Positive Deviance and Hearth in Indonesia

1. Positive Deviance and Hearth in Indonesia

2. PD/Hearth in Indonesia June 2008 2 PD/Hearth in Indonesia PD/Hearth implementation in Indonesia Preliminary results of Evaluation Disclaimer: I�m afraid that I am not the original presenter and perhaps even worse, I did not design this presentation for you. I will do my best to answer all questions, but I may have to refer back out to our field team, in which case I�ll get you an answer via email. I know that there are other PVOs in the room who have taken part in this evaluation � is there anyone here who has directly taken part?Disclaimer: I�m afraid that I am not the original presenter and perhaps even worse, I did not design this presentation for you. I will do my best to answer all questions, but I may have to refer back out to our field team, in which case I�ll get you an answer via email. I know that there are other PVOs in the room who have taken part in this evaluation � is there anyone here who has directly taken part?

3. PD/Hearth in Indonesia June 2008 3 THE PREVALENCE OF UNDERWEIGHT PRE-SCHOOL CHILDREN (1989-2003) Malnutrition has decreased since 1989 but does not continue to decrease indicating that the rate has reached a plateau and new approaches are needed to continue to decrease rates of under weight Underweight = low weight for age (< -2 WAZ). Malnutrition has decreased since 1989 but does not continue to decrease indicating that the rate has reached a plateau and new approaches are needed to continue to decrease rates of under weight Underweight = low weight for age (< -2 WAZ).

4. PD/Hearth in Indonesia June 2008 4 Stunting Among Pre-School Children (1990 � 2001) Stunting, (low height for age, is very high. Stunting indicates a chronic nutritional problem and is an indicator of chronic poverty Stunting = low height for age (< -2 HAZ). Due to chronic food shortage, nutrient deficiency, illness, aflatoxin exposureStunting, (low height for age, is very high. Stunting indicates a chronic nutritional problem and is an indicator of chronic poverty Stunting = low height for age (< -2 HAZ). Due to chronic food shortage, nutrient deficiency, illness, aflatoxin exposure

5. PD/Hearth in Indonesia June 2008 5 Wasting Among Pre-School Children (1990 � 2001) Wasting (weight for height) is an acute condition. Rates of wasting in Indonesia are similar to some African countries. Wasting = low weight for height (<-2 WHZ). More than 1/3 of all deaths worldwide are due to maternal and child undernutrition Wasting (weight for height) is an acute condition. Rates of wasting in Indonesia are similar to some African countries. Wasting = low weight for height (<-2 WHZ). More than 1/3 of all deaths worldwide are due to maternal and child undernutrition

6. PD/Hearth in Indonesia June 2008 6 Positive Deviance In most settings, a few at risk individuals follow uncommon, beneficial practices and consequently experience better outcomes than their neighbors who share similar risks. - Sternin, BMJ (British Medical Journal), 13 November 2004 In every community there are certain individuals whose uncommon practices/behaviors enable them to find better solutions to problems than their neighbors who have access to the same resources Community must DISCOVER what the Positive Deviants are doing that is different from their neighbors Designing public health interventions around uncommon, beneficial health behaviors that some community members already practice. These behaviors are likely to be acceptable (presenting little barrier to adoption) because they are already practiced by at-risk community members, thereby demonstrated to be successful and not in conflict with local cultureIn every community there are certain individuals whose uncommon practices/behaviors enable them to find better solutions to problems than their neighbors who have access to the same resources Community must DISCOVER what the Positive Deviants are doing that is different from their neighbors Designing public health interventions around uncommon, beneficial health behaviors that some community members already practice. These behaviors are likely to be acceptable (presenting little barrier to adoption) because they are already practiced by at-risk community members, thereby demonstrated to be successful and not in conflict with local culture

7. PD/Hearth in Indonesia June 2008 7 Positive Deviance Processes in PD implementation: Social Mobilization Information Gathering Behavior Change Social mobilization: community members are usually eager to take part, responding with excitement and enthusiasm. Reporting motivation through learning what is going RIGHT in the community, that they already have the solution to childhood nutrition on hand. In contrast to some programming, which seems to emphasize what has been going WRONG. Information gathering: In-depth inquiries, studying community norms and community vetting to identify positive, transferable behaviors. (We�re talking about nutrition programming now, but obviously, this methodology is useful in many different types of programming.) Behavior change: creating the context in which behavior change can occur, which in nutrition programming, leads to Hearth. Activity: Insuring that we all understand the concept : Everyone needs coffee in the morning. But someone in here doesn�t need it. Who is it, and how have they avoided addiction. Are there any other examples of positive deviance in our lives?Social mobilization: community members are usually eager to take part, responding with excitement and enthusiasm. Reporting motivation through learning what is going RIGHT in the community, that they already have the solution to childhood nutrition on hand. In contrast to some programming, which seems to emphasize what has been going WRONG. Information gathering: In-depth inquiries, studying community norms and community vetting to identify positive, transferable behaviors. (We�re talking about nutrition programming now, but obviously, this methodology is useful in many different types of programming.) Behavior change: creating the context in which behavior change can occur, which in nutrition programming, leads to Hearth. Activity: Insuring that we all understand the concept : Everyone needs coffee in the morning. But someone in here doesn�t need it. Who is it, and how have they avoided addiction. Are there any other examples of positive deviance in our lives?

8. PD/Hearth in Indonesia June 2008 8 Hearth Adopting successful strategies identified in the positive deviance inquiry. 3 Goals: Rehabilitate malnourished children Sustain improved status Prevent future malnutrition Parents of malnourished children bring daily contributions of common, PD foods to a comfortable, informal setting. In Indonesia, they practiced together for an established time period, practicing cooking, active feeding, and other healthy behaviors identified in the PD inquiry. In Cenkareng Timur, they devised menus based on PD foods, providing extra protein and calories at low cost. Participants also created health communication activities allowing mothers to practice PD behaviors. Hearth sessions took place during 2 weeks over a one month period. Parents of malnourished children bring daily contributions of common, PD foods to a comfortable, informal setting. In Indonesia, they practiced together for an established time period, practicing cooking, active feeding, and other healthy behaviors identified in the PD inquiry. In Cenkareng Timur, they devised menus based on PD foods, providing extra protein and calories at low cost. Participants also created health communication activities allowing mothers to practice PD behaviors. Hearth sessions took place during 2 weeks over a one month period.

9. PD/Hearth in Indonesia June 2008 9 PD/Hearth in Indonesia New PD implementers trained and PD Network born in 2002 Vision = Government of Indonesia adopts PD as country-wide strategy August 2002 -- PATH organized a TOT including several INGOs and facilitated by Jerry SterninAugust 2002 -- PATH organized a TOT including several INGOs and facilitated by Jerry Sternin

10. PD/Hearth in Indonesia June 2008 10 Since the 2002 training, PD Hearth has been implemented across Indonesia from Aceh in the far West all the way to Papua in the East.Since the 2002 training, PD Hearth has been implemented across Indonesia from Aceh in the far West all the way to Papua in the East.

11. PD/Hearth in Indonesia June 2008 11 PD Network Indonesia Regular meetings to discuss lessons learned and share successes attended by INGOs, LNGOs, district and national health offices Jerry and Monique Sternin attended several meetings and gave additional TA Cross Visits Advocacy, Training, Publications Informal network, strengthened DAP consortium PD network has conducted several trainings together to build capacity of LNGOs, local government and other INGOs. In addition, the network produces a bulletin on current �goings on� in PD in Indonesia. You can access them at positivedeviance.orgPD network has conducted several trainings together to build capacity of LNGOs, local government and other INGOs. In addition, the network produces a bulletin on current �goings on� in PD in Indonesia. You can access them at positivedeviance.org

12. PD/Hearth in Indonesia June 2008 12 PD in Indonesia Network and Replication/Scaling up Challenges (2004) Lack of National �standard� for PD � confusing for government partners PD is the intervention �du jour� � partners want to implement regardless of conditions Government budgeting and planning mechanisms make planning for PD difficult In 2004 the network discussed the challenges to replication. Government complained that each NGO had their own �way� of implementing PD and called for a standardized methodolgy. While this is a good idea, because PD is community based and based on local successes, it is important not to make a cookie cutter approach. Another issue is that because PD is new and exciting everyone wants to implement it even if there is not appropriate i.e. at least 30% malnutrition. Saying �no� to a local partner who is really eager is proving difficult and frustrating and saying yes could mean poor results. In order to get local government to fund PD, it is vital to start a year ahead advocating for funds. These lessons learned lead to National Standards manual for PD being drafted by MOH with input from INGOs Better advocacy so that now most local government partners finance implementation of PD/Hearth A key �take away� was the overwhelming desire on the part of NGOs and government to implement PD and the need for training and capacity building In 2004 the network discussed the challenges to replication. Government complained that each NGO had their own �way� of implementing PD and called for a standardized methodolgy. While this is a good idea, because PD is community based and based on local successes, it is important not to make a cookie cutter approach. Another issue is that because PD is new and exciting everyone wants to implement it even if there is not appropriate i.e. at least 30% malnutrition. Saying �no� to a local partner who is really eager is proving difficult and frustrating and saying yes could mean poor results. In order to get local government to fund PD, it is vital to start a year ahead advocating for funds. These lessons learned lead to National Standards manual for PD being drafted by MOH with input from INGOs Better advocacy so that now most local government partners finance implementation of PD/Hearth A key �take away� was the overwhelming desire on the part of NGOs and government to implement PD and the need for training and capacity building

13. PD/Hearth in Indonesia June 2008 13 Suggestions for starting a PD Network Start with quality training of all partners Create standards for implementation Need good consultant or strong local �experts� with PD experience to keep PD on track Advocacy at all levels from the beginning Clear understanding of roles and responsibilities of each partner in network Recommendations after 2 years implementationRecommendations after 2 years implementation

14. PD/Hearth in Indonesia June 2008 14 Positive Deviance Resource Center Faculty of Public Health - UI Vision: Become a Center of Excellence of the PD Approach in Indonesia Mission: Strengthen:1. Education and training 2. Research 3. Community services http://www.pdrc.or.id Since 2007, the PD Network is being facilitated by the PD Resource Center at the University of Indonesia. They organize meetings and have a vision to become a center of excellence for the PD Approach. They have conducted the evaluation and hosted and the 2nd national workshopSince 2007, the PD Network is being facilitated by the PD Resource Center at the University of Indonesia. They organize meetings and have a vision to become a center of excellence for the PD Approach. They have conducted the evaluation and hosted and the 2nd national workshop

15. PD/Hearth in Indonesia June 2008 15 Second National Workshop on PD Five Years of Implementing Nutrition Programs Using the Positive Deviance Approach: Lessons Learned and the Way Forward 188 attendees Key issues identified: Evaluating and documenting current PD /Hearth programs is crucial for making further decisions as to where and how to implement PD. A standard training package must be used by all implementers to avoid common problems It is important to gather people from different parts of Indonesia with diverse PD experiences Evaluation planned and executed: CARE, CRS, Mercy Corps, Save the Children and World Vision contracted the Positive Deviance Resource Center and Judiann McNulty to conduct an evaluation of the PD/Hearth activities of all 5 USAID-funded INGOs. Began in March this year. Data analysis is continuing and a final report is still some weeks away, but preliminary results are available, which is what I want to spend the rest of our time on today. Evaluation planned and executed: CARE, CRS, Mercy Corps, Save the Children and World Vision contracted the Positive Deviance Resource Center and Judiann McNulty to conduct an evaluation of the PD/Hearth activities of all 5 USAID-funded INGOs. Began in March this year. Data analysis is continuing and a final report is still some weeks away, but preliminary results are available, which is what I want to spend the rest of our time on today.

16. PD/Hearth in Indonesia June 2008 16 Evaluation Partners: CARE, CRS, Mercy Corps, Save the Children, World Vision GOAL: Provide guidance to the Ministry of Health on using the methodology.

17. PD/Hearth in Indonesia June 2008 17 Evaluation: Preliminary Results Number of Communities: 168 Number of Hearths: 434 Number of Children: 7,836 Graduation Rate: 36 � 55% Some quick quantitative results # of communities by PVO: CARE: 20 CRS: 32 MC: 79 WV:29 SC: 8 Number of Hearths: CARE: 188 CRS: 32 MC: 157 WV: 45 SC: 12 # Children targeted CARE: 3141 CRS: 802 MC: 2169 WV: 1044 SC: 680 Graduation rate varied among PVOsSome quick quantitative results # of communities by PVO: CARE: 20 CRS: 32 MC: 79 WV:29 SC: 8 Number of Hearths: CARE: 188 CRS: 32 MC: 157 WV: 45 SC: 12 # Children targeted CARE: 3141 CRS: 802 MC: 2169 WV: 1044 SC: 680 Graduation rate varied among PVOs

18. PD/Hearth in Indonesia June 2008 18 Evaluation: Preliminary Results Overall, 45.6% of children who entered the Hearth gained sufficient �catch up� weight over one month. The Hearths were 2 weeks in length, so the time period includes the time children were participating intensively in the Hearth as well as when they return home and mothers are practicing behaviors in their home with less intensive support from health volunteers. The Hearths were 2 weeks in length, so the time period includes the time children were participating intensively in the Hearth as well as when they return home and mothers are practicing behaviors in their home with less intensive support from health volunteers.

19. PD/Hearth in Indonesia June 2008 19 Evaluation: Preliminary Results Hypothesis: Children who are more malnourished respond better to this kind of intervention. We are not presenting the success rates for each NGO, so know at least anecdotally that more children gained weight in the CRS areas. These were the only rural areas and they had the most malnourished children. In all other sites, a lage proportion of children are either mildly malnourished or well nourished when they enter the Hearth. Overall, about 40% of participants are well nourished or mildly malnourished, which may be affecting the rates of weight gain. This has generated some argument that only moderately and severely malnourished children should be in the Hearth. We are not presenting the success rates for each NGO, so know at least anecdotally that more children gained weight in the CRS areas. These were the only rural areas and they had the most malnourished children. In all other sites, a lage proportion of children are either mildly malnourished or well nourished when they enter the Hearth. Overall, about 40% of participants are well nourished or mildly malnourished, which may be affecting the rates of weight gain. This has generated some argument that only moderately and severely malnourished children should be in the Hearth.

20. PD/Hearth in Indonesia June 2008 20 Evaluation: Preliminary Results Factors identified with success: Rural Complementary activities De-worming Frequency of staff support Frequency of home visits Rural influence mentioned previously� Complementary activities: Positive deviance is not just Hearth. Implementers tended to implement hearth only and not find other channels for communicating PD messages. This limited the audience for the messages to mothers with malnourished children. We have learned that social support/pressure is a key enabler of behavior change. If neighbors/friends/family members are not exposed to new strategies/messages, it will be hard for families to maintain behavior change at home. De-worming: Health exams important for children before they start Hearth activities. An underlying health issue could prevent weight gain even with improved diet. The evaluation showed that de-worming in Indonesia increased success (in terms of weight gain) Staff support: One-off training is not enough. On-going mentoring and supervision of community health workers (kaders) are essential. Key skills for kaders: Counseling, guiding principles for infant/child feeding, problem solving with mothers, conducting effective home visits, referral and follow-up of sick children. Continual reinforcement of PD concepts also required. Recommendation: Each kader visited 2-3 times a week when they first start Hearth activities. Rural influence mentioned previously� Complementary activities: Positive deviance is not just Hearth. Implementers tended to implement hearth only and not find other channels for communicating PD messages. This limited the audience for the messages to mothers with malnourished children. We have learned that social support/pressure is a key enabler of behavior change. If neighbors/friends/family members are not exposed to new strategies/messages, it will be hard for families to maintain behavior change at home. De-worming: Health exams important for children before they start Hearth activities. An underlying health issue could prevent weight gain even with improved diet. The evaluation showed that de-worming in Indonesia increased success (in terms of weight gain) Staff support: One-off training is not enough. On-going mentoring and supervision of community health workers (kaders) are essential. Key skills for kaders: Counseling, guiding principles for infant/child feeding, problem solving with mothers, conducting effective home visits, referral and follow-up of sick children. Continual reinforcement of PD concepts also required. Recommendation: Each kader visited 2-3 times a week when they first start Hearth activities.

21. PD/Hearth in Indonesia June 2008 21 Evaluation: Preliminary Results Factors identified with success (cont.): Community health workers and health clinics understand key PD/H concepts Leaders know the causes and consequences of malnutrition and support Hearth activities. Kader= community health volunteers Puskesmas= sub-district level health center Leader involvement: The evaluation found that overall, the PD/Hearth activities in Indonesia needed to better engage community leaders in the process. The evaluation seems to show that there�s a much larger role for these stakeholders, especially for recruiting volunteers, conducting the PD inquiry, contributing material input (such as food, utensils, etc), and encouraging other community members to support families with malnourished children in adopting new practices. Kader= community health volunteers Puskesmas= sub-district level health center Leader involvement: The evaluation found that overall, the PD/Hearth activities in Indonesia needed to better engage community leaders in the process. The evaluation seems to show that there�s a much larger role for these stakeholders, especially for recruiting volunteers, conducting the PD inquiry, contributing material input (such as food, utensils, etc), and encouraging other community members to support families with malnourished children in adopting new practices.

22. PD/Hearth in Indonesia June 2008 22 Evaluation: Preliminary Results Group Discussion

23. PD/Hearth in Indonesia June 2008 23 Evaluation: Preliminary Results Discussion

24. PD/Hearth in Indonesia June 2008 24 Evaluation: Preliminary Results Remaining data to explore: Factors for rural success Further analysis on sustained status Qualitative findings relevant to MoH Sustainability of behavior changes On Sustainability: The theory says that the next generation of �siblings� should be better nourished (not stunted).On Sustainability: The theory says that the next generation of �siblings� should be better nourished (not stunted).

25. The End Thank you! If you�d like a copy of this presentation, please email me at cbergman@mercycorps.org.