1. Community Transformation in Bolivia & Mozambique through a Behavior- change Focus and Targeted Food Aid Presentation for the 2007 International Food Aid Conference Tom Davis, MPH Director of Health Programs, FH

2. Who are the “Producers” or “Generators” of Health and Nutrition in Young Children? In any system, there are producers. The producers of health and nutrition should be the people whose actions have the most impact on health and nutrition outcomes and the health and nutrition status of a population. Who are they? Physicians, nurses, CHWs, Administrators? We will briefly examine our assumptions.

3. What are the “production tasks” that relate to the burden of disease concerning Undernutrition? food production/purchase and storage; dietary selection and meal preparation; family food allocation; dietary practices in pregnancy and postpartum; breastfeeding and complementary feeding practices; etc. Production tasks: WHO MAKES THESE DECISIONS AND TAKES ACTION ON THESE THINGS? WHERE DO THESE THINGS HAPPEN? WHAT IS NEEDED TO DO THEM? Family members (mostly mothers) at the household level, using the values (e.g., food allocation), knowledge (e.g., dietary selection), skills (e.g., breastfeeding), and to a lesser degree, physical resources (e.g., food) that they have available.

4. Malnutrition demands a focus on the first two years of life.

5. The Positive Deviance Principle PD Principle: Almost everywhere, a portion of children born to poor families are well nourished. One key: Find the differences in values, skills, and behaviors between poor mothers with thriving children and poor mothers with malnourished children. Promote the values, skills, and behaviors of the families that are thriving despite their poverty. PD in Vietnam: More than 250 communities brought an estimated 50,000 malnourished children out of malnutrition from 1991-1999. Children born after the PD workshops were less malnourished. The PD Principle is seeing the glass half- full.

6. What needs to happen to reduce malnutrition

7. Where has this led FH in its thinking? Changing values, motivations, beliefs, and behaviors at the household level are central: Persuading members of households, especially mothers, to do things differently and to think about things differently, in order to be more resourceful. 80% or more of what we do should be targeted at these tasks. Example of thinking differently: Barrier Analysis in Bolivia (see http://barrieranalysis.fhi.net) found that mother’s believed that the common cold was more serious than malnutrition.http://barrieranalysis.fhi.net We need to operate more as Teachers and Persuaders rather than Doctors & Logisticians: Focus primarily on helping people to change rather than giving resources or supervising people to get tasks done. Use high-quality behavior change tools and methods.

8. Where has this led FH in its thinking? Approaches to improving health/ nutrition based primarily in health facilities should be ruled out. Approaches that rely mostly on adding physical resources (e.g., food, cash) should be ruled out. Food should be used in a targeted way, as an incentive for behavior change (e.g., attending), and as a supplement.

9. Importance of Integrating Approaches Some Reasons for Integrating Programs: Each sector supports other sectors (Ex: production of vitamin A rich foods enables mothers to diversify the child’s diet; NRM leads to higher agricultural yields) Increasing productivity and income without changes in values and skills will not necessarily lead to changes in health and nutritional status. Water and sanitation is highly linked with nutritional status. Ex: Mozambican children whose mothers said that their drinking water was purified were 3.6 times more likely to be well nourished. (p=0.03)

10. Evidence of Approach: Two Examples Bolivia Integrated Food Security Project, 2002-2006 Mozambique Integrated FS Projects, 1997- 2004

11. FH/Bolivia Target Areas Areas of Extreme Food Insecurity 410,000 total beneficiaries 5 % of Bolivia’s population DepartmentMunicipality Potosí Ravelo Ocurí Toro Cochabamba Capinota Tapacarí ChuquisacaSucre 212,290 direct beneficiaries 7 Municipalities 2 Cities; 260 Communities

12. Integrated Approach Household Food Security Improving nut. practices through GM/P and CHW training, PD/Hearth model, WATSAN improvements, IMCI, food rations). + Separately- funded Child Development Program Technology transfer, improved infrastructure and market access (esp. improved roads+irrigation), marketing TA, capitalization. Education, health, other community actions Micro-watershed management

13. Exclusive Breastfeeding A 34% increase in exclusive breastfeeding.

14. Oral Rehydration Therapy An 85% increase in oral rehydration therapy (ORS, RHFs, or increased liquids).

15. Prenatal Care 76% increase in prenatal care.

16. FH/B: Health Impact Indicator 36% drop in malnutrition in five years. (Most change in first two years.)

17. Did Food Rations Contribute to the Decrease in Malnutrition? Study examined differences between 2004 (n=683 children 3-35m) and 2002 baseline study (n=451 children 3-35m)Study examined differences between 2004 (n=683 children 3-35m) and 2002 baseline study (n=451 children 3-35m) 24.3% decrease in malnutrition at that point.24.3% decrease in malnutrition at that point. 40.4% of children in families who received rations were chronically malnourished in 2004 vs. 47.3% of children whose families did not receive rations. This 7% percentage point difference was not statistically significant (p=0.09).40.4% of children in families who received rations were chronically malnourished in 2004 vs. 47.3% of children whose families did not receive rations. This 7% percentage point difference was not statistically significant (p=0.09). Regardless, rations were a big incentive for much of the other work (e.g., NRM, roads).Regardless, rations were a big incentive for much of the other work (e.g., NRM, roads).

18. Watsan: Handwashing

19. Watsan: Access to Improved Water Source 106% increase in water access

20. Agriculture Impact Indicator Agricultural Income Generation 170% increase in household income

21. Agriculture Income Generation More than doubled target.

22. Income Generation Activities: Road Improvement 154 Km of roads were improved, strengthening the linkage to markets and commercialization of agricultural products. 4,500 families benefited directly through these projects, and 10,000 families benefited indirectly

23. NRM: roads improvement BEFOREAFTER Farmers and those improving roads are encouraged to work with food rations. The monthly ration was given for 9 days work (72 hrs.). About 2,500 families have received an average of 4 rations per year.

24. NRM: Improved soil/water management Natural Resource Management 26 fold increase in soil and water management practices. Beneficiaries : 37,342 persons, 15,556 families in 162 communities from 5 municipalities in the Departments of Cochabamba and Potosí.

25. NRM: River Defensive Walls In 4 years of intervention, 1,400 lineal meters of defensive walls have been built up. 55 hectares of agricultural land were recovered from riverbeds and is now currently in production. An additional 80 hectares of productive lands have been protected.

26. FFW in Sucre: 84% Municipal Investment Share Ration costs (Bs) Rations USAID Investment (Bs) Municipal Counterpart (Bs) Municipal Investment Labor and Materials (BS) Final USAID investment (Bs) TOTAL Investment (Bs) 215.11,418.0305,011.830,501.21,392,952.1274,510.61,697,963.9 1.8%82.0%16.2%100.0% INVESTMENT RELATION (%) 83.8%16.2% Final USAID Investment ($us) 33,890.2 Families Directly Benefited6,760.0 Families Indirectly Benefited1,418.0 Women participation81.21% Men participation18.79% Implemented Projects14

27. Mozambique Food Security Project Health Results, 1997-2000 & 2000-2004  Groups of 12 HH established with mothers of children 0-59m of age or pregnant women.  One Leader Mother (LM) is elected to represent each group of 12 HH.  10-14 LMs meet biweekly in the Care Group to learn from the paid Promoter, and then do health promotion in “their” households.  Intensive behavior-change effort: LMs receive 104 hours of training/year. Beneficiary mothers receive 13+ hours of training/year.  Health messages/activities improved through positive deviance studies. 100% monetization Care Group approach for health/nutrition program with strong focus on changes in behavior and values: Agriculture program focused on agricultural extension, applied and adaptive research, farmer’s associations and agribusiness development

28. Care Groups: A Multiplier Model for Health Promotion HP #4 HP #2 12 Leader Mother 10 families HP #3 Health Promoters Each Health Promoter educates and motivates 10 Care Groups. Each Care Group has 12 Leader Mothers. 10 families HP #1 HP #6 10 families 12 Leader Mother Each Leader Mother educates and motivates other mothers with children 0-59m of age and pregnant women in 10 households. Care Groups With this model, one Promoter can cover 1,200 children 0-59m + pregnant women. 12 Leader Mother HP #5 12 Leader Mother

29. Children receiving ORT...

30. Exclusive breastfeeding...

31. Vitamin A coverage...

32. Deworming...

33. Diarrheal prevalence...

34. Malnutrition (stunting, stat. sig.)...

35. Malnutrition (severe stunting, stat. sig.)...

36. Other factors that may have contributed to the Mozambique Care Group Results Mothers were trained to start or expand kitchen gardens where they grow vitamin A rich vegetables Agricultural production program interventions were conducted in the same communities as the health and nutrition program.

37. Decrease in Child Mortality, 2000-2004: A study by Johns Hopkins University (conducted in conjunction with World Relief and Food for the Hungry) found that child deaths decreased by 62% in areas where the Care Group approach was used.

39. What about cost per beneficiary and sustainability??  Cost per beneficiary for health activities was $4.50/benficiary/year.  WR CG project sustainability data:  93% of the volunteer Leader Mothers (LMs) were still active twenty months after the project ended.  Communities, on their own, replaced 40 of the 132 vacant volunteer positions. Remaining LMs trained new Leader Mothers and gave them educational materials.  Women in half of the households surveyed reported that their Leader Mother had visited their household within the last two weeks.

40. Sustainability of Final Indicator Levels at 30m and 48m Post-Project in the WR-Mozambique Care Group Project: Home Care of Sick Children End of Project Goal Actual

41. Conclusions 1.Efforts to change behavior and values need to be central to our programming efforts to achieve program impact. Significant contact time with beneficiaries is required for high levels of behavior change. 2.Understanding coping mechanisms through positive deviance studies can improve messaging and results. 3.Integrated programming may lead to more significant gains. 4.Food rations can play an important role as incentives for program participation and as nutritional supplements.