Sustainability Using Positive Deviance/Hearth to Address Childhood Malnutrition in Burundi

Children under the age of five in resource-poor countries have a decreased life expectancy. Many causes of morbidity and mortality are exacerbated by malnutrition. To address this need, agencies often import milk and oil to treat malnourished children. This is unsustainable. Leininger’s Cultural Care Model invites nurses to clearly identify which local practices need to be preserved or which need to have modification, either through negotiation or re-patterning.  Two main interventions were implemented simultaneously in Burundi (East Africa) over a five year period (2007-2012): care groups and positive deviance/hearth (PD/H). Men and women were selected by their local communities to be trained in primary health care as care group members. They were given the responsibility to teach their neighbors healthy behaviors. In order to build on the concept of positive deviance, care group members identified impoverished but well-nourished children. Parents of these children were then interviewed to determine what nutritional practices they used. Based on the results of this inventory, care group members then taught mothers of malnourished children how to incorporate these affordable and culturally appropriate practices. This helped preserve healthy habits and gave them an opportunity to teach mothers of malnourished children ways to modify their feeding practices.

Quantitative data was collected using the KPC 2000 survey and analyzed with EPI INFO. Focus groups with mothers, community elders and stakeholders provided qualitative data. At baseline, 16% percent of the children aged 0 – 23 months (n = 13,376) were underweight. Malnutrition increased to 36.5% at midterm. This seemed to be due to all members of the care groups having the responsibility of monitoring malnourished children. Monitoring children in PD/H was thus delegated to one mother per care group. At end of project, the rate had dropped to 4.2% (n = 18,330).

Children maintained weight gain for more than 2 months. Sustainability was accomplished by embedding PD/H into care group activities. Members supported their neighbors in changing their nutritional practices, thus fostering long term behavior change. Factors which impact malnutrition also changed: diarrhea and malaria rates decreased, and, immunization coverage increased. Three unexpected outcomes occurred. The Ministry of Health (MOH) instituted a new policy that PD/H was to be used by all organizations responding to childhood malnutrition. The care group model is being tested in other communities as a grassroots strategy to impact childhood diseases. It furthermore strengthened community cohesion during a post-conflict situation. 

Some limitations were experienced during data collection. Remote villages were difficult to access due to terrain conditions, and, local MOH personnel were often called away to respond to other responsibilities. An implication for practice is that nurses in resource-rich countries could modify PD/H as an intervention for childhood obesity.