Sonia Blaney, Ph.D., Dt - Positive Deviance

Positive Deviance for nutrition in
Dzanga-Sangha Protected Areas,
Central African Republic (CAR)
A pilot project of WWF and CAR Ministry of Health
Sonia Blaney, Ph.D., Dt.p.
UNICEF-Indonesia
Positive Deviance Forum
Bali, 19-21 January 2010

Outline
• Context
• Description of the health and nutrition project
• PD process
• PD results
• PD follow up
• Lessons learned

CAR: Landlocked in the fragile centre of Africa
Chad
Sudan
Nigeria
Darfur
Cameroon
CAR
Rebellion or internal conflict
Source: Hamburg University
Gabon
Congo
DRC
Uganda

CAR: A fragile state, left behind in a violent
region
Of the 10 bottom countries on the HDI, only CAR and DRC haven’t advanced since 1985
Human Development Index (HDI) Growth, Base = 100 (1985)
Burkina Faso, Niger, Guinea-Bissau,
Mali, Mozambique, Chad, Ethiopia
CAR
DRC
+45%
+30%
+15%
100
-15%
1985 1990
1995 2000 2004
Source: HDR (2007)

Central African Republic…
• One of the poorest country in Africa: GDP: $328/year/cap, (UNDP, 2007)
• Human Development Index: 172/177 countries (UNDP, 2007)
• Life expectancy: 44 years (UNDP, 2007)
• Under-five mortality: 173/1000
• Stunting prevalence: 43%, Wasting: 12%, Underweight: 29% (UNICEF,
2010)
• Natural resources are an important food source in rural areas

Dzanga‐Sangha Protected Areas location

• Population:
– 6,188 inhab.; CU5: 1,426 (23%); PW: 191 (3%) (WWF/GTZ, 2007, 2008)
– Different ethnic groups: Ngaya (29%) and BaAka (23%) (Kamisse, 2007)
– One town (Bayanga) and 6 villages
• Undernutrition rate among CU5 (Bayanga):
– 44% stunted, 21% underweight, 5% wasting (WWF/MoH, 2008)
• Care practices among children and women
(Health center statistics, 2008)
– Immunization coverage: BCG: 43%, DTP3: 77%, Measles: 71%
– < 50% of PW with > 1 ATV, 75% with IFA, 46% malaria prevention
(amodiaquine), 7% of PW < 18 y.o.
– No data on feeding practices

• Access to health:
– I health center (Bayanga) and 2 health posts, 1
trained nurse, 4 health agents, one TBA
– Bayanga: 1 safe water site; Villages; 5/5 with at
least 1 safe water site

Health/nutrition project(1)
• Before December 2007:
• Use of funds (similar activities from one year to another) for
health and nutrition activities to cover treatment fees of
pop., no defined objectives
• No joint planning with stakeholders (communities, line
ministries, NGOs)
• Early 2008: Review of project objectives and workplan
• Meeting with communities
(e.g. Bayanga chiefs) and MoH rep.
(department)

Health/nutrition project(2)
(and PD initiation)
• Implementation of project activities
• Census of all children under‐five (CU5) and pregnant women
• Assessment of nutritional status of CU5
• Capacity‐building: GMP and IYCF counseling, planning and budgeting
• Immunization support (logistics)
• Malaria prevention
• Development of IEC materials
• Monitoring and evaluation
• Supply (scales, bednets, boards, drugs)
• Support to the establishment of a
revolving‐fund to ensure sustainable drug
supply
Meeting with communities on how to address undernutrition
(based on results and UNICEF framework)
Bongoville: 22%; Jolisoir: 24%
Introduction to the PD approach in 2 neighborhoods

PD process (1)
• Training of health personnel on PD (9 health center
staff and 3 community health agents)
• Creation of a health village committee (including
criteria for selection of members, definition of the
job description, recruitment of the 5
members/committee)
• Orientation and training of health committees
members on PD (2)
• Preparation of PD survey
• Review of secondary data on health and
nutrition
• Development and pre‐test of tools such as
observation grids and questionnaire
• Mapping of communities (e.g. type of houses,
infrastructures, access, location of U5 and PW,
etc.)
• Wealth ranking of households, calendars of
food availability, market survey

PD process (2)
• Implementation of the PD survey:
• Identification of health resources in the communities (healer, TBA, retired health
staff, vendors)
• Interviews and observations amongst 10 HHs at meal time during the evening (same
socioeco characteristics but with U5 well and undernourished based on underweight
results) per neighborhood (see grid)
• Data analysis to identify good and poor behaviors
• Good behaviors: exclusive breastfeeding in the first 6 months of life, encouragements to
the child to eat at meal time and, bathing young children twice a day
• Poor behaviors: traditional treatment of diarrhoea (‘lavement’), hand washing without
soap before meal, insufficient number of meals (1‐2 on a daily basis) and lack of animal
source of food in child diets
• Meetings with the communities (e.g. leaders, parents) for feedbacks and
implementation of PD
• This includes the selection of two key and “feasible” behaviors to be adopted during PD
period and maintained in the future (hand‐washing of child and mother with soap before
giving meal and ensuring 2‐3 meals per day to the child)

PD process (3)
• Design of PD sessions along with mothers, fathers, leaders, health committees
– Agreement on number of foyers based on results on undernutrition (Bongoville: 40,
Jolisoir: 23 children with weight‐for‐age < ‐2 z‐scores)
– Agreement on criteria of success (400 g after 12 days) and criteria for refusal (2 days
of absence, no attendance of mother/father) to the foyers
– Selection of the volunteers mothers (2/foyer, 5 foyers)
– Planning of PD menus with focus on local available food
– Planning of IEC sessions (definition of topics, preparation of materials, see schedule)
– Additional intervention agreed: deworming
– Agreement on contribution of each “stakeholder”:
• Contribution of project to the purchase of cooking pots and utensils (one set per
foyer, kept at the chief place) and contribution to the purchase of meat/chicken
• Contribution of the neighborhood: safe water
• Contribution of health center: dewormers
• Contribution of mothers: provide food such as oil, vegetables, staple food, fruits,
peanut paste, etc.
• Contribution of health committee members:
• Home visit for deworming (day 1) and daily collection of food from the mother
• Mid‐day visit to get the mothers coming on time to PD session
• Organization of PD session (e.g. purchase meat/chicken, ensure that
materials is available on time, complete, clean, hand‐washing, etc.)

PD process: Sessions (1.5 hours)
• Greetings of mothers by health committee members
and health staff
• Weight measurement of children and questions about
illnesses and meals pattern in the past 24 hours
• Installation of the mothers/children
• IEC sessions accompanied by encouragements of
mother to put in practices the two selected healthy
behaviors
• Hand‐washing with soap of children and mothers
• Consumption of meal with help of mothers/fathers
• Hand‐washing with soap and return to home

Results
• On total, 5 PD groups:
– 60 children for the 12‐day period (attendance 95%)
– Bongoville: 76% and Jolisoir: 50% of children gained weight (400 g)
– Cause of “limited” success:
• A child can not eat too much: “if he has eaten well at noon, he does not
need another good meal in the evening”
• Mother availability to prepare food for the evening meal, Jolisoir vs
Bongoville: more HH involvement in agriculture
• No late evening meal: the child was sleeping
– Follow up (monthly GMP)
– Most of them (55) did not lose weight after the PD sessions but maintained
or kept gaining weight
– Promotion of appropriate IYCF (in particular, number and composition of
meals) and hand‐washing with soap

Post PD activities (Bongoville and Jolisoir)
• Health services:
– Monthly monitoring by health center chief of supply and revolving fund to ensure
sustainability (e.g. vaccines, dewormers)
– Unicef continuous support in bednets supply (for PW and newborns)
– GMP at community level and health center/post accompanied by IEC sessions and
counseling to parents on IYCF, distribution of bednet
– Update with MoH on project activities and results (department and provincial levels)
– Support to the establishment of mother groups
• Village chiefs and health committees:
– Support to monthly GMP session at community level and health post, follow up of
children with undernutrition (support to identification of HH challenges, discussion with
families and in particular with the head of HH, encouragements)
– Development of a community micro‐ POA with the objective of improving health/nutrition
of children and mothers (use of other funds)
• Mothers:
– Advocacy to their peers for improvement of feeding practices
– Formation of mother support groups (2) for the promotion of breastfeeding (Pregnant and
breastfeeding mothers)

Lessons learned
• Involvement of parents, local authorities and MoH essential in
all steps of the process
• Knowledge of local context (e.g. populations, customs and
beliefs, etc.) indispensable
• Establishment of a “trust” relationship
• Selection of appropriate “team members” (e.g. trained and
motivated health staff as well as motivated mothers,
motivated health committee members)
• Proper training and follow up
• Dissemination of results at all levels (e.g communities,
department, donors)
• Potential to lead to other types of projects/partnerships

Overall project result
Undernutrition in Bayanga,
% children 0-59 mo (n=496) with score Z ≤ -2, weight/age
May-September 2008
35
30
25
20
15
10
Mai
Juin
Juillet
Août
Sept
National rural
National urbain
5
0
Beretia Assabisse Mokoko Bomitaba Bongo Ville Jolisoir Bayanga National
2006