000.1 Among children below six months old, 15% have stunted growth 2; presumed causes are lack of appropriate breastfeeding and low birth weight. Low birth weight is reported in 18% of the cases, but it is important to consider that only a low percentage of newborns are weighed.2 Justification of this low weight could be the high rate of maternal malnutrition, as 21% of the women in reproductive age are underweight.2 Rates of underweight and stunting rise with the age of the children, there is a first peak at 13 -14 months and it reaches the highest level, 52% for underweight and 58% for stunting, at 45-50 months of age.1 Figures vary throughout the year, revealing higher prevalence during the rainy season, and depending on the geographical situation, rural areas show higher levels of malnutrition than urban ones.1 Fortunately, infant and child under-five mortality rates have also declined between 1990 and 2000. Regardless, 63,000 children under five die of preventable causes each year, 37,000 of them could be saved if simple health and childcare interventions were carried out. Infant mortality rate is 95 per 1000 live births and under-five mortality rate is 124 per 1000 live births. The causes for half of the deaths are Acute Respiratory Infections and diarrheal diseases, followed by malaria and dengue.2 Evidences suggest that malnutrition is associated with 56% of the cases of childhood mortality. Furthermore, micronutrient deficiencies, a public health concern in Cambodia, increase morbidity and the risk of impaired cognitive development and growth. The three main micronutrients Cambodians are deficient of are Iron, Iodine and Vitamin A.3 Iron Deficiency Anemia (IDA) is seen in 79% of children from 6-11 months old 3, 70% of children below the age of two and 63% of children under five, as well as 66% of pregnant women.2 Causes are low intake of iron, mainly related to the high cost of animal food, which is the principal source of Iron, but also a combination recurrent of diarrhea, hookworms and malaria, in some areas.3 In the year 2003, results of the blood surveys conducted in 197 villages, where 1589 children randomly sampled were tested, showed that 1022 were found to be Plasmodium Falciparum positive (Malaria mosquito).2

1 Ministry of Planning, National Council for Nutrition. 2002. Cambodia Nutrition Investment Plan 2003 – 2007. 2 Medicam. 2004. Cambodia’s health situation, priorities and responses. Medinews Vol 3, Issue 12. 3 Helen Keller International. 2001. Initial findings from the 2000 Cambodia National Micronutrient Survey.

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It is estimated that 1.3 million individuals are at risk of Iodine Deficiency Disorders (IDD) in the country. A National Program to achieve Universal Salt Iodization (USI) started by the end of 1998, with UNICEF support, but the objective has not been achieved yet. CDHS showed that nationwide only 14% of the households are using iodized salt.1 Vitamin A Deficiency Disorders (VADD) are caused by a poor daily intake of food rich in this vitamin and fat, which is needed to absorb this vitamin, not sufficient supplementation coverage (only 29% of children under five received Vitamin A supplements six months prior to the survey in 2000) and the presence of diseases like ARI, diarrhea and measles which are responsible for over 40% of Vitamin A deficiencies. Micro-surveys conducted from 1990 to 1996, in about three quarters of the provinces, show prevalence rates of night blindness up to 12% in several areas. Currently, the Expanded Program of Immunization (EPI) is aiming to improve the coverage of Vitamin A supplementation. Regarding the dietary sources it remains still low. However good practices as breastfeeding and early initiation of breastfeeding are increasing these days, improving Vitamin A intake in young children.1 Food insecurity is one of the underlying causes of malnutrition in Cambodia. On the one hand, is the poor access to food due to economic reasons (40% of the households in Cambodia live in poverty). On the other hand, is the non availability of food in some areas, as a consequence of poor infrastructure: bad roads, no marketing system and damaged irrigation.4

3.2. Background Based on the theory that the behaviors of the mothers is the primarily cause of malnutrition,5 in April 2002, Partners for Development (PFD) initiated the Model Nutrition Project “Krusa Kumru L’ol” with a bi-level approach:

Community education on health related subjects, provided by the Village Health Volunteers (VHVs) and some Community Based Distribution Agents (CBD Agents); Hearth- monitoring, education and rehabilitation in areas with high rates of

malnutrition. While the original project aimed at targeting 30 villages in Chhlong Operational District (OD) in Kratie Province, it was found to be far too ambitious and so the target was reduced to 15 Hearth Villages in this area. This first stage of the project ended in July 2004. In a second phase, which began in August 2004, the program has expanded to include:

Three villages in Sre Ambel OD, Koh Kong Province, Two in Kratie OD and Two in Chhlong OD.

It is expected that three more villages will be targeted in Chhlong before the end of the year, making a total of 25 Hearth Villages (see Annex 11.1). Currently, 62 VHVs supported by more than 20 other volunteers (CBD agents, VHSG, VDC) are working on this project, under the supervision of PFD’s Community Officers (CO) and Junior Community Officers (JCO).

4 MAFF/FAO. 1999. National Food Security and Nutrition. National Seminar on Food Security and Nutrition. 5 CORE. 2003. Positive Deviance / Hearth. A resource guide for sustainably rehabilitating malnourished children.

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3.3. Objectives of the research Document the Hearth activities, lessons learned and best practices performed by

PFD in the different villages. Analyze cost-effectiveness of the project in order to help in the decision regarding

the course of action: continue with Hearth as it is, adapt it or find another model.

4. RESEARCH METHODS In order to understand well and in depth the Project, observation during the different sessions was necessary. In Chhlong OD, GMP was observed and documented in two villages and NERP in nine villages (once during the 10 day sessions), as well as the assessment for a new village. In Sre Ambel OD, the assessment for a new Hearth Village and the first day of NERP in this village were observed. Related to Kratie OD, one village was visited during NERP. All the activities observed were documented as qualitative information for further analysis. Quantitative data regarding GMP and NERP was obtained from the records kept by PFD offices. This register includes baseline figures and results after each GMP and NERP session that are compiled and filed to monitor the evolution of the villages. The data analyzed is from the beginning of the program (April 2002) to February 2005. Finance information as it relates to NERP activities was also provided by PFD’s offices. Nine focus group discussions were conducted in Hearth villages in Chhlong OD with mothers of children enrolled in NERP. The topics related to malnutrition, feeding and homecare practices, food availability in the area, common diseases in the village, VHVs, NERP and health education. The qualitative data collected was recorded, compiled and analyzed. During all the activities PFD staff working in the project were consulted in an informal approach to complement the information.

5. RESULTS

5.1. Program description 5.1.1. Process to start a new Hearth Village It takes about 3 or 4 days to one week depending on the size of the village. 5.1.1.1. Selection of the village The VHVs provide information about prevalence of malnutrition in their communities. PFD considers the village for Hearth intervention if VHVs believe malnutrition is an important problem in the area. 5.1.1.2. Orient the VHVs The VHVs of the village are informed about Hearth, the PD inquiry and the assessment process. In Kratie and Sre Ambel a whole training was prepared where

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VHVs, CBDs and other volunteers were taught about Hearth as well as basic nutrition concepts (it took 2 days in Sre Ambel and 3 in Kratie). 5.1.1.3. Weighing children All children from 6 to 36 months of age are weighed on the first day of the assessment. If malnutrition rates among the children are over 30% in a village, then the process goes on, if not, another village should be selected. 5.1.1.4. Environmental analysis

Hearth assessment presentation in Dey Dos Krom village, Chhlong

Collect information about services available in the village: wells, schools, health services, shops, as well as kinds of foods available and prices. 5.1.1.5. Focus Groups PFD staff conduct focus groups with mothers, fathers, grandmothers and siblings to gather information about health related topics. The objective is to have a better understanding of the situation in the village, common practices, knowledge and beliefs. 5.1.1.6. PD assessment With the help of the Village chief or the VHVs, PFD do a wealth ranking of the families. Among the poorer families, three that have well nourished children (PD families) are selected, and among the wealthier households, three with malnourished children (ND families). These families are interviewed about their feeding practices, hygiene, childcare and health care. Whenever possible, the staff observe while the food is prepared.

5.1.1.7. Presentation Results regarding nutritional status of the children and the information obtained during the focus groups and interviews are presented to the community. Participants are asked if they would like to be a Hearth village and if they are willing to contribute.

Hearth assessment presentation in Phoum Thmey village, Sre Ambel

5.1.1.8. Training the volunteers After the village has been selected to become a Hearth village the volunteers are trained to conduct NERP, on nutrition, childcare and other health related topics. A few weeks later they are also trained on growth monitoring.

5.1.2. Growth Monitoring Program (GMP) During a growth monitoring session usually one or two PFD staff with the local VHVs and other volunteers, occasionally also a member of the Health Center staff (if they are available), weigh all children from six to 36 months of age in the village. The

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volunteers help bring mothers together and sometimes help bring children whose mothers are busy. During the session: 5.1.2.1. The caretaker (mother, grandmother, older sibling, father …) presents the yellow card. If the child’s details are not in the GMP record book the staff fill out: child’s name, date of birth, sex and mother’s name. 5.1.2.2. The child is weighed by a VHV. 5.1.2.3. Another VHV or PFD staff record the weight in the yellow card and plots in the chart. Caretakers are informed about the nutritional status of the child. 5.1.2.4. PFD staff record the weight in the GMP record book (for PFD’s record) and in the child’s individual file (for VHV’s record).

GMP in Prolay Triek village, Chhlong

5.1.2.5. The child is given a snack (usually crab chips in Chhlong, biscuits in Sre Ambel and Kratie) contributed by PFD. In the large villages, several weighing points are set up during the day. In some instances, when children were unable to come, the scale is taken to their houses in order to weigh them, or PFD staff go by motorbike to pick them up. GMP is conducted in 17 villages in Chhlong, three villages in Sre Ambel (six different hamlets, so six GMP sessions) and 2 villages in Kratie OD.

5.1.3. Nutrition Education and Rehabilitation Program (NERP) During GMP, children found to be malnourished are invited by the VHVs to join the NERP session. Their mothers or caretakers come along with them. Whenever a mother is unable to come, older siblings or grandmothers are encouraged to do so. Other than malnourished children from six to 36 months old, in NERP we can find children that after a few sessions have already reached a normal weight (graduated) who are invited to attend some more sessions to ensure they stay in a normal weight; in the same way, children that become overage (older than 36 months) and have not graduated yet are encouraged to continue attending. These two categories are kept off record. NERP sessions last for ten days and are planned to take place a month after GMP. Before starting a new NERP the local authorities are contacted and they are asked to contribute food for the sessions. As well as the mothers, who are requested to contribute food everyday in order to prepare a nutritious meal for the children. PFD staff are usually on charge of going to the market to purchase the ingredients the organization contributes. The mothers are also asked to come early to help in the preparation of the food, in rotation, so they all come eventually. Food is often prepared by the volunteers, some mothers with the help of PFD’s JCO and CO (particularly when the CO is female).

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During the first day, all children are weighed to check their nutritional status. They are weighed once again the last day to put variation in evidence. Once the food is ready, VHVs, supported by JCOs and COs, conduct an education session about nutrition, breastfeeding, diarrhea, immunization, malaria or some other health related topic. Subsequently, mothers are invited to bring the children to the washing area to clean their hands and faces. Children are then served food (mothers bring their own dishes and spoons). Each mother (or caretaker) is responsible to feed her child. Severely malnourished children are given more protein (meat, fish or an extra egg) than the others. The children are allowed and even encouraged to eat more than once, if they are still hungry. If there is enough food after the children have eaten, the mothers, siblings or not malnourished children that usually also come, can have it. If there is still leftover it is given to the participants to continue feeding the child back home later on. In some cases the caretakers come after the education session is over, just in time to have the food. Other times the child does not come to attend NERP but the caretaker arrives by the time the food is served to ask to take the ration home, it happens usually when the child is sick. Occasionally, if the child is absent the VHVs go to his/her house and bring the food. 5.1.3.1. NERP in Chhlong NERP is conducted in 13 villages in Chhlong. The sessions are supervised by one of the two Junior Community Officers and eventually one of the nine Community Officers. The JCOs work exclusively in Hearth in a part time schedule, whereas the COs, full time staff, are responsible for all the interventions PFD has in the area. Each CO is in charge of some villages (up to three, depending on their catchment area), the JCOs work in all the Hearth villages.

Generally, the JCO stays the 10 days, the CO may also do so depending on his/her other duties. Eventually, several NERPs are conducted at the same time in villages nearby (example: Boss, Sre Triek and Prohout), then PFD staff need to alternate to be present in all of them.

NERP in Prohout village, Chhlong

When having NERP in a village, sometimes it is interrupted during the weekends, depending on the availability of the volunteers, the participants and PFD staff.

The food prepared in the sessions is usually similar in all the villages: rice porridge with fish, chicken, pork or eggs, plus green leafy vegetables, usually pumpkin, garlic, oil, soy beans, peanuts, sugar, and iodized salt. Once or twice in the 10 days they also prepare bean sweet. PFD staff have a budget of about US$ 50 for each village for the ten days, with this amount of money PFD provides the protein sources everyday (fish, chicken, pork or eggs) as well as garlic, sugar, oil, peanuts, soy beans, fish sauce and salt;

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vegetables are also bought by PFD to complement in case the community’s contribution is not enough (see Annex 11.2.1). The instructions given to the staff are to spend as little as possible, and encourage the community to contribute. Deworming is done, by the local Health Center staff, every 6 months, in some areas. In certain villages it is not possible because the nurses do not have enough time or the NERP center is too distant from the Health Center. PFD staff are very participative in the activities, helping cooking, washing hands, serving food and conducting education. 5.1.3.2. NERP in Sre Ambel PFD Sre Ambel hired two people to work exclusively in Hearth (Community Nutrition Officers - CNOs). Each one is responsible for half of the villages, however both work together during the NERP sessions. Currently NERP is conducted in six hamlets, in three villages. The sessions are interrupted during the weekends. The CNOs are in charge of the purchase of the food PFD contributes but regarding the rest of the activities their approach is to encourage the volunteers and mothers to assume the responsibility as soon as possible (cooking, conducting education, etc.), under their supervision. The food prepared varies from one village to the other depending on the availability in the market. During the 10-day sessions some days rice porridge is prepared and the rest of the days, white rice with vegetables and meat. Ingredients also change during the 10 days. They prepare daily, as well, either soy bean juice or bean dessert. Sre Ambel office provided almost all the ingredients needed for the meal, during the first NERPs, because the mothers’ contributions are very weak (see Annex 11.2.2). Currently, Sre Ambel is working on the policies regarding the food they will contribute and the maximum expense per child.

NERP in Phoum Thmey village, Sre Ambel

Deworming treatment has not been coordinated yet with the Health Centers. 5.1.3.3. NERP in Kratie PFD Kratie has two staff members working exclusively for this project, in two Hearth villages that started on November 2004. Responsibilities are not divided for the villages but one of the COs is in charge of the Hearth Project and the other is her assistant. They normally work as a team during GMP and NERP sessions. During NERP, porridge (similar to Chhlong’s) is prepared everyday and fruit is also provided some days. Three times during the 10 sessions soy bean juice is added. Only a few mothers collaborate with the cooking therefore this activity is mainly the responsibility of the volunteers. Equally, mother’s contributions in food are not enough, but the VHVs keep record of them and encourage the mothers who are not

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collaborating. PFD’s contributions are similar to Chhlong’s, adding some fruit. PFD Kratie has assigned 0.5 US$ per child per day as maximum expense (see Annex 11.2.3). The volunteers are responsible for all the activities during NERP (only the purchase of the food is sometimes done by PFD staff, because there are no markets in some areas). PFD staff only guide, supervise and support the volunteers, but they do not cook, serve food or conduct education.

All the children that participate eat during the session; mothers do not take the food to feed the children at home. At the end of each day’s session the volunteers have a meeting with PFD staff to decide what is going to be done the next day. Currently both members of the staff attend the 10-day sessions of NERP, since the villages are just starting, but it is part of their plans to delegate more responsibilities to the volunteers and only visit some days to supervise.

In Chavillage away fr Dewormare verthe villa 5.1.4. A childensuresession Regardbeginnthe vilmalnouGMP einterve

Focus Phong,In somrest, it later. A

NERP in Chang Krang village, Kratie

ng Krang the activities are sometimes stopped during the weekends, as it is a near Kratie and PFD staff can come back home. Koh Khnae is 100 km far om town, so the staff prefer to continue with NERP during the weekends.

ing sessions are part of NERP in Chang Krang where the Health Center staff y participative during the sessions; that is not the case in Koh Khnae because ge is distant from the Health Center.

Graduating from NERP

graduates from NERP when he attains a normal weight for age. However, to he remains in a good nutrition status, he is invited to continue attending a few s more.

ing graduation of the Hearth villages, the criteria has changed since the ing of the program. At first, they graduated when the rates of malnutrition in lages attained less than 20%, now they do when there are less than 5 rished children attending NERP. These villages are still monitored through very two months. In case the malnutrition rates reach more than 30%, the ntions will restart, this has already happened in some villages in Chhlong.

5.2. Focus groups results

groups were conducted in nine villages in Chhlong OD (three in Domrey four in Snuol, two in Prek Presop), with mothers of children attending NERP. e of the villages the discussion took place right after the NERP session, for the was in the same day of NERP or GMP, but the mothers were asked to come n average of 10 to 15 mothers was present each time, but only some of the

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participants answered the questions, the rest of them were too shy to talk in the group. The mothers believe that food insecurity is the cause of malnutrition in their villages. Poverty is for them the reason why children are malnourished and not lack of knowledge. However their answers suggest that education in some topics is needed to improve behaviors and have an impact on the nutritional status of the children. That is the case, for example, with snacks consumption, which they know that interfere with the normal feeding practices but they do not contemplate it as inadequate. Another topic is diseases, since the ones mentioned as frequents in the area, are preventable if simple practices are carried out. Unfortunately, many people in some areas do not bring their children to the Health Centers when they are sick, principally because they live far way from it. In any case, these populations are fond of taking medicines to treat discomforts, which leads to a frequent and dangerous practice to get them from unqualified drug sellers. NERP sessions and the VHVs job are very well received by the communities, getting total support from the mothers. Mothers want NERP sessions to continue because they realize that the children’s health has been improved since the beginning of Hearth (see Annex 11.3).

5.3. Qualitative analysis 5.3.1. Hearth impact In order to be able to monitor the impact of Hearth, records are systematically kept in PFD’s offices. GMP results show the evolution of the nutrition situation in the villages, as a result of the combined success of rehabilitation and education, over a period of two months. NERP results illustrate, in the short term, the effect of rehabilitation principally, but also of education (mostly related to prevention of infections). Although there are no records regarding knowledge gain, by means of informal evaluation through questions and games, it is possible to get an impression of how much the mothers are learning. 5.3.1.1. Growth Monitoring Program (GMP) Since the beginning of the project, 156 sessions have already been carried out in the 22 Hearth villages. The average attendance is over 80%, although diverse villages show very different rates of participation. In addition, fluctuations are observed throughout the seasons, mothers sometimes do not come because it is raining or flooded, or because they are busy or it is too hot. Some villages, as Prek Kdey and Prey Kou in Chhlong, have low attendance (66% and 61% respectively). In these areas lots of mothers work in the fields and bring their children with them, staying out of their houses for days or weeks. In Prey Kou during some sessions attendance was as weak as 32 and 34%, compared with villages like Meanchey (Chhlong) were the average is 91%, Kampong Sre (Chhlong) 89% and Prohout 88% (Chhlong). In average, one new malnourished child is detected each session and can be enrolled in NERP. Fortunately, the same average is observed for children who overcome malnutrition and qualify as normal (see Annex 11.4).

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5.3.1.2. Nutrition Education and Rehabilitation Program (NERP) To date, 117 NERP sessions have been conducted. Almost 90% of the enrolled children attend the sessions (although not all of them are present the whole 10 days). Approximately 14% of the children graduate from Moderate Malnutrition to Normal and 7% from Severe Malnutrition to Moderate Malnutrition in each session. Facts make evident that 79% of the children gained weight during the 10 days rehabilitation (maximum rates in Boeung Learch, 91% average in five rounds and Sre Triek, 88% in 9 rounds), against 13% that did not change and 8% that lost weight. (see Annex 11.5)

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m

Kam

pong

Sre

Kbal

Kla

Koh

Khna

e

Kron

g

Mea

nche

y

O'L

oung

Prey

Kde

y

Prey

Ko

Proh

out

Prol

ay T

riek

Phou

m T

hmey

Sam

poch

Sre

Trie

k

Trop

eang

Lea

rk

Trop

eang

Sre

Veal

Average weight variations

% gained weight % no changed % lost weight

30%

25%

20%

5%

10%

15%

0%

35%

Boeu

ng K

iep

Boeu

ng L

eark

Boss

Cha

m S

rey

Cha

ng K

rang

Dey

Dos

Kro

m

Kam

pong

Sre

Kbal

Kla

Koh

Khna

e

Kron

g

Mea

nche

y

O'L

oung

Prey

Kde

y

Prey

Ko

Proh

out

Prol

ay T

riek

Phou

m T

hmey

Sam

poch

Sre

Trie

k

Trop

eang

Lea

rk

Trop

eang

Sre

Veal

Average variations of nutritional status

% moderate malnutrition to normal % severe malnutrition to moderate malnutrition % fell channel

14


Note: Chhlong Villages Boeung Kiep, Boeung Leark, Boss, Dey Dos Krom, Kampong Sre, Kbal Kla, Krong, Meanchey, O’Loung, Prey Kdey, Prey Kou, Prohout, Prolay Triek, Sampoch, Sre Triek, Tropeang Leark, Tropeang Sre. Kratie Villages Chang Krang, Koh Khnae Sre Ambel Villages Cham Srey, Phoum Thmey, Veal

egarding knowledge oR f the mothers, during the sessions it has been observed that

f them are now aware of the importance of improving feeding practices, and ould like to continue the rehabilitation at home, they state the economic situation as

tions (diarrhea, malaria, dengue, ARI) are still

given in Chhlong and 580 kcal in Kratie. As mentioned mbel provides more food, thus, referring to energy, they provide 1266

In r htly morattasoy beans. Iodine recommended dietary intake (RDI) is covered by the NERP food, at least for the youngest children. Iron is provided in around 60% of the RDI in Chhlong and Kratie and more than 100% for Sre Ambel. Finally, Vitamin A’s needs are covered by the NERP food supplied by PFD in Sre Ambel, as they provide vegetables and include liver everyday, in the other two cases the majority of the foods sources of this vitamin are contributed by the mothers (see Annex 11.7 and 11.8). 5.3.2. Present nutrition situation As of February 2005 the malnutrition rate in the 22 Hearth villages is 37% (includes moderate and severe malnutrition) with 6% of the children in these villages that present severe malnutrition. Malnutrition:

In Chhlong, the average for malnutrition is 33%, 4% for severe malnutrition o Excluding the already graduated villages: 37% and 4% respectively. In Kratie, 49% for malnutrition, 10% for severe malnutrition. In Sre Ambel, the rates are even higher, 59% total malnourished children and

19% severe malnutrition (see Annex 11.9).

about half of the mothers participate when they are questioned, quickly and proudly answering, as for the rest we cannot be certain if they do not know the answer or if they are quiet due to timidity. To sum up, according to the Northeast Cambodia Child Survival Program Final Evaluation, there has been a significant gain of knowledge in breastfeeding and nutrition in Chhlong villages from 1999 to 2004. (see Annex 11.6) More interesting would be to find out if this education leads to behavioral change. The mothers, when asked, do not mention lack of knowledge as a cause of malnutrition. Some of them believe that even if they learn how to improve practices they do not have the means to change behaviors (money to buy food). Although

ost omwan impediment. In addition, infecfrequent in these villages. In terms of nutrition, NERP food follows the CORE’s Hearth Manual guidelines, regarding energy, for Chhlong and Kratie. Taking in account only the food contributed

y PFD, 688 kcal per child arebbefore, Sre Akcal per child per day.

egard to proteins, the contribution of this nutrient in the NERPe th

food is sligan the suggested by CORE’s Manual for Chhlong and Kratie, in Sre Ambel it

ins almost double the recommendations, principally due to the high amount of

15


0%

10%

20%

30%

40%

50%

60%

70%

% o

f mal

nour

ishe

d ch

ildre

n

Boe

ung

Kie

p

Boe

ung

Lear

k

Bos

s

Cha

m S

rey

Cha

ngkr

ang

Dey

Dos

Kro

m

Kam

pong

Sre

Kba

l Kla

Koh

Khn

ae

Kro

ng

Mea

nche

y

O'L

oung

Pre

y K

dey

Pre

y K

ou

Pro

hout

Pro

lay

Trie

k

Pho

um T

hmey

Sam

poch

Sre

Trie

k

Trop

eang

Lea

rk

Trop

eang

Sre

Vea

l

village

Malnutrition among children from 6 to 36 months in the Hearth villages (February 2005)

Malnutrition Severe Malnutrition

5.3.3. Evolution of the nutrition situation Currently, the rate of malnutrition, for all the villages, is 37% compared to 44% at the starting point for the 22 villages, although it is important to consider that villages in Sre Ambel and Kratie started recently.

Sre Ambel started Hearth with malnutrition rates of 68%, 55% and 54%. Severe malnutrition 27%, 13%, 17%, respectively, the highest of the program. In Chhlong, the malnutrition rate at baseline for the 17 villages was 41%.

Severe malnutrition 7%. Maximum values of 52%, 50% and 49% (21% and 20% for severe cases). In Kratie 48% and 44% malnutrition, 8% and 12% severe malnutrition.

In Chhlong, it has decreased from 41% to 33% in 32 months. The average reduction is 10%, with a maximum diminution of 34% in Kampong Sre and 29% in Prey Kou. In 12 out of 16 villages (Dey Dos Krom excluded because it just started) malnutrition rates are currently lower than the baseline. For the four villages that show an increase, O’Loung is up 15% but this data may not be accurate because only 79% of the children were weighed for the baseline; the other three villages (Boeung Leark, Prolay Triek and Tropeang Leark) have experienced many oscillations on their rates. In any case, all the villages, with the exception of the graduated ones, show fluctuation in their levels of malnutrition and not a clear tendency to decrease rates (see Annex 11.10). Regarding the already graduated villages, they all present these days rates lower than the baseline, and in half of the cases the percentages are even lower than the moment of graduation (see Annex 11.11). The evolution on the nutrition situation cannot be analyzed in Sre Ambel and Kratie since the project is just starting.

16


5.3.4. Obstacles identified During GMP and NERP sessions in Chhlong, mothers are consulted about the causes for weight loss or stagnation, reasons often link to infections: diarrhea, malaria, dengue or respiratory infections. According to the Health Center staff, hookworms are frequent in these populations and may also interfere in the nutritional status of the children. Hygiene is still a big issue, so perseverance and more education are still needed to improve in this area. Equally, the economic situation has an important role in the children’s development. Reasons cited for scant behavioral change regarding nutrition are, in most of the cases, economic: lack of money and lack of time (because they work). On the one hand, some parents cannot afford vegetables and/or proteins (fish, meat, etc). On the other hand, they are forced to work all day long leaving the children with the older siblings most of the time. Seasonal variations may also be involved in the nutritional status of the children, as a consequence of food unavailability in certain areas and also due to the increased workload of the mother. This last issue leads to differences in the household income and also in the quality of the child care.

The variations are directly related to the weather. Cambodia has two seasons, a dry season, from November to April, and a rainy season from May to October. The chart above shows peaks of malnutrition during the months of February-March, since during the dry season food is scarce in some areas. The situation improves as the first rains start coming and once again malnutrition raises in June, probably due to the increased workload of the mothers in the fields, and consequently the children’s care practices are affected. Later, in October-November, harvest time; better food availability and the fact that the mothers spend more time at home, leads to better feeding practices and a decrease of the malnutrition rates.

Average percentage of malnourished children in the Hearth Villages per month

40%

50%

60%

seasonIncreased workload Dry

20%

30%

perc

enta

ge

2002

2003

2004

2005Harvest

Rains start

10%

0%1 2 3 4 5 6 7 8 9 10 11 12

month

17


6. DISCUSSION

6.1. Theory vs. practice

.1.1. 6 The Positive Deviance approach

oblems. Undoubtedly, uation of the households was

bors can “do better” than they do, with

The practices have not changed but families cannot combat

nd to respond what they think is the best answer. For example, when hildren, they would answer “fish and vegetables” and

sessions, coordination is needed between PFD staff,

While Hearth experiences in other countries demonstrate that through the PD methodology the communities are able to solve some of their nutrition problems and to improve health, Cambodian experience elicits a different response. To start with, it is not easy to change people’s minds when everybody, from the villager to the

rofessional, is convinced that poverty is the cause of all the prpif food was available in all areas and if the economic sitbetter, malnutrition rates would be lower. Anyhow, education can make a difference, families with access to a wider variety of food sometimes make the wrong choices and are also affected by malnutrition, and poor families could make the best use of their limited resources if they had the knowledge. People in the communities are

metimes reluctant to believe that their neighsothe same or less income. Even part of PFD local staff mentioned that they are hesitant about this concept, since they have seen children from PD families became malnourished after the initial assessment; during the rainy seasons more food is available and then the children are healthy, but many of them become malnourished

uring the dry season. dthe food insecurity. Gathering information about good practices is also a challenge as, in some cases, he mothers tet

asked what they feed their clater on, when working for NERP, the staff find out that fish is rarely available in the area. The PD concept is still controversial. Researchers6 suggest that underprivileged families are PD families just because they can cope differently with adverse situations, which would mean that the “good practices” carried out by the family are not the justification for a good nutritional status of the children. 6.1.2. Conducting GMP and NERP every 2 months This periodicity is a challenge for PFD staff, principally in Chhlong (where most of the Hearth villages are) since these staff also work in the rest of PFD interventions in the community. For this reason sometimes NERP or GMP sessions must be postponed because they are carrying out other priorities. n addition, for GMP or NERPI

volunteers and the mothers, and eventually, when PFD staff have organized to start, the volunteers are busy or during certain months the mothers are busy, as their workload is increased. Currently, in Chhlong, the GMP and NERP sessions are taking place, in average, every three months instead of two, but efforts are being made these last months to improve that. 6.1.3. The volunteers’ role

6 Shekar, M., Habicht, J. P., Latham M. C.. Is positive deviance in growth simply the converse of negative deviance?

18


Once the volunteers are trained to conduct NERP they should be able to work on the nevertheless, sometimes PFD staff perform this task. Volunteers

the VHVs, but ey recognize that some of these volunteers are not able to conduct education on

. In addition, they are performing honorary tasks, motivated by the respect nd honor they get from the community. They are remunerated by PFD only with

NERP food t the end of each session the VHVs are supposed to work with the mothers on the

prepared depends on the availability on

ound 700 kcal, in Sre mbel 1250 kcal and in Kratie 600 kcal. The difference among Sre Ambel and the

is important to keep in mind that these are calculated values, assuming that the

tribution to NERP earth’s aim is to make the communities responsible for their children’s health and

for an improvement. To begin with, mothers are invited and encouraged to participate everyday in the food preparation but usually the same

education sessions, should, also, after a few sessions of NERP, conduct the program on their own, without PFD staff permanently there. Despite that fact, because of the limited capabilities of some VHVs, PFD’s JCOs (or COs) must always attend the 10 days of NERP (unless several NERPs are being conducted at the same time in villages nearby, in that case she would alternate between the villages). PFD is, at present, making an effort to give more responsibilities to ththeir own. Moreover, it occurs that if PFD is not present some volunteers omit this part of the session and only prepare food. They claim that they are bored of always presenting the same subjects, as in some villages the same topics are being repeated for over two years. Further, delegating the responsibility of the money for NERP foods needs special consideration but PFD is willing to trust them in this task under appropriate supervision. It is a reality that, even if literacy is a condition to be a VHV, the level of education is not high among them, as it is for the majority of the villagers of their generationasmall incentives, occasionally (a bicycle when they start and then t-shirts, hats, etc.), therefore, PFD has not the authority to compel them to do more than they do, they can only try to motivate them to attain improvement. 6.1.4. Amenu for the next day. Given that the foodthe market most of the time, principally in areas with high food insecurity, the same meal is prepared everyday with the only kind of vegetables offered in the area and differ in the protein source, fish, pork or eggs, depending also on what is accessible that day. To prepare a menu in advance is almost impossible in certain areas where they cannot predict what would be offered in the market the next day. Regarding nutritional value, CORE’s Hearth Manual advises to provide 600 to 800 kcal and 25 to 27 g of proteins per child per day to guarantee that this extra meal will have an impact in the children’s nutritional situation. PFD does not have strict guidelines for the amount of food that should be given to each child each per day, the food preparation is mostly empirical. The analysis of some NERPs in three different villages show that PFD’s contributed food in Chhlong provide arAother two offices can be explained by the fact that PFD Sre Ambel provides the rice and also that a dessert or soy bean juice is prepared everyday in addition to the porridge. Ittotality of the food is divided in equal parts among the children. However, it is known that usually there is a part of it that is eaten by other people and that the severe malnourished children are given more proteins than the rest (see Annex 11.7 and 11.8). 6.1.5. Community conHtherefore responsible to work

19


mothers come and frequently the number is not big enough, as a result, PFD staff also collaborate in the cooking session. Moreover, the original project intended to ask the community (mothers of children attending NERP and the communal structures) to contribute with the food needed for NERP except for the protein sources, which would be provided by PFD as it is the most expensive ingredient. In spite of that, PFD is supplying some other ingredients as well in Chhlong and Kratie, and 100% of the food in Sre Ambel. The reason why PFD provides things as peanuts, beans, oil and sugar is because the families do not have these goods available in their houses o contributing them implies that they would need to buy them.

or Chhlong NERPs, the guidelines are not to spend more an 50 US$ per village whereas in Kratie is 0.5 US$ per child. Sre Ambel is currently

leave it up to the mothers’ ill, it is unfortunately omitted. Equally, some mothers or siblings take care of the ygiene of the children’s hands but not of theirs and they are the ones who feed the

kids.

ood nutrition and help to change the families’ hoices regarding food.

thers to repare this food at home. Unfortunately, in these areas, there is no solution other

6.2. Analysis

s The village chiefs provided food during the first sessions of the first Hearth villages but they do not do it after that. In fact, the communities seem not to be willing to contribute with food when they know that if they do not do it somebody else will pay for it (PFD in this case). This leads us to the subject of costs, although in Hearth the aspiration is that the NGO contributes as little as possible, reality shows that it is difficult to get contribution from the communities and therefore the costs for PFD are higher than desired. Nevertheless, fthworking on its policies. 6.1.6. Hygiene practices A must on the NERP sessions is to wash the children’s hands before eating (and after also), but apparently this reflex is not easy to create. Although the volunteers always prepare the “washing hands area” with clean water, soap and a towel, whenever they fail to remind the mothers of this practice (perfectly understandable due to the high workload they have during the session) orwh

6.1.7. Practice at home Lack of time and money are the main reasons mentioned as to why some of the mothers cannot replicate the NERP’s cooking and feeding practices at home. Even though during the sessions the mothers are encouraged to continue giving the high calorie extra food prepared in NERP, this implies that they need to have the time to cook one more time a day and the money to afford it. Even if it is not expensive, an extra meal can represent an extra disbursement, and for some families this can make a difference. In opposition, it is known that money is spent in snacks, so education should emphasize the importance of gc Difficulties with putting in practice what is taught are more pronounced in areas of high food insecurity. Provided that NERP food contains ingredients that are rare (namely protein sources), it is not only complicated but expensive for the mopthan bringing meat or fish from the bigger towns (Chhlong or Kratie), or going to villages nearby to get them in order to add in the food. Although PFD knows that this is not an example for the families of what to do at home, they are constrained to do it, otherwise rehabilitation during NERP cannot be possible.

20


Mothers do not identify lack of knowledge as a cause of malnutrition but food insecurity. Nevertheless, for example, an important amount of children buy and eat snacks several times a day (these snacks are usually cookies or crab snacks). This implies, firstly, that money is spent on these, and also, that children are not hungry when they are supposed to eat their meals, as mentioned by the mothers in the focus groups. People do not recognize this as a costly practice; they think they are contributing to the children’s growth by providing these extra foods. Education needs to emphasize more that good nutrition is not about quantity of food but more about quality, and that this includes snacks. Growth monitoring sessions are being very effective to permit a close follow up of the nutrition situation in the Hearth Villages. Attendance is globally acceptable although

some cases it is due to the hard work of PFD staff and the volunteers. GMP is very

is means that in ome cases they are doing more than desired in terms of sustainability. In some

lenge to make the families adopt healthier practices. An verage of 14% of the children graduate from moderate malnutrition after 10 days of

oreover, unfortunately, there are children that attain the age of six months that are

spite these facts, malnutrition has globally decreased; going from 41% to 33% in

s that in e last few years, knowledge has remarkably improved in Chhlong, thanks to the

inuseful to identify malnourished children in order to invite them to join NERP. NERP sessions are thriving in some areas where the mothers show a real commitment. In regards to volunteers as well as PFD staff, most of them are very dedicated and work very hard to make the program work, however thsvillages the issue is to decide the point where a reevaluation needs to be done to conclude if it is worthwhile to continue when the community is not responding. Results show that during NERP the majority of the children gain weight (almost 80%). The cases of weight lost are almost always consequence of diseases. Although Hearth is a component of a program that provides education in disease prevention it remains a chalaNERP, and 7% from severe malnutrition to moderate. However, when the practices are not followed later at home the children may lose weight and fall channel. For some children it has been observed that they graduate after a round of NERP and then for the GMP session the following month they are malnourished again (the data gathered at the beginning of the project did not permit counting the number of children that had definitely graduated from malnutrition, this is one of the reasons why the recording method was changed). Mmalnourished and become a target of the intervention. As a consequence, more than a fourth of the “old” Hearth Villages (started before December 2004) have been in the program for more than two years and malnutrition rates are still high, another fourth have surpassed the year and a half and a third more than one year. DeChhlong villages. This proves that the program is having a positive impact in the health of the children. Excellent examples of this are two of the graduated villages that have decreased 29% and 34% since the beginning. It is even more gratifying to know that most of the villages not having NERP sessions anymore these days are still lessening malnutrition rates, implying that the education provided is still having an effect in the community. It remains unknown how much the mothers are learning, presently, during the sessions, since they state that they agree with repeating the same topics over and over in order to refresh knowledge. Thus the challenge is to find new methods to communicate and improve this; formal evaluations may also be useful in every village to recognize the topics that need to be reinforced. However, evidence showth

21


combined impact of several interventions, including Hearth, as stated in the Final Evaluation of the Child Survival Program. Changing behaviors is a challenge, however, there is a link missing between education and practice and it is the implementation of the Positive Deviance approach. As mentioned before, the PD concept is not easy to put into practice but an improvement in the methodology currently applied can be favorable to better the program (see recommendations). Regarding the extra food provided in order to rehabilitate malnutrition, differences are notable among Hearth in Chhlong, Kratie and Sre Ambel. No formal guidelines exist on this subject, moreover, Kratie and Chhlong are limited by money, but it is not the ase of Sre Ambel. This office does not have any previous experience in the model

eneral instructions are found in the implementation manual, but exact amounts of

vene and the results are different.

he daily requirements of malnourished children form six to 36 onths. Moreover, the food contains significant quantities of the three micronutrients

gue and respiratory infections are equent in some areas, implying that any effort to improve nutrition will be vain if the

On the food security side the experience reveals that villages near the Mekong River are less concerned about food insecurity, as water is available, planting is possible,

s well as fishing and animal raising. Unfortunately, the villages far away from the river are also remote with a bad road infrastructure making it difficult to bring food

om other areas.

e back). Home care and

cand is still in a learning process, therefore restrictions have not been set up yet and a bigger meal is provided, leading to higher nutritional value and costs. Gfood or costs per village or child are not explicit. This leads us to the point that when there are no written instructions, even if everybody receives the same training, once decisions need to be made during the implementation, personal experience, knowledge, beliefs and even wishes inter From the point of view of nutrition, the NERP food is providing an adequate amount of calories, enough to cover the recommended dietary intake for the younger moderate malnourished children, and at least half of it for the severe malnourished. Equally, for the older children, half of their needs are covered. Protein contribution is enough to grant tmof which deficiencies are frequent in Cambodia, Iron, Iodine and Vitamin A, thus the intake of these is also improved during the rehabilitation period. Assuming that this is only an extra food, it is certain that the children are receiving effective amounts of food to rehabilitate malnutrition. If, unfortunately, the food provided at the children’s homes does not add much in terms of calories or nutrients, at least we can be sure that an important percentage of what they need is provided during NERP. Malnutrition in the targeted villages oscillates throughout the year sometimes in an unpredictable way. Yet, in all of them, the main obstacles for success are infections and food insecurity. Diseases like diarrhea, hookworms, malaria, denfrchildren are sick every week (as known, these malnourished children are prone to be sick again soon, and the cycle goes on).

a

fr To sum up, the economic situation of the majority of the families in these villages causes that both, mother and father, are forced to go to work in the fields. This implies that the children are usually with older siblings or grandmothers everyday, they are usually only fed at the same time of their parents (early morning before

oing to work and in the evening when the parents comg

22


hygiene practices are also questionable principally when the care taker is a sibling that is still a child. Finally, it is essential to keep in mind that the real impact of the intervention will be measured in the long term, if in the next years fewer children die or get sick in these villages and their physical and intellectual development is improved. In return, we can be sure that thanks to Hearth some children are still alive and some others are tarting their lives with a better health condition.

communities.

s Though it is known that behavioral change is not easy, in 632 children that attended NERP, even if a small percentage of the mothers learned something, that will be the seed we plant to multiply positive changes in the

7. BEST PRACTICES PFD, working with the communities, has already conducted 156 growth onitoring sessions in 22 villages. Wm ith over 1500 children being weighed, it has

g after the ten days, will surely have a positive impact on

lunteers working on Hearth, trained on health topics to help the ommunity and very committed to it are the key for the education sustainability. They re pleased to accept the challenge of proving to the mothers that good nutrition is portant and train them on how to improve it.

PFD field staff have a good relationship with the volunteers, always supporting

and motivating them, through a very friendly approach. The staff are respected in the villages by the whole community. They are recognized as good professionals and therefore with knowledge to share, as well as people caring about the communities and willing to help. This may fortunately favor their job as people respect their opinion and consequently follow their advices. A significant number of mothers are regularly participating and collaborating with

the sessions. They are satisfied with the program, as they recognize health in the villages is being improved and are willing it continues. Even though it may take a long time, there are mothers that learn and, at some degree, behaviors are slowly but surely starting to change. Inviting children already graduated and other over 3 years old that have not

already graduated, to continue attending NERP, knowing that food would still be enough to give them is a good initiative. Although the original program does not contemplate this, if it does not affect the normal practices and costs it is something positive to be done.

been possible to monitor the nutrition situation of the villages and take action to address malnutrition. Thanks to this intervention one new malnourished child, in average, is identified per session and invited to join NERP. NERP sessions for more than 630 children, with four fifths of them gaining weight nd almost 15% graduatina

the quality of life of the new generation. An improved health status, leading to the possibility of a better education level (children learn more when they are in good health) will collaborate with the progress of the village. The future population will have improved physical and intellectual strength to work for development. More than 80 vo

caim

23


8. LESSONS LEARNED This approach aims to empower the communities, since working for development

implies the NGO will not be assisting eternally, so once the community is left on its own the villagers should be able to continue the task. Therefore, PFD is starting to delegate more responsibilities to the VHVs as a way to seek improvement. It will be a challenge to make Hearth work out in the hands of the communities but, that is the final objective, and if it does not work on that way, the program would be unsuccessful. Although mothers are preferably invited to NERP, in case they are not available

grandmothers or siblings can take their place. They are requested to pass on the information they receive to the children’s mothers. As mothers can be working, NERP sessions are accommodated to be done at a

time where the most part of them can attend. Thus, depending on the village and the season, the sessions can take place at different hours. Moreover, sometimes the VHVs decide for the first sessions and later on it is changed because another time of the day would suit better more people. The time the sessions take place depends, as well; on the time the children

usually eat at home to make sure that it does not substitute any of the accustomed meals. The experience shows that malnourished children tend to be satisfied soon and

also that there is usually a left-over eaten by other people. So, in order to give a good amount of proteins to the children, the fish/meat/eggs are kept apart and served on top of each child’s portion. This also allows providing a bigger portion of these foods to the severe malnourished children. In Chhlong, the food started to be standardized for all villages, preparing in

almost all the cases the same kind of porridge. At present, in some villages, changes in the menu are being done, preparing a different kind of meal during some of the days. Results have been positive in terms of weight gains, so this will be repeated in the other villages. A good record keeping system is essential to monitor and evaluate the evolution

and the impact of the program. At the beginning, although records were kept, the method was not effective; the formularies were difficult to interpret and did not gather all the necessary information. For that reason, they have been changed and improved since the beginning of 2004 allowing nowadays a better use of it. VHVs have been trained and are also responsible for record keeping on their own.

9. RECOMMENDATIONS Although PFD’s Hearth Program is having an impact in the communities, it requires a long time and big effort to obtain results. Some adjustments and additions to the current program can lead to a better outcome. Hearth is based on the power of education. Although mothers, when asked, state

that education is as important as rehabilitation in the NERP sessions, still many mothers skip the education sessions. Even if rehabilitation is essential to have a positive impact in the physical and intellectual development of malnourished children,

24


this part of the program is of uncertain sustainability. Given that nowadays it is tough to obtain contributions from the communities, it would be hard to implement such a model without the NGO’s intervention. In contrast, knowledge remains; mothers that learn healthy practices make use of this learning with the rest of their children, besides this information is transferred to the next generations, and in some degree we can assume that it is also spread in the community. Moreover, the target of the intervention is the children up to three years old, meaning that after that age the families are not receiving the support of the extra meal, which explains the fact that the parents need to have the knowledge to go on with good feeding and caring practices to ensure a good development of the children. A closer analysis of the attitudes of the mothers, regarding participation and

contribution to the NERP sessions needs to be done in the villages where PFD and VHVs are compelled to make a big contribution (in food and workforce). Likewise, support should also be obtained from the community leaders. In case the community does not respond, efforts to continue the program are in vain; therefore the best decision is to stop the interventions in the area. Knowledge exchange among the villagers and mutual help are the foundations to

improve health in the villages thus, accepting that mothers come without a contribution (without a reason) contradict the project philosophy. A new methodology is required regarding the Positive Deviance model. After

almost three years implementing this model, as a result of experience, some practices have evolved, willing to adapt them to the reality. For example, it has prove easier and more efficient to always prepare the same NERP food, which is known to be appropriate for the children from the point of view of nutrition, although it leads sometimes to a meal that includes ingredients not easily accessible by the villagers. As a consequence, families cannot reproduce at home these feeding practices. To avoid this, a return to the initial model is suggested, through a better examination of the PD and ND families feeding practices in order to adapt the NERP food to what is available at the village. If Hearth can ensure that the ingredients are available and affordable for all the families it will be easier to get contributions for the NERP food, as well as it will be more likely for the mothers to adopt these practices at home. It is also recommended to do the PD inquiry twice, in order to get complete information about food available in the different seasons and because the children nutritional status may be different depending on the availability of food, however there will always be some PD families on each season. Inquiry about food security should be more accurate during the assessment to

get full information about the feasibility of the program. Records about food availability in the Hearth villages are similar these days, making evident that no village has a market. Some small shops sell fruits and vegetables and are more abundant during the rainy season. However, reality has shown afterward that the situation regarding food security is very different from one village to the other. When starting a new village a maximum duration for the program needs to be

planned. In case the village does not graduate before that date, interventions should stop anyway because that implies that Hearth is not the solution for the problem and the real causes of malnutrition need to be investigated, for example food availability. Education will go on nevertheless through home visits the VHVs would do to the mothers not trained during NERP. A time frame of one and a half year seems appropriate.

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To guarantee better education sessions during NERP, new techniques and topics need to be developed. After a few sessions, many VHVs stop conducting sessions unless PFD staff encourage them because they are bored. Games, songs and multimedia materials can make education sessions more pleasant and attractive. Working together with the Maternal Health program can help to reduce the

number of six months old children that need to join NERP. Education about the importance of antenatal care, nutrition in pregnancy and exclusive breastfeeding, imparted by the Health Center Midwives and the TBAs can be part of NERP, as it is known that a big percentage of the participants will be mothers again. In order to reinforce the impact of education, mothers should receive after the

sessions, easy-to-understand educational materials to take home to review between rounds of NERP. Regarding diarrhea, dengue and malaria, namely, a booklet explaining causes and treatment can be prepared to give to the mothers when their children are attained by these diseases. Occasionally it is impossible for a member of the family to attend some NERP

sessions and the volunteers want to bring the food to the children anyways. In such cases, provided that the absences are not regular, that they usually contribute with food and that they have asked for it, this can be done. Conversely, it cannot be allowed that this becomes a habit as well as it should not be acceptable that mothers come everyday by the time education session is over only to feed the children or, what is even worse, to ask for food to bring home. Undoubtedly, the volunteers allow these slips because they know the importance of an extra meal for the children, but if rehabilitation does not go together with education and behavior change, then the impact is extremely reduced. Access to food needs to be ensured in every area, Hearth is not workable and

what is more, not effective if the villagers do not have a minimum of food available. Moreover, areas where water is scarce almost guarantee the complications due to the lack of food, no possibility of agriculture, and hygiene issues, with its consequent link to infections. Food security interventions as well as agriculture programs need to be started before Hearth to make this program possible. It is a fact that malnutrition is not only the result of lack of quantity and quality

feeding but also of a deficient access to health care and not enough interventions to fight against diarrhea, malaria, dengue, respiratory infections and micronutrient deficiencies (principally through supplementation and fortification). Special attention needs to be paid to hygiene, trying to reinforce the education on this topic (namely making the hand-washing compulsory before eating in NERP). The Health Center should be more involved in the treatment of malnutrition. Other

than deworming sessions, which would be desired for all the Hearth villages, the Health Center is also needed to identify illnesses and treat children with persistent malnutrition with no apparent cause. Periodical visits to NERP can facilitate these practices, as for now, parents are counseled to take the children to be treated but it remains their responsibility to do it, which also means that it will depend on the economic situation of the family. Everyday at the end of the session, in the areas where this is possible, it is

recommended to plan with the mothers the food for the next day, organizing who is going to bring what and which are the mothers that will cook the next day. This would help to improve contributions and rotation for cooking among the mothers.

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By the 5th day of NERP, it is suggested to ask the mothers if they have been able to put in practice at home what they have learned in the session. This can allow finding out the reasons why they are not able to do it and try to find solutions among the group. Formal evaluation of knowledge should be periodically done. It can be done as a

game at the last day of NERP and even give small prizes (ex. soap). In addition, once in a while, in a month where there is no NERP sessions, visits some of the mothers to ask the same questions of the last day evaluation of NERP will allow us to know if knowledge has being incorporated or not. This time can also be a good opportunity to talk with the mothers about behavior change and the problems they are finding with that. Results need to be recorded and analyzed to identify villages where education is not being effective in order to improve. GMP sessions are a good opportunity to introduce some kind of education

activity. The majority of the mothers, plus a good amount of onlookers participate of the session, thus education about malaria, dengue, even HIV or any kind of topics can be imparted guaranteeing a good coverage. Since the staff working on GMP are busy, they cannot be in charge of education sessions, but it can be particularly successful to use attractive techniques as karaoke, films, posters, etc. Coordination between the offices in the three locations is essential as PFD’s

Hearth should be only one. Record keeping methods need to be standardized in order to be able to compare and analyze data. Regular meetings are strongly recommended to exchange information and work together to surpass obstacles. The program can be run with fewer difficulties if more staff are hired for that task.

Hearth is very time-consuming and as the staff have multiple activities it is not possible to be up to date with the desired frequency of the sessions, the records, the supervision, etc. It is recommended to set stronger guidelines for the food provided in NERP,

regarding amounts, procedures and also financial aspects. Supervision should be done to ensure this is respected. Regarding cooking practices, other than adopting the best practices learned from

the PD families some small modifications can improve the impact: o Serving the peanuts with the protein source food will help to improve the

amount of proteins the children get. o Instead of using big amounts of oil to cook, just use the minimum necessary

to avoid sticking to the pan, and add the rest, uncooked, on the top of each portion, as done with the proteins. This will improve the quality of the fat provided.

o Special attention is required when feeding children with diarrhea as the food provided is rich in fat and sometimes in green leafy vegetables and that can worsen the condition. Only if it is a mild case of diarrhea a moderate quantity can be provided.

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10. CONCLUSION The Hearth Model is not easy to implement in Cambodia. Principally food insecurity, but also the economic situation and the low level of education of the adult population in the villages, make this kind of intervention hard to run. In addition, the communities are used to receiving help from outsiders (principally NGOs) so they lack experience in programs from and for the community, where the villagers need to be auto-supportive. Despite these facts, PFD’s Hearth in Cambodia is having an impact on the children’s health status although it is taking a long time to see the results. The biggest constraint is that the strength of this program is education and it cannot be proved that the villages where it is implemented lack knowledge. Conversely, it is a fact that they lack food. In some villages, where Hearth has been conducted for almost three years, mothers have undoubtedly gained knowledge but they cannot put it in practice because food is not available and/or affordable. It remains also difficult to succeed in rehabilitation when depending on the communities’ contribution since the households do not even have enough food for them. Therefore Hearth can only be implemented once the food security in the village is guaranteed, for example through Agriculture Projects. In a hypothetical situation of food security, if PFD follows the recommendations listed previously, Hearth can be as successful as it has been in neighbor countries. The volunteers’ commitment and the support expressed by the mothers will be important assets when working for a new and improved Hearth.

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11. ANNEXES 11.1. PFD’s working areas in Cambodia

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11.2. PFD contributions for the NERP sessions Note: The data showed afterwards correspond to NERP sessions chosen randomly and may not be representative of all the instances. 11.2.1. Chhlong (Prohout – March 2005) Average

amount/child/day (*) Cost

(US$) Sugar 0.036 Kg 0.018 Oil 0.018 Cc 0.016 Salt 0.009 Kg 0.002 Fish sauce 0.009 Cc 0.003 Vegetables 0.091 Kg 0.023 Garlic 0.009 Kg 0.005 Fish (1) 0.091 Kg 0.182 Pork (2) 0.068 Kg 0.182 Eggs 0.273 unit 0.034 Coconut (3) 0.018 unit 0.005 Green beans (4) 0.018 Kg 0.009 Sakou (5) 0.009 Kg 0.003 Soy beans 0.036 Kg 0.018 Peanuts 0.018 Kg 0.018 Total 0.518

Total cost of the NERP session, for 11 children, is US$57 (1) Fish was given 5 days, 180g per child each time. (2) Pork was given 5 days, 140g per child each time. (3) Coconut was given 2 times, 1 fruit was enough to prepare sweet for all the children. (4) The green beans were also part of the sweet; it corresponds to 100g of beans per child each time. (5) Sakou, also part of the sweet, 50 g per child.

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11.2.2. Sre Ambel (Cham Srey – February 2005)

Average amount/child/day (*)

Cost (US$)

Rice 0.089 Kg 0.027 Sugar 0.062 Kg 0.025 Oil 0.020 Cc 0.035 Salt 0.014 Kg 0.002 Vegetables (garlic included) 0.250 Kg 0.162

Pork 0.060 Kg 0.180 Beef 0.016 Kg 0.056 Fish 0.049 Kg 0.086 Eggs 1.040 unit 0.104 Fish sauce 0.008 Cc 0.005 Soy sauce 0.004 Cc 0.006 Beans 0.118 Kg 0.065 Peanuts 0.008 Kg 0.007 Liver 0.004 Kg 0.012 Total 0.771

Total cost of the NERP session, for 25 children, is US$ 192.76 (1) Pork was prepared 6 times, 100g per child. (2) Beef was prepared 1 time, 160g per child. (3) Fish was prepared 3 times, 160g per child. 11.2.3. Kratie (Chang Krang – January 2005)

Average amount/child/day (*)

Cost (US$)

Fish and meat 0.164 Kg 0.329 Salt 0.007 Kg 0.001 Peanuts 0.018 Kg 0.021 Oil 0.018 Cc 0.015 Garlic 0.007 Kg 0.004 Sugar 0.014 Kg 0.005 Soy beans 0.018 Kg 0.006 Fish sauce 0.004 Cc 0.001 Bananas 1 unit 0.022 Eggs 0.357 unit 0.045 Vegetables 0.034 Kg 0.017 Total 0.466

Total cost of the NERP session, for 28 children, is US$ 130.35 (*) The amount of food is showed in gross weight.

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11.3. Focus group discussions results

Knowledge about malnutrition What are the causes?

• Lack of food o Not enough money (poverty) o Not enough time to go to collect food in the forest o Food not available in the local market o Principally during dry season

• Diseases • Children don’t want to eat • Mothers work and cannot take care of the children • Lack of hygiene

What are the consequences? • Children are thin • Children get sick

How to heal malnutrition? • Hygiene • Boiled water • Food • Going to the Health Center • With medicines and injections • Quality homecare (hygiene + good nutrition) • Sleeping inside mosquito nets to prevent diseases

When and what do the children eat at home? • No regular times. • 1 to 5 times a day depending on: money, hunger (if children eat snacks

they are not hungry). • Food prepared depends on the money, if they have money they buy

proteins, if not they just feed rice and prohok, sometimes soup. The majority of the families do not have money to afford proteins.

• Sometimes the mothers cook, others they buy food. • The children usually eat the family’s food. • Children eat snacks when the mothers have enough money.

Who takes care of the children at home? The mother, if she works the caretaker is an older sibling, sometimes the grandmother. They identify this as a cause of malnutrition and weak health among the children.

Is there a variety of food available in the village? • In some villages the only source of protein available is dry fish. • In other villages the major problem is not food availability but lack of

money because of unemployment. • In the rainy season some families can hunt in some areas to obtain meat. • In the dry season some families depend on the wild vegetables from the

forest as the only source of vegetables. • During the rainy season growing vegetables is a common practice in

some areas (i.e. Snuol) • There are more vegetables available during rainy season. • Mothers do not have time to go fishing. • In some areas the market is far away and people depend on occasional

sellers that bring vegetables but they are expensive.

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What are the most common diseases in the area?

• Malaria • Dengue • Diarrhea • Cold • Cough • Fever • ARI

What is your opinion about the Health Center? Do you go to it? • Inexpensive, in Snuol/Ksim and Prek Prasop, although transport is

expensive. • Expensive in Domrei Phong, sometimes it is cheaper going to private

clinics. • Expensive to pay for the transport to the Referral Hospital. • People in Snuol say they go in case of illnesses, in Domrei Phong and

Prek Prasop they only go in case of serious illnesses (fever or severe diarrhea).

• They usually use traditional medicine or local drug sellers if they have money.

What is your opinion about the VHV’s? • Mothers are very grateful for the dedication of the VHVs. • They do an important job. • They provide education to the neighbors. • In some villages they are contacted and asked for advice when the

children are sick. What is your opinion about NERP?

• Very good for the village. • Helps to improve health. Nutrition status is improved in the villages

since the beginning of Hearth, children are sick less often and grow up faster.

• Useful education is provided. • Mothers consider education as important as rehabilitation. • Generally they cannot practice at home what they learn because of lack

of time or money. • Repeating the education sessions is good to refresh knowledge. • Suggestions to improve:

- Give medicines (first answer in the 3 focus groups). - Teach about HIV AIDS - Feed also lactating mothers, because if they are undernourished

they cannot breastfeed. - Give more food or do it everyday.

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11.4. GMP results

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TROPEANG LEARK 12 08 03 1 44 42 95% 25 60% 16 38% 1 2% 17 40% 10 10 03 2 46 43 93% 23 53% 15 35% 5 12% 20 47% 0 0 11 12 03 3 44 40 91% 25 63% 12 30% 3 8% 15 38% 0 0 11 02 04 4 44 32 73% 16 50% 13 41% 3 9% 16 50% 0 0 20 04 04 5 46 40 87% 19 48% 8 20% 2 5% 10 25% 3 0 22 07 04 6 42 29 69% 19 66% 8 28% 2 7% 10 34% 0 0 19 08 04 7 46 28 61% 18 64% 8 29% 1 4% 9 32% 0 0 28 10 04 8 41 27 66% 13 48% 11 41% 3 11% 14 52% 0 2 08 12 04 9 37 31 84% 16 52% 15 48% 3 10% 18 58% 1 2 21 01 05 10 41 32 78% 17 53% 14 44% 1 3% 15 47% 1 4 BOEUNG LEARCH 12 01 04 1 43 40 93% 26 65% 11 28% 3 8% 14 35% 17 01 04 1' 50 47 94% 26 55% 15 32% 6 13% 21 45% 0 0 17 03 04 2 52 45 87% 33 73% 9 20% 3 7% 12 27% 0 0 09 07 04 3 49 36 73% 17 47% 13 36% 6 17% 19 53% 3 1 28 09 04 4 52 43 83% 27 63% 12 28% 4 9% 16 37% 1 1 29 12 04 5 58 54 93% 29 54% 20 37% 5 9% 25 46% 5 2 18 02 05 6 54 51 94% 32 63% 16 31% 3 6% 19 37% 3 3 KRONG 17 06 03 1 71 64 90% 38 59% 24 38% 2 3% 26 41% 27 10 03 2 75 26 35% 16 62% 9 35% 1 4% 10 38% 0 0 10 12 03 3 78 68 87% 47 69% 18 26% 3 4% 21 31% 0 0 10 02 04 4 78 59 76% 35 59% 22 37% 2 3% 24 41% 0 0 20 04 04 5 79 64 81% 49 77% 15 23% 0 0 15 23% 0 0

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28 07 04 6 85 40 47% 23 58% 16 40% 1 3% 17 43% 2 3 09 12 04 7 68 47 69% 33 70% 10 21% 1 2% 11 23% 3 2 20 01 05 8 72 61 85% 47 77% 13 21% 1 2% 14 23% 1 4 SRE TRIEK 17 12 02 1 29 29 100% 20 69% 6 21% 3 10% 9 31% 20 02 03 2 31 31 100% 23 74% 7 23% 1 3% 8 26% 0 0 04 06 03 3 31 21 68% 12 57% 9 43% 0 0% 9 43% 0 0 09 07 03 4 33 22 67% 10 45% 11 50% 1 5% 12 55% 0 0 02 09 03 5 37 30 81% 20 67% 9 30% 1 3% 10 33% 0 0 20 10 03 6 40 31 78% 23 74% 7 23% 1 3% 8 26% 0 0 09 12 03 7 43 36 84% 31 86% 4 11% 1 3% 5 14% 0 0 11 02 04 8 45 36 80% 21 58% 14 39% 1 3% 15 42% 0 0 29 04 04 9 46 38 83% 32 84% 5 13% 1 3% 6 16% 1 6 14 07 04 10 44 35 80% 29 83% 4 11% 1 3% 5 14% 1 2 20 10 04 11 49 35 71% 22 63% 11 31% 2 6% 13 37% 1 0 15 12 04 12 49 43 88% 28 65% 13 30% 2 5% 15 35% 5 3 16 02 05 13 45 43 96% 36 84% 5 12% 2 5% 7 16% 1 5 SAMPOCH 23 12 03 1 34 32 94% 19 59% 12 38% 1 3% 13 41% 14 02 04 2 36 33 92% 19 58% 11 33% 3 9% 14 42% 0 0 21 04 04 3 36 30 83% 23 77% 4 13% 3 10% 7 23% 1 0 21 07 04 4 38 26 68% 14 54% 8 31% 4 15% 12 46% 1 0 27 10 04 5 42 30 71% 16 53% 10 33% 4 13% 12 40% 2 0 19 01 05 6 39 32 82% 21 66% 10 31% 1 3% 11 34% 1 3 PREK KDEY 10 09 03 1 62 52 84% 34 65% 17 33% 1 2% 18 35% 21 11 03 2 64 50 78% 43 86% 7 14% 0 0% 7 14% 0 0

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12 02 04 3 64 42 66% 31 74% 10 24% 1 2% 11 26% 0 0 20 04 04 4 62 37 60% 28 76% 8 22% 1 3% 9 24% 3 0 20 07 04 5 58 30 52% 16 53% 13 43% 1 3% 14 47% 2 0 28 10 04 6 58 31 53% 21 68% 10 32% 0 0% 10 32% 1 1 19 01 05 7 56 40 71% 28 70% 12 30% 0 0% 12 30% 1 3 O' LOUNG 16 01 04 1 48 38 79% 25 66% 10 26% 3 8% 13 34% 11 03 04 2 46 39 85% 18 46% 18 46% 3 8% 21 54% 2 1 08 07 04 3 44 40 91% 20 50% 14 35% 6 15% 20 50% 2 0 29 09 04 4 43 38 88% 18 47% 17 45% 3 8% 20 53% 1 1 28 12 04 5 43 35 81% 21 60% 14 40% 3 9% 17 49% 1 2 17 02 05 6 43 35 81% 18 51% 12 34% 5 14% 17 49% 1 0 PROLAY TRIEK 12 08 03 1 44 42 95% 25 60% 16 38% 1 2% 17 40% 10 10 03 2 50 44 88% 27 61% 14 32% 3 7% 17 39% 0 0 16 12 03 3 52 48 92% 32 67% 14 29% 2 4% 16 33% 0 0 13 02 04 4 52 40 77% 22 55% 17 43% 1 3% 18 45% 0 0 30 04 04 5 48 24 50% 15 63% 7 29% 2 8% 9 38% 3 2 03 08 04 6 50 15 30% 9 5 33% 1 7% 6 40% 2 1 09 12 04 7 49 35 71% 20 57% 14 40% 1 3% 15 43% 2 3 02 02 05 8 47 35 74% 19 54% 13 37% 3 9% 16 46% 3 1 BOSS 17 12 02 1 51 41 80% 20 49% 20 49% 1 2% 21 51% 20 02 03 2 51 41 80% 27 66% 12 29% 2 5% 14 34% 0 0 04 06 03 3 46 36 78% 22 61% 13 36% 1 3% 14 39% 0 0 08 07 03 4 48 34 71% 19 56% 14 41% 1 3% 15 44% 0 0 03 09 03 5 50 42 84% 22 52% 16 38% 4 10% 20 48% 0 0

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30 10 03 6 46 37 80% 24 65% 12 32% 1 3% 13 35% 0 0 10 12 03 7 45 38 84% 26 68% 11 29% 1 3% 12 32% 0 0 10 02 04 8 50 47 94% 30 64% 12 26% 5 11% 17 36% 0 0 28 04 04 9 51 48 94% 36 75% 9 19% 3 6% 12 25% 5 4 13 07 04 10 57 49 86% 31 63% 14 29% 4 8% 18 37% 1 0 19 10 04 11 69 56 81% 35 63% 20 36% 1 2% 21 38% 5 1 16 12 04 12 62 59 95% 36 61% 20 34% 3 5% 23 39% 5 4 15 02 05 13 53 48 91% 32 67% 15 31% 1 2% 16 33% 5 3 KAMPONG SRE 24 06 02 1 41 41 100% 21 51% 15 37% 5 12% 20 49% 08 08 02 2 41 37 90% 23 62% 12 32% 2 5% 14 38% 0 0 31 10 02 3 41 35 85% 22 63% 12 34% 1 3% 13 37% 0 0 31 01 03 4 41 41 100% 30 73% 10 24% 1 2% 11 26% 0 0 06 05 04 5 39 35 90% 27 77% 6 17% 2 6% 8 22% 0 0 09 07 03 6 52 46 88% 33 72% 11 24% 2 4% 13 28% 0 0 22 10 03 7 47 43 91% 33 77% 7 16% 3 7% 10 23% 0 0 01 03 04 8 49 49 100% 41 84% 6 12% 2 4% 8 16% 0 0 03 06 04 9 55 48 87% 33 69% 14 29% 1 2% 15 31% 3 1 28 10 04 10 58 34 59% 28 82% 5 15% 1 3% 6 18% 0 1 20 01 05 11 75 66 88% 56 85% 9 14% 1 2% 10 15% 4 3 PREY KOU 24 06 02 1 70 70 100% 35 50% 28 40% 7 10% 35 50% 08 08 02 2 70 57 81% 33 58% 15 26% 9 16% 24 42% 0 0 31 10 02 3 70 43 61% 25 58% 11 26% 7 16% 18 42% 0 0 31 01 03 4 70 34 49% 16 47% 9 26% 9 26% 18 53% 0 0 07 05 03 5 94 30 32% 17 57% 9 30% 4 13% 13 43% 0 0 11 07 03 6 90 60 67% 32 53% 25 42% 3 5% 28 47% 0 0

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14 10 03 7 80 44 55% 38 86% 4 9% 2 5% 6 14% 0 0 12 12 03 8 85 49 58% 41 84% 5 10% 3 6% 8 16% 0 0 19 08 04 9 76 26 34% 18 69% 8 31% 1 4% 9 35% 2 3 10 11 04 10 72 44 61% 27 61% 17 39% 0 0% 17 39% 0 1 19 01 05 11 70 52 74% 41 79% 11 21% 0 0% 11 21% 3 2 PROHOUT 27 01 03 1 29 14 48% 9 31% 6 21% 15 52% 05 06 03 2 32 32 100% 17 53% 13 41% 2 6% 15 47% 0 0 10 07 03 3 32 24 75% 16 67% 6 25% 2 8% 8 33% 0 0 02 09 03 4 37 37 100% 30 81% 7 19% 0 0% 7 19% 0 0 31 10 03 5 36 36 100% 33 92% 3 8% 0 0% 3 8% 0 0 11 12 03 6 37 37 100% 32 86% 5 14% 0 0% 5 14% 0 0 11 02 04 7 32 28 87% 13 46% 15 54% 0 0% 15 54% 0 0 27 04 04 8 33 27 82% 20 74% 6 22% 1 4% 7 26% 3 1 15 07 04 9 31 20 65% 8 40% 10 50% 2 10% 12 60% 1 1 21 10 04 10 34 28 82% 13 46% 13 46% 2 7% 15 54% 1 1 14 12 04 11 33 28 85% 18 64% 10 36% 0 0% 10 36% 2 2 15 02 05 12 31 29 94% 16 55% 13 45% 0 0% 13 45% 1 4 SRE SDACH 27 01 03 1 n/a 11 7 64% 4 36% 0 0% 4 36% 05 06 03 2 18 16 89% 12 75% 4 22% 0 0% 4 25% 0 0 11 07 03 3 17 13 76% 12 71% 0 0% 1 8% 1 8% 0 0 03 09 03 4 18 17 94% 13 76% 3 18% 1 6% 4 24% 0 0 12 02 04 5 16 16 100% 12 75% 3 19% 1 6% 4 25% 0 0 BOEUNG KIEP 28 01 03 1 n/a 40 21 52% 16 40% 3 8% 19 48% 14 03 03 2 47 44 94% 23 52% 19 43% 2 5% 21 48% 0 0

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08 05 03 3 41 26 63% 14 54% 8 31% 4 15% 12 46% 0 0 08 07 03 4 44 42 95% 15 36% 23 55% 4 10% 27 64% 0 0 20 09 03 5 56 37 66% 24 65% 10 27% 3 8% 13 35% 1 8 21 11 03 6 43 29 67% 16 55% 12 41% 1 3% 13 45% 3 0 03 03 04 7 50 41 82% 17 41% 24 59% 0 0% 24 59% 0 0 02 06 04 8 48 36 75% 11 31% 21 58% 4 11% 25 69% 4 1 07 09 04 9 54 34 63% 16 47% 13 38% 5 15% 18 53% 2 1 11 11 04 10 56 38 68% 23 61% 11 29% 4 11% 15 39% 2 1 18 01 05 11 51 36 71% 22 61% 12 33% 2 6% 14 39% 1 1 TROPEANG SRE 22 10 02 1 24 24 100% 17 71% 6 25% 1 4% 7 29% 28 11 02 2 24 22 92% 15 68% 7 32% 0 0% 7 32% 0 0 19 02 03 3 27 24 89% 16 67% 8 33% 0 0% 8 33% 0 0 13 05 03 4 17 13 76% 9 69% 4 31% 0 0% 4 31% 0 0 10 07 03 5 17 16 94% 13 81% 2 13% 1 6% 3 19% 0 0 27 10 03 6 25 18 72% 12 67% 6 33% 0 0% 6 33% 0 0 22 04 04 7 30 23 77% 18 78% 4 17% 1 4% 5 22% 3 1 18 01 05 8 28 26 93% 19 73% 5 19% 2 8% 7 27% 0 0 MEANCHEY 22 10 02 1 38 38 100% 22 58% 13 34% 3 8% 16 42% 28 11 02 2 43 37 86% 24 65% 11 30% 2 5% 13 35% 0 0 20 02 03 3 42 42 100% 29 69% 11 26% 2 5% 13 31% 0 0 14 05 03 4 43 38 88% 24 63% 12 32% 2 5% 14 37% 0 0 17 07 03 5 40 36 90% 26 72% 8 22% 2 6% 10 28% 0 0 04 09 03 6 44 41 93% 30 73% 9 22% 2 5% 11 27% 0 0 25 10 03 7 46 41 89% 32 78% 9 22% 0 0% 9 22% 0 0 11 12 03 8 49 47 96% 38 81% 8 17% 1 2% 9 19% 0 0

39


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22 04 04 9 49 35 71% 27 77% 8 23% 0 0% 8 23% 0 0 18 01 05 10 42 40 95% 30 75% 8 20% 2 5% 10 25% 0 0 KBAL KLA 25 08 04 1 24 24 100% 14 58% 10 42% 0 0% 10 42% 05 02 05 2 26 22 85% 13 54% 8 36% 1 5% 9 41% 2 1 DEY DOS KROM 16 02 05 1 n/a 70 n/a 45 64% 20 29% 5 7% 25 36% CHAM SREY 18 12 04 1 n/a 79 n/a 25 32% 33 42% 21 27% 54 68% VEAL 11 11 04 1 n/a 113 n/a 51 45% 47 42% 15 13% 62 55% PHOUM THMEY 22 02 05 1 n/a 72 n/a 33 46% 27 38% 12 17% 39 54% CHANG KRANG 10 12 05 1 n/a 68 n/a 38 56% 22 32% 8 12% 30 44% 09 02 05 2 n/a 54 n/a 27 50% 21 39% 6 11% 27 50% n/a n/a KOH KHNAE 12 01 05 1 n/a 40 n/a 21 53% 16 40% 3 8% 19 48%

AVERAGES 48 39 81% 24 63% 12 31% 2 6% 14 37% 1 2% 1 2%

Note: Numbers in italics in the table show values after graduation

40


11.5. NERP results 11.5.1. Average weight variations sorted by area

Attended (%)

Gained weight

(%)

No change

(%)

Lost weight

(%)

Severe to Moderate

(%)

Moderate to Normal

(%)

Fell channel

(%) Chhlong 91.0 77.6 13.0 7.3 5.2 16.8 0.9 Sre Ambel 95.5 78.4 6.8 14.9 17.6 10.1 4.7 Kratie 81.6 72.5 17.5 2.5 2.5 0.0 0.0 Average 90.7 78.7 12.8 8.4 6.5 14.1 1.4 11.5.2. Average percentage of graduated children sorted by village

Village Moderate malnutrition to Normal

Severe malnutrition to Moderate malnutrition Fell channel

Boeung Kiep 17% 3% 0% Boeung Leark 16% 10% 0% Boss 20% 5% 2% Cham Srey 14% 34% 2% Chang Krang 0% 4% 0% Dey Dos Krom 32% 12% 0% Kampong Sre 12% 3% 6% Kbal Kla 18% 0% 0% Koh Khnae 0% 0% 0% Krong 8% 2% 1% Meanchey 15% 4% 3% O'Loung 10% 2% 0% Prey Kdey 19% 0% 2% Prey Kou 6% 4% 0% Prohout 17% 6% 1% Prolay Triek 20% 4% 0% Phoum Thmey 7% 17% 7% Sampoch 13% 14% 0% Sre Triek 31% 5% 0% Tropeang Leark 13% 3% 1% Tropeang Sre 14% 5% 0% Veal 10% 6% 5%

41


11.6. Northeast Cambodia Child Survival Program Final Evaluation results

Indicator Results at baseline

(KPC 1999) Results at final evaluation

(KPC 2004) % of children exclusively breastfed the 6 first months of life 12% 78% % of mothers who know when to start complementary feeding 34% 78% % of mothers who know what kind of additional foods the child needs 9% 58% % of mothers who know which foods contains Vitamin A 9% 91% % of households where iodine is present in the salt used at home 1% 41% % of children who where given the same amount or more fluids during diarrhea

34% 62%

% of children with diarrhea in the last 2 weeks who were given ORT 15% 81% % of mothers who know to feed their children more often when recovering from diarrhea

17% 85%

% of children ages 12 – 23 months fully immunized 17% 79%

42


11.7. Nutritional value of NERP food 11.7.1. PFD’s provided foods

Amount of food per child and frequency

Chhlong Sre Ambel Kratie

Pork 140 g 5 times

100 g 6 times

Beef - 160 g once

Fish 180 g 5 times

160 g 3 times

160 g daily

Eggs 50 g twice

50 g daily

17 g daily

Vegetables 100 g daily

250 g daily

34 g daily

Bananas - - 50 g 5 times

Rice - 89 g daily -

Beans (*) 54 g daily

118 g daily

18 g daily

Peanuts 18 g daily

8 g daily

18 g daily

Sugar 36 g daily

62 g daily

14 g daily

Oil 18 g daily

20 g daily

18 g daily

Salt 9 g daily

14 g daily

7 g daily

(*) Mostly soy beans, but other kinds of beans, used in dessert, have been included. 11.7.2. Nutritional value of PFD’s contributed food

Carbohyd. (g)

Proteins (g)

Fat (g)

Iron (mg)

Vit. A (µg RE)

Iodine (µg)

Energy (kcal)

Chhlong 44.48 33.31 41.88 6.16 155.09 59.43 688 Sre Ambel 148.23 52.47 51.43 11.9 482.16 93.51 1266 Kratie 25.54 28.48 40.46 4.99 96.90 52.06 580

43


11.8. Nutrition guidelines 11.8.1. Recommended Dietary Intake for children from 6 to 36 months

Energy (kcal)

Proteins (g)

Iron (mg)

Vitamin A (µg RE)

Iodine (µg)

Normal 6 to 12 months old 600 to 1000 14 10 375 50 1 to 3 years old 1000 to 1300 16 10 400 70

Malnutrition Moderate 750 to 1600 15 to 29 Severe 1400 to 2200 16 to 33 11.8.2. CORE’s Hearth Manual Guidelines for NERP food Energy: 600 to 800 kcal (if not possible, at least 500 kcal) Proteins: 25 to 27 g (minimum 18 to 20 g) 11.9. Nutrition situation of children from 6 to 36 months of age in the

Hearth villages (February 2005)

Round Underweight Severe Malnutrition

Boeung Kiep 11 39% 6% Boeung Leark 7 37% 6% Boss 13 33% 2% Cham Srey 1 68% 27% Chang Krang 2 50% 11% Dey Dos Krom 1 36% 7% Kampong Sre (*) 11 15% 2% Kbal Kla 2 41% 5% Koh Khnae 2 48% 8% Krong 8 23% 2% Meanchey (*) 10 25% 5% O'Loung 6 49% 14% Prey Kdey 7 30% 0% Prey Kou (*) 11 21% 0% Prohout 12 45% 0% Prolay Triek 7 46% 3% Phoum Thmey 1 54% 17% Sampoch 6 34% 3% Sre Triek 10 16% 3% Tropeang Leark 10 47% 3% Tropeang Sre (*) 8 27% 8% Veal 1 54% 13% Average 37% 6%

(*) Villages already graduated: Kampong Sre graduated in round 7 Meanchey graduated in round 7 Prey Kou graduated in round 8 Tropeang Sre graduated in round 4

44


11.10. Evolution of the nutrition situation in the Hearth villages

MALNUTRITION RATES IN HEARTH VILLAGES (I)

0%

10%

20%

30%

40%

50%

60%

70%

Round1

Round2

Round3

Round4

Round5

Round6

Round7

Round8

Round9

Round10

Round11

Round12

Round13

GMP session

% o

f mal

nutr

ition

Boeung KiepBossProhoutSre Triek

MALNUTRITION RATES IN HEARTH VILLAGES (II)

0%

10%

20%

30%

40%

50%

60%

Round 1 Round 2 Round 3 Round 4 Round 5 Round 6 Round 7 Round 8 Round 9 Round 10

GMP session

% o

f mal

nutr

ition

KrongPrey KdeyProlay TriekTropeang Leark

45


MALNUTRITION RATES IN HEARTH VILLAGES (III)

0%

10%

20%

30%

40%

50%

60%

Round 1 Round 2 Round 3 Round 4 Round 5 Round 6

GMP session

% o

f mal

nutr

ition Boeung Leark

Dey Dos KromKbla KlaO'LoungSampoch

MALNUTRITION RATES IN THE ALREADY GRADUATED HEARTH VILLAGES

0%

10%

20%

30%

40%

50%

60%

Round 1 Round 2 Round 3 Round 4 Round 5 Round 6 Round 7 Round 8 Round 9 Round 10 Round 11

GMP session

% o

f mal

nutr

ition

Kampong SreMeancheyPrey KouTropeang Sre

graduate graduate

graduate

graduate

46


11.11. Percentage of malnourished children in the Hearth villages per month

Jun 02

Jul 02

Aug 02

Sep 02

Oct 02

Nov 02

Dec 02

Jan 03

Feb 03

Mar 03

Apr 03

May 03

Jun 03

Jul 03

Aug 03

Sep 03

Oct 03

Nov 03

Dec 03

Kampong Sre 49% 38% 37% 26% 22% 28% 23% Prey Kou 50% 42% 42% 53% 43% 47% 14% 16% Meanchey 42% 35% 31% 37% 28% 27% 22% 19% Tropeang Sre 29% 32% 33% 31% 19% 33% Boss 51% 34% 39% 44% 48% 35% 32% Sre Triek 31% 26% 43% 55% 33% 26% 14% Boeung Kiep 48% 48% 46% 64% 35% 45% Prohout 52% 47% 33% 19% 8% 14% Sre Sdach (*) 36% 25% 8% 24% Krong 41% 38% 31% Prolay Triek 40% 39% 33% Tropeang Leark 40% 47% 38% Prey Kdey 35% 14% Sampoch 41% Boeung Leark O'Loung Kbal Kla Veal Cham Srey Chang Krang Koh Khnae Dey Dos Krom Phoum Thmey Averages 50% 40% 38% 34% 41% 43% 31% 48% 36% 39% 36% 40% 32% 29% 30% 26% (*) Sre Sdach is nowadays part of Prohout

47


Jan

04 Feb 04

Mar 04

Apr 04

May 04

Jun 04

Jul 04

Aug 04

Sep 04

Oct 04

Nov 04

Dec 04

Jan 05

Feb 05

Reduction/ Increase

Kampong Sre 16% 31% 18% 15% -34% Prey Kou 35% 39% 21% -29% Meanchey 23% 25% -17% Tropeang Sre 22% 27% -9% Boss 36% 25% 37% 38% 39% 33% -18% Sre Triek 42% 16% 14% 37% 35% 16% +7% Boeung Kiep 59% 69% 53% 39% 39% -9% Prohout 54% 26% 60% 54% 36% 45% -7% Sre Sdach (*) 25% -15% Krong 41% 23% 43% 23% 23% -18% Prolay Triek 45% 38% 40% 43% 46% +3% Tropeang Leark 50% 25% 34% 32% 52% 58% 47% -2% Prey Kdey 26% 24% 47% 32% 30% -5% Sampoch 42% 23% 46% 40% 34% -7% Boeung Leark 35% 27% 53% 37% 46% 37% +2% O'Loung 34% 50% 50% 53% 49% 49% +15% Kbal Kla 42% 41% -1% Veal 55% - Cham Srey 68% - Chang Krang 44% 50% - Koh Khnae 48% - Dey Dos Krom 36% - Phoum Thmey 54% - Averages 35% 40% 38% 26% 24% 50% 43% 36% 48% 39% 39% 43% 30% 36% -10%

Note: Numbers in italics in the table show values after graduation.

48


12. BIBLIOGRAPHY BASICS II. 2004. Essential Nutrition Actions in Nigeria. Berggren G., Berggren W.. 2003. Foyers d’apprentissage et de rehabilitation nutritionelle. Hearth / Positive Deviance Workshop (report). Caribbean Food and Nutrition Institute (PAHO/WHO). 1993. Nutrition Handbook for Community Workers in the Tropics. Macmillan. CORE. 2002. Positive Deviance / Hearth for Nutrition Technical Advisory Group Meeting (meeting report). CORE. 2003. Positive Deviance / Hearth. A resource guide for sustainably rehabilitating malnourished children. Government, Kingdom of Cambodia. 2003. Sub-Decree on Management of Iodized Salt Exploitation. Helen Keller International. 2001. Initial findings from the 2000 Cambodia National Micronutrient Survey.

PFD. 1998. Training for Health workers on Iodine Deficiencies Disorders.

Helen Keller International. 2002. An overview of Nutrition Sector Activities in Cambodia. MAFF/FAO. 1999. National Food Security and Nutrition. National Seminar on Food Security and Nutrition. Medicam. 2004. Cambodia’s health situation, priorities and responses. Medinews Vol 3, Issue 12. Medicam. 2004. Reducing Iron Deficiency Anemia and changing dietary behaviors. Medinews Vol 3, Issue 12, Dec 2004. Medicam. 2005. Reducing Child Survival Partnership Workshop. Medinews Vol 4, Issue 1, Jan 2004. Medicam. 2005. Wilder use of anti-parasite drugs provides increased benefit. Medinews Vol 4, Issue 1, Jan 2004. Ministry of Planning, National Council for Nutrition. 2002. Cambodia Nutrition Investment Plan 2003 – 2007.

PFD. 2002. Nutrition training curriculum and lesson plan for nutrition educators. PFD. 2002. The Hearth Nutrition Model: an implementation manual. PFD. 2004. PFD Model Family Nutrition Project (Krusa Kumru L’ol), Reports to CIDA. PFD. 2004. Final Evaluation, Northeast Cambodia Child Survival Program.

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PFD. Community Growth Monitoring Project (GMP). Manual for Community Volunteers. PFD. Community Growth Monitoring Project (GMP). Training for Community Volunteers. Savage King, F., Burguess, A.. 1996. Nutrition for developing countries. Oxford University Press. Shekar, M., Habicht, J. P., Latham M. C.. Is positive deviance in growth simply the converse of negative deviance? Wardlaw, G..1999. Perspectives in nutrition. Mc Graw Hill. World Relief, Basics. 1997. Hearth Nutrition Model: Applications in Haiti, Vietnam and Bangladesh.

Worthington-Roberts, B. S.. 1996. Nutrition throughout the life cycle. Mc Graw Hill.

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pfd’s hearth program in cambodia - · pdf fileto ms. kim chadwick for her “village...

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