The Hearth Nutrition Model is a relatively new and holistic approach to community-based nutrition rehabilitation. Hearth begins with Positive Deviance surveys to ask the question, “How do some poor families have well-nourished children when their neighbors do not? That is, what is their “deviant” behavior?” The Hearth method then generalizes and promotes Positive Deviance findings to the rest of the community.

The Hearth model involves mothers, families, and neighborhoods in rehabilitating their own malnourished children by using local foods and knowledge. Growth monitoring and counseling, de-worming, and micronutrient supplementation are usually an integral part of Hearth. The goal of Hearth is not only to rehabilitate the participating children but also demonstrate to the importance of good feeding practices. This helps to reduce the prevalence of childhood malnutrition in the community and to energize the mothers and community to take broader, sustained action against malnutrition and poor health.

The Hearth approach was initiated in Bangladesh in the early 1990s by World Relief Corporation and the Christian Service Society as part of a PVO child survival program, in Haiti by the Albert Schweitzer Hospital, and in Vietnam by Save the Children (U.S.) and the local government. An evaluation of the Haiti program indicates that, while the short-term rehabilitation of severely and moderately malnourished children was highly motivating to mothers, the most important long-term impact of the program was the prevention of nutritional deterioration in mildly malnourished children. NGOs are successfully using Positive Deviance and Hearth methodology in more than twenty countries (CSTRM).

The Hearth Approach in Vietnam

Save the Children in collaboration with more than 250 communities used the Hearth approach and local resources in Vietnam to rehabilitate an estimated 50,000 malnourished children from 1991 to 1999. This Hearth
program consisted of:

• Identification of successful behaviors among families through Positive Deviance inquiry.

• Weighing of all children in the target group, monthly or every other month, as part of a growth monitoring and promotion activity.

• Monthly nutrition education and rehabilitation sessions for identified malnourished children and their caretakers in local kitchens run by community members.

• Community management of the Hearth Program through meetings of the Village Health Committee, monthly or every other month.

• Vital Events Monitoring. 

Positive Deviance practices identified in Vietnam included the addition of shrimps/crabs and greens to a child's diet, increased frequency of feeding, good hygiene, and timely health-seeking behavior. In the program communities, moderate and severe malnutrition in children under age 3 was reduced by an estimated 55% to 85%. Of even greater significance, their younger siblings, many of whom were not yet born at the time of the nutrition program implementation, are benefitting from the same levels of enhanced nutritional status. Simply stated, Positive Deviance provided a tool for radically changing the conventional wisdom regarding nutrition and child-caring practices in these communities (Sternin, Trinh).

The Hearth Approach in Mozambique

The Hearth strategy for the Vurhonga Child Survival project in Chokwe, Mozambique included a two-week period of home-based teaching and coaching of mothers to feed their undernourished children an enriched porridge (identified by a Positive Deviance survey) made of locally available foods. Hearth children also received vitamin A, iron supplements and an anti-helminthic treatment.

This nutrition program was based on monthly weighing sessions to identify low weight-for-age “at risk” children. Most  Vurhonga volunteers and animator-trainers felt that Hearth was their most important intervention, because it cut across development areas – from infancy, through pregnancy and childbirth to the lactation and weaning period.

The key nutrition indicators were the proportion of children who were regularly weighed and the proportion of mothers with growth-faltering children who received nutrition counseling. The percentage of children weighed during the previous three months increased from 58.6% at baseline to 91% at the time of the final Knowledge Practice & Coverage (KPC) survey. Nutrition counseling provided to mothers of underweight children increased from 20% in 1995 to 87% in 1999.

The first two Hearth cycles were attended by 2,000 malnourished children and mothers. During the second two-week Hearth cycle, over 80% of the children attained adequate growth with an average weight gain of 471g. The table below demonstrates both the effectiveness of the Hearth program as well as Vurhonga's learning curve in applying lessons learned in the first Hearth cycle. The attendance at the Hearth sessions improved considerably from the first to the second Hearth, and that is reflected in the improved weight gain of the participating children. 
  

Vurhonga Results for Hearth 1 and 2
Level of Participation	Hearth 1	Hearth 2
Number of Children beginning Hearth	934	1071
Percent who attended 12/12 days	32%	44%
Percent attending at least 9/12 days	NA	83%
Degree of Malnutrition at the beginning of Hearth
First	75%	82%
Second	18%	13%
Third	7%	4%
Weight Gain by the end of Hearth
Inadequate (<200 g)	33%	19%
Adequate (200-400 g)	30%	29%
Catch-up (>400 g)	37%	52%
Average weight gain per child	NA	471g

  
After the Hearth, only 6% of the mothers attributed their children's malnutrition to lack of food. Instead, the mothers felt that the causes of malnutrition were in their power to control. With prompt treatment of childhood diseases, and maternal education and encouragement, the mothers said they could control malnutrition in their children (Baer).

A Final Note

It is important to note that, while enriching the porridge may be applicable elsewhere, it is not the universal answer; e.g., in Vietnam one of the extra foods turned out to be little crabs gleaned from the rice paddies. It is important to understand that Hearth is not as much about a pre-set menu as it is about the process of working with mothers to learn what is available in their community, teaching them to make and incorporate the extra foods into their children's diet, and enabling the community to recognize malnutrition for what it is (e.g., poor diet vs. spiritual origin), so they can treat it in their homes.
 

References:

Baer, F. et al. The Vurhonga Child Survival Project: Final Evaluation, Aug. 1999. World Relief, 2000. See also “Vurhonga- A New Dawn” in “The CCIH Forum” issue #1) 

CSTRM: Child Survival Technical Reference Manual, USAID Bureau for Humanitarian Response, Office of Private and Voluntary Cooperation; Dec. 2000.

Sternin, M., Sternin, J., Marsh, D.R.; Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach – A Field Guide. Save the  Children. 1998;

Trinh, A., Marsh D.R., Schroeder D.G. Sustainable Positive Deviant Child Care Practices in Vietnam. Submitted to Am. J. Public Health. 2000.2

Wollinka, O., Erin Keeley, Barton R. Burkhalter, and Naheed Bashir; Hearth Nutrition Model: I. Applications in Haiti, Vietnam, and Bangladesh.