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

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.


Positive Deviance Forum

Bali, 19-21 January 2010


• 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







Rebellion or internal conflict

Source: Hamburg University





CAR: A fragile state, left behind in a violent


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








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,


• 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.


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


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


• Orientation and training of health committees

members on PD (2)

• Preparation of PD survey

• Review of secondary data on health and


• 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,


• 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


• Hand‐washing with soap of children and mothers

• Consumption of meal with help of mothers/fathers

• Hand‐washing with soap and return to home


• 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












National rural

National urbain



Beretia Assabisse Mokoko Bomitaba Bongo Ville Jolisoir Bayanga National


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