Gretchen Berggren has dedicated most of her life to children survival in the developing world and especially in Haiti. She was a health advisor at Save the Children when she introduced the Sternins to the work of Marian Zietlin and others on the use of Positive Deviance in Child nutrition. In Viet Nam, she provided invaluable advice and coaching on growth monitoring and other technical aspects of childhood nutrition. She also made an evaluation of the project in 1995. Dr. Berggren introduced the learning cycle theory or “learning by doing” to enable the caregivers of malnourished children to rehabilitate their children together at a special session in a neighbor house where they practiced PD feeding, caring, health-seeking and hygiene behaviors. This learning cycle took place through 12 sessions over a 2 weeks period. The Sternins introduced a special “6th day” where the caregivers fed their children only the food they contributed to the extra meal and where the behavior change message was;” Tomorrow (7th day) you will be at home with your child. Make sure to practice what you have learned together during this week. See you next week.” Dr. Berggren shares her insight here.
Introduction:
Working with Jerry Sternin and his wife, Monique Sternin under the auspices of Save the Children, USA, and later with Muriel Elmer, a nurse-specialist in behavioral change training was a great privilege. My husband, Dr Warren Berggren and I, had been involved with organizations that focused on nutrition rehabilitation and training of mothers of malnourished children from 1967-87, at first in Haiti and then world-wide. Our insight into why and how to approach the problem of malnutrition in under-fives took a new turn from Dr Marion Zeitlin’s insight that there were always, even among the poorest of the poor, some well-nourished under-fives. She dubbed them “positive deviants”, and urged follow-up to better understand and then allow other mothers to be enrolled in a training method to adopt their practices. These “positive deviant” mothers, even in the poorest areas, not only knew the least expensive way to provide a relatively well-rounded diet, but they provided care for children suffering growth faltering, often due also to infections that needed early detection and treatment. Their children’s home-based “weight-for-age growth charts” gave testimony to the need for child-hood “catch-up growth” after treatment of infection. Such “catch-up growth,” experts had already pointed out, was seen commonly in children in industrialized countries but was often lacking in the children of mothers in poor areas of developing countries. The end result for the latter were children whose growth and development, seriously hampered, could and would lead to faltering growth and even early demise.
Lessons Learned from “Positive Deviant Mothers” and Behavioral Change Intervention:
A looming problem at first was how to transfer the knowledge and practices of the successful “positive deviant” mothers to mothers of children beginning to suffer malnutrition and growth faltering. The answer was allowing such mothers to practice, practice, practice! With their hands and with their hearts! And in their own villages, surrounded by supportive health workers! And, as we and the Sternins discovered, in many developing countries, this could be done in the homes of volunteer mothers or grandmothers who, to our great surprise, in Haiti they would allow use of hearths and homes as a place for mothers to practice, once they had discussed and comprehended the need. The growth-faltering children, once rehabilitated, often remained in better health, and as the Sternin’s showed, severe growth faltering began to disappear on a village-wide basis.
A remaining question was: “Why and how did this work?” The answer was spelled out later by Muriel Elmer, a nurse whose worldwide experience had brought her insight into the “adult learning cycle” (see below). The village level “training sessions” for mothers of malnourished children was not just knowledge transfer, but, because it offered a chance to practice new nutrition behaviors (plus or minus 21 times) in the presence of other mothers, it led to feeding-practice behavioral change. It also began to answer the question: How long should this take? Here we corroborated the work of Dr Jane Vella, a behavioralist, whose experience in Africa taught her that behavior changes come best if one is allowed to practice a new behavior “at least 21 times!” Anyone who has tried to teach cooking arts will usually nod in agreement! Julia Child, a famous teacher of the art of cooking, would insist that to teach one how to, for example, bone a chicken, you would learn best if she stood beside you helping with every step. And the more often you practiced, the more skilled you became.
So why does this work and why is it necessary? An explanation came from the work of Muriel Elmer and her husband, both specialist in human behavioral change.
The “learning cycle” is described as follows by Muriel Elmer and her husband as follows:
Especially in the area of nutrition, instead of allowing mothers to “ practice practice, practice” (as above), health educators may simply use pictures on a flip chart, tell the mothers of malnourished children what to do, and then disappear. What a difference, if, as depicted above, mothers have a chance to, for example, puree the beans rather than feeding whole beans to her child day after day (even if it takes extra time and effort) until it becomes a habit.
The next question is how to reach all the mothers most in need of such training. Village health workers may do their best, but often mothers most in need are left out. A lesson from the experience of World Relief, in reaching “all the mothers” is to begin by doing a simple map. House numbering, and registration, allowing all mothers to be invited to, for example, a village “weighing exercise” under the direction if a trained health worker who forms “care groups.” From such groups one finds the volunteer mothers who are willing that their “hearth and home” can serve for 2 to 3 weeks as a training ground for practice.
Conclusion:
The above depiction implies that, instead of simply “setting up camp” in a village or villages and seeing the sick children and pre-supposing that “all the children are reached”, one looks for and trains (ahead-of-time) volunteers who can see that “all the children” are in growth monitoring groups. Thus, through growth monitoring (regular wt/age/supine length measurement), one can identify the children suffering growth faltering whose mothers are most in need of practicing nutrition behavioral change under the guidance of trained health workers. These “mini training sessions” in volunteer homes were called “hearths” in World Relief’s and Save the Children’s experience, especially in rural African villages Many mothers of malnourished children were provided 2 week nutrition training (in small groups in volunteer homes). The lessons taught came from the previous study of the “positive deviant” mothers.