No abstract

This paper details the steps to design and implement a positive deviance-informed, "Hearth" approach for the nutritional rehabilitation of malnourished children in the district of Leogane, Haiti. Groups of four to five children met daily for two weeks at the home of a local volunteer mother for nutritional and health messages and a well-balanced meal. Health messages and meal components were determined using information gathered from interviews with the mothers of positive deviant children in the community who are well nourished despite their family's limited economic resources. Hearth participants were then followed for six months in their own home by the program "monitrices," women hired from each village and intensively trained to supervise the Hearth program, periodically weigh the children to evaluate their progress, and liaise between the hospital and the community. Monitoring from the first cycle indicated that 100% of children in eight villages and 66% of children in the remaining five villages continued to gain weight as fast or faster than the international standard median six months after participating in a Hearth program. At the conclusion of this cycle, programmers interviewed participant and non-participant families and made six modifications to the model, including the addition of a microcredit option for participating mothers.

Deaths and their causes in a rural Haitian population of 8820 were studied through hospital records, death registration, a disease survey, and health surveillance. The results were used in selecting eight diseases for the delivery of health services by village-level health workers. The impact of the services was measured by monitoring annual age-specific and disease-specific mortality rates and by comparing them with officially estimated national mortality rates. Mortality rates fell progressively during five years, to levels only one fourth as high as the national estimates. The fall in mortality was associated principally with services that prevented deaths due to tetanus, malnutrition, diarrhea, and tuberculosis. The total program of hospital and village health services saved 495 years of potential life per thousand population per year. Most of the saving was attributable to preventive services. The program eventually served more than 115,000 persons, and it has been replicated by other agencies for an additional 135,000 Haitians.

This paper details the steps to design and implement a positive deviance-informed, "Hearth" approach for the nutritional rehabilitation of malnourished children in the district of Leogane, Haiti. Groups of four to five children met daily for two weeks at the home of a local volunteer mother for nutritional and health messages and a well-balanced meal. Health messages and meal components were determined using information gathered from interviews with the mothers of positive deviant children in the community who are well nourished despite their family's limited economic resources. Hearth participants were then followed for six months in their own home by the program "monitrices," women hired from each village and intensively trained to supervise the Hearth program, periodically weigh the children to evaluate their progress, and liaise between the hospital and the community. Monitoring from the first cycle indicated that 100% of children in eight villages and 66% of children in the remaining five villages continued to gain weight as fast or faster than the international standard median six months after participating in a Hearth program. At the conclusion of this cycle, programmers interviewed participant and non-participant families and made six modifications to the model, including the addition of a microcredit option for participating mothers.

These findings support the conclusion that a well-developed system of primary health care, with outreach services to the household level, integrated with hospital referral care and community development programmes, can make a strong contribution to reducing infant and child mortality in severely impoverished settings.