Reflective Statement on Promise SheetsDescribe:
This is a collection of materials used by field staff that conducted nutritional outreach services in rural communities of Bolivia, under a USAID funded Integrated Food Security Initiative, which I managed for over five years from 2002-2007. Although the program had interventions to increase household food availability and access, as well as maternal child health and nutrition interventions, the ultimate success for USAID food security programs worldwide is reduction in infant and child malnutrition. It is important to note that the intention of the promise sheets is to select the most relevant practice a mother could use to improve the ways in which she feeds her children. The selected behavior is marked in the box above a blank smiley face. Typically our nutrition workers weighed children monthly in community growth monitoring sessions and then visited their household at least once during the month. Using the promise sheet as an aide, the nutrition worker can see the behavior negotiated during their last visit and can follow up with the mother to see if they were able to implement the desired practice. If the mother did, they draw a happy face on the blank smiley face, and if not they draw a sad face. They then discuss how the baby is doing and what the mother will focus on before the next community growth monitoring session or household visit. The nutritional “promise sheets” shown here lists age specific feeding practices for mothers of infants or young children to follow. The ages are broken down into 0-5 months, the stage where exclusive breastfeeding is the desired practice; 6-8 months or the weaning period, where semi-solid foods are introduced; 9-11 months where the quantities of food and number of feedings is increased; and finally, 12-23 months where the quantity and number of feedings again increases and where continued breastfeeding is encouraged. In addition to the promise sheets there are also two brain scans; one, which shows a healthy active brain and another one that shows a brain with reduced neural activity. Analyze: The window of opportunity for improving nutrition is small—from pre-pregnancy through the first two years of life. There is consensus that the damage to physical growth, brain development, and human capital formation that occurs during this period is extensive and largely irreversible. Optimal feeding practices in the first 24 months of life are crucial for the survival and health of infants. Prior to developing these tools our program was faltering. Although we had extensive growth monitoring activities going on and nutrition workers in the field, nutritional impact was inconsistent. Furthermore, each supervisor conducted supervision differently. This artifact includes both promise sheets and brain scans. This was because as we modified our program, we went through an extensive community sensitization process about why nutrition was important and what the consequences of malnutrition were for babies’ future cognitive abilities. Furthermore, we engaged entire communities not just pregnant and lactating mothers but school teachers, health workers, council representatives, effected officials and fathers, grandparents and opinion makers. We asked if they knew the nutritional status of their grandchild, son or daughter, or community’s children. We asked if this was relevant to them as teachers, parents, officials or grandparents. We also used a common analogy of a light bulb prompting reflection about whether or not it would turn on if not connected to wiring and how bright the bulb would shine depending on the wattage of the light bulb and the amount of energy provided. We found unequivocally that when communities recognized that malnutrition limited the potential of a child they were moved. Previously they assumed that if a child was malnourished but didn’t die they had been saved and were ok. They also assumed that some children were naturally more talented or intelligent than other children. They never associated cognitive abilities with proper nutrition. Recognizing this association and their ability to prevent it empowered all stakeholders to take action. I chose this artifact because it demonstrates my ability to understand community health and nutrition and to simplify complex issues in a meaningful and actionable manner. It also shows how I monitored for results and took corrective actions when the program was not meeting program goals. Appraise: Developing these tools was a collaborative effort, which relied on literature from international maternal infant and child health and nutrition (MCHN) guidelines as well as technical support from Save the Children USA’s Nicaragua Field Office and Washington DC headquarters. Nonetheless, these tools were tested and validated in Bolivia and customized to reflect realities in our operating environment. Linking the promise sheets to brain development was unique and the tipping point to our MCHN interventions. Nevertheless, a tool is only as good as the people who use it. Common mistakes were that health workers read the list of behaviors to the mother and told her to do all of them or they reprimanded mothers who’s babies had lost weight. It was very important to model correct use of these tools for health workers and months were dedicated to ensuring proper utilization during rollout. Prior to prioritizing a behavior with mothers, a health worker was trained to ask probing questions and listen to the answers. However, the tool served multiple purposes. It focused the nutrition worker on behaviors specific to the child they visited. It permitted follow up with the mother. It also guided the supervisor to know what to look for when supervising the health workers. Finally, mothers loved having the sheets in their household and were keen to use them. Transform: When my program manager and I initially decided to use the “promise sheets” we were using them in conjunction with the minimum weight gain table for infants and young children. This was a radical departure from our previous program set up and required substantial reorientation of teaching aids. We were surprised to receive negative encouragement from our HQ and strong reluctance from our MCHN advisor in Bolivia, but we were both adamant that the program was faltering and needed reengineering. Our insistence eventually paid off as we eventually achieved a 16% reduction in stunting and 7% reduction in global malnutrition. This experience taught me the importance of involving and sensitizing more than mothers to the importance of nutrition in order to create more enabling environments. It also showed me the importance of being very focused and deliberate with what behaviors or practices you want to change and having adequate and focused supervision of program delivery. Later when I went to Bangladesh and found a similar faltering program, our success from Bolivia informed key programmatic changes. Once again associating nutrition with brain development seemed to be critical for gaining buy-in from mothers, fathers and key community members for optimal feeding practices and again we were able to impact both chronic and global malnutrition. The final slide shown is of a community health worker referring to a Bangladeshi-adapted version of the Promise Sheet. |