analysis of project nutrition intervention and results … · analysis of project nutrition...

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Community-Based, Impact-Oriented Child Survival Project in Huehuetenango, Guatemala

USAID Child Survival and Health Grants Program October 1, 2011 – September 30, 2015

Cooperative Agreement No: AID-OAA-A-11-00041

Analysis of Project Nutrition Intervention and Results

Ramiro Llanque MD MPH, Ira Stollak MA MPH, Mario Valdez MD MPH,

Patty Loo, MD MPH, and Henry Perry MD MPH PhD

November 2015

318 West Millbrook Road, Suite 105, Raleigh, NC 27609 Tel: 919-510-8787; Fax: 919-510-8611

The Community-Based Impact-Oriented Child Survival in Huehuetenango, Guatemala Project in Huehuetenango, Guatemala is supported by the American

people through the United States Agency for International Development (USAID) through its Child Survival and Health Grants Program. The Project is

managed by Curamericas Global, Inc. under Cooperative Agreement No. AID-OAA-A-11-00041. The views expressed in this material do not necessarily

reflect the views of USAID or the United States Government. For more information about The Community-Based Impact-Oriented Child

Survival in Huehuetenango, Guatemala Project, visit: http://www.curamericas.org/

http://www.curamericas.org/

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TABLE OF CONTENTS

Glossary

3

Executive Summary

4

Background

7

Methodology 8

Findings

10

Discussion 15

Limitations 17

Conclusion/Recommendations 17

GLOSSARY

ARI- Acute respiratory infection

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Barrido – Anthropometric census which weighs and measures every 0-23 month old child in the Project service

area

Care Group - Group of mother peer educators (Care Group Volunteers); also name given entire training

infrastructure

CBIO – Community-Based Impact-Oriented Methodology (project service platform)

CBIO+CG – Combined methodologies of CBIO and Care Groups

CF- Community Facilitator

Círculos de adolescentes –Support groups for adolescent girls

Círculos de madres lactante – Support groups for lactating mothers

Comunicadora - Care Group Volunteer (mother peer educator)

Community Facilitator- Volunteer community health worker who trains Comunicadoras

Educadora –Curamericas Guatemala staff Health Educator

KPC- Knowledge, Practice and Coverage (type of household survey)

MSPAS – Guatemalan Ministry of Health and Social Assistance

PEC- Extension of Coverage Program

PY – Project year (October 1 through September 30)

OR- Operational Research

PD/Hearth – Positive Deviance/Hearth nutrition intervention

SD – Standard deviation; statistical term expressing extent of variation from a norm

Self Help Group – Group of women taught health-related lessons by a Comunicadora

Taller hogareño – Home/hearth workshop to teach mothers to prepare meals using locally available and

affordable nutritious foods

WHIP – Western Highlands Integrated Project

WHO- World Health Organization

1. Executive summary

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Background. A huge challenge to improving the health of under-5 children in the rural indigenous (Maya)

population of Guatemala has been combating a very high prevalence of stunting and underweight. According to

the most recent Guatemala DHS survey (2008/09), in the department of Huehuetenango, with an

overwhelmingly rural Maya population, 64.7% of under-five children are stunted; 30.4% are underweight; and

0.7% suffer from wasting.1 This malnutrition compromises immune systems and underlies the high under-five

child mortality in the rural indigenous population. According to the 2008/9 DHS survey, the under-five mortality

rate for indigenous children was 52 per 1,000 live births vs. only 33 for the non-indigenous population.2

Therefore the operational research of the Community-Based, Impact-Oriented Child Survival Project in

Huehuetenango, Guatemala included the following research question:

Does de CBIO + CG methodology produce significant improvements in the nutritional status of children

compared to a control/comparison area (Project Phase 2 communities) and compared to selected municipalities

of Huehuetenango department and/or the rural population of Huehuetenango department (after four years of

Project implementation)?

The Project devoted 30% of its level of effort to address the moderate acute malnutrition and high prevalence

of underweight and stunting in the under-2 population with a prevention focus through regular growth

monitoring, improved knowledge of and skills in appropriate child feeding practices, and improved access to

preventive nutrition services. A Community-Based Growth-Promotion approach was utilized, in which staff

Educadoras (Health Educators) and community health workers known as Community Facilitators (CFs) properly

trained in anthropometric techniques, regularly measured height/length and weight of under-2 children, utilizing

CBIO community registers and maps to locate, visit and identify as early as possible children with insufficient

growth progress in order to target them and their caretakers for additional nutritional counseling and problem

solving. Mothers of stunted and underweight children were targeted for either support groups for breast-feeding

women (Círculos de madres lactantes) or hearth workshops (talleres hogareños) to learn proper complementary

feeding practices. Their children were then closely monitored for improvement. Cases of wasting were referred

to MSPAS health posts or clinics for provision of nutritional supplementation and medical attention. Crucial to

this strategy was the integration of Care Groups and the Positive Deviance/Hearth methodologies. The Care

Group training cascade was utilized to bring nutritional skills and knowledge to every mother with an under-five

child via Self-Help Groups. Locally available and affordable nutritious foods were identified utilizing the

Positive Deviance/Hearth methodology. A household survey identified “positive deviants”- the children who

were at or above the normal weight and height for their age- and the mothers of these children were then

interviewed to discover what and how they were feeding their children. It was found that they were using locally

available and affordable foods that included cheap vegetable oil, garden vegetables, wild greens, fruits, eggs, and

legumes. Curamericas then designed a two-week menu cycle supplemented by these additional nutritious

foodstuffs. Then, assisted by the Community Facilitators, they utilized the Self-Help Groups to implement

talleres hogareños (“hearth workshops”) in which the mothers in the Self-Help Groups received hands-on

instruction and practice in preparing the foods of the two-week menu cycle. These interventions were

implemented in the 91 communities of project Phase 1 from March 2012 through May 2015, and in the 89

communities of project Phase 2 from October 2013 through May 2015.

Methods. We analyzed the anthropometric data for under-two children from three household surveys: 1) the

Baseline KPC Survey of 599 mothers of under-two children conducted in January 2012 in 30 Phase 1

communities (n=299) and 30 Phase 2 communities (n=300) randomly selected utilizing stratified cluster

sampling, and which examined only underweight; 2) a Household Survey of 288 mothers of under-two children

conducted in September 2012 in 30 Phase 1 communities randomly selected utilizing stratified cluster sampling

and which examined stunting, underweight, and wasting; and 3) the Final KPC Survey of 600 mothers of under-

two children conducted in June 2015 in 30 Phase 1 communities (n=300) and 30 Phase 2 communities (n=300)

randomly selected utilizing stratified cluster sampling, which examined stunting, underweight, and wasting. For

each survey data set, the data was first analyzed with EpiInfo 7 using z-scores to detect and eliminate outliers.

Then the data sets for each survey were exported into Excel tables and each entry reviewed and corrected as

necessary utilizing the WHO reference tables.3 Then records that were <-2SD for underweight, stunting, and

1 Encuesta Nacional de Salud Materna-Infantil 2008/9. Ministerio de Salud Pública y Asistencia Social. Guatemala: 2009.

2 Encuesta Nacional de Salud Materna-Infantil

3 WHO population reference tables. Available at http://www.who.int/childgrowth/standards/en/

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wasting were counted and malnutrition rates calculated. For the children from Phase 1 communities, Final KPC

Survey anthropometric results were compared with the Baseline KPC Survey results for underweight and with

the September 2012 household survey results for underweight, stunting, and wasting. For children from the

Phase 2 communities, Final KPC Survey results were compared with the Baseline KPC Survey results for

underweight. Final KPC Survey results for the children from Phase 1 communities were compared with the Final

KPC Survey results for the children from Phase 2 communities for underweight, stunting, and wasting. We also analyzed the data from the project’s anthropometric censuses, known as barridos. Beginning in June

2013 in the Phase 1 communities and August 2014 in the Phase 2 communities, an attempt was made to measure

and weigh every under-two child in the project service area two or three times per year, with the last

census/barrido in both Phase areas occurring in November 2014. The coverage of children <2 years old ranged

from 93% to 100% for each census. For the children from the Phase 1 communities, November 2014 final census

results were compared with the first June 2013 census results for underweight, stunting, and wasting. For the

children from the Phase 2 communities, the November 2014 final census results were compared with the first

Phase 2 August 2014 census results. Final November 2014 census results for the children from Phase 1

communities were compared with the November 2014 census results for the children from Phase 2 communities.

For comparing the final anthropometric results for the Phase 1 communities with selected municipalities of

Huehuetenango Department or with the rural population of the Department, we utilized the anthropometric data

from the 2013 baseline Monitoring and Evaluation Survey for the Western Highlands Integrated Program

(WHIP). The WHIP survey collected anthropometric data for stunting, underweight, and wasting for 3,312

under-five children in 30 municipalities very comparable to our project’s three municipalities in five departments

that included Huehuetenango. These data were compared with the corresponding anthropometric data from the

June 2015 Final KPC Survey for the under-2 children from the Phase 1 communities.

Findings. Looking at the KPC Surveys and the September 2012 household survey results for the under-two

children from Phase 1 communities, we see a significant decline in stunting, which fell from 74.5% for the

September 2012 survey to 39.5% for the June 2015 Final KPC Survey (p=0.00). For underweight, we see no

significant change from Baseline to Final KPC Surveys, but a significant change from the September 2012

household survey, 29.8%, to Final KPC Survey, 20.1% (p=0.009). We see no significant change in wasting,

with a final prevalence of wasting detected that is rather high (3.1%). For the under-2 children weighed and

measured who were from Phase 2 communities, we see no significant change in underweight from the Baseline

to Final KPC Surveys. As with the children from the Phase 1 communities, we also see here a relatively high

final prevalence of wasting (4.4%). Comparing the anthropometric results from the June 2015 Final KPC Survey

of the children from the Phase 1 communities with the results for the children from the Phase 2 communities, we

see a significant difference only for stunting, with 39.5% of the children from the Phase 1 communities classified

as stunted vs. 51.7% of the children from the Phase 2 communities (p=0.004). Looking at the data from the anthropometric censuses (barridos) for the children in the Phase 1 communities,

and comparing the results from the first June 2013 census with the results of the final November 2014 census,

we see significant declines in the percentage who were stunted, from 53.1% to 39.8% (p=0.00); in the percentage

who were underweight, from 23.2% to 10.9% (p=0.00); and in the percentage who were wasted, from 1.9% to

0.3% (p=0.00). For the children in the Phase 2 communities, we see a significant decline from August 2014 to

November 2014 only for underweight, from 20.1% to 15.5% (p=0.00). Comparing the results of the final

anthropometric census of November 2014 for the children from the communities of the two Phases, we see

significantly lower prevalence of stunting, underweight, and wasting in the children of the Phase 1 communities:

39.8% stunting vs. 52.2% for the children from Phase 2 communities (p=0.00); 10.9% underweight vs. 15.5%

for the children from the Phase 2 communities (p=0.00); and 0.3% wasting vs. 0.8% for the children from the

Phase 2 communities (p=0.027).

Dramatic and significant decreases were detected by the anthropometric censuses in stunting and underweight

in the 0-5 month old children of the Phase 1 communities: stunting dropped from 26.9% in June 2013 to 14.6%

in November 2014 (p=0.00); and underweight from 12.3% to 3.0% (p=0.00). These changes were to a great

extent due to an increase in the percentage of 0-5 month children who were exclusively breastfed.

Comparing the under-2 children from the Phase 1 communities in the Final KPC Survey with the under-5

children from the WHIP survey, the Phase 1 children showed significantly less stunting (39.5% vs. 67.4%,

p=0.00), comparable underweight (20.1% vs. 17.3%), and significantly more wasting (3.1% vs. 0.8%, p=0.00).

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Discussion. The data supports our hypothesis that the CBIO+Care Groups methodology produced significant

improvements in the nutritional status of children in the Phase 1 communities compared to a control/comparison

area. The Final KPC Survey shows significantly lower stunting at end of project in the children of Phase 1

communities compared to those of Phase 2 communities, and the November 2014 anthropometric census shows

significantly lower stunting, underweight, and wasting in the children of the Phase 1 communities. The data

from the surveys and from the anthropometric censuses concur that the project’s nutrition intervention succeeded

in significantly reducing the prevalence of stunting in under-two children in the communities of Phase 1. No

such change was noted for the communities of Phase 2. It appears the longer project intervention in Phase 1

communities produced the desired dose-response effect in reducing stunting in under-2 children.

Less clear is if the project’s nutrition intervention was also successful in lowering the prevalence of

underweight and wasting. While the final November 2014 census indicates significant declines in both

underweight and wasting for the children of Phase 1 communities (and in underweight for those of Phase 2

communities), the June 2015 Final KPC Survey shows effectively no change in these indicators. But these dates

are seven months apart and underweight and wasting can change in that timeframe under the influence of food

insecurity and increased child disease incidence. There is some evidence to support the hypothesis that

underweight and wasting may have increased between November 2014 and June 2015 as a result of a general

deterioration in the local health system during that same time period, which the project could not overcome.

The successful integration of the Positive Deviance/Hearth (PD/Hearth) intervention confirmed that there are

locally available and affordable nutritious foods and that costly food supplementation programs may often not be

necessary. The contribution of the Care Groups also must be noted, revealed by the statistically significant

increases from Baseline KPC Survey to Final KPC Survey in the communities of both Phases in key household

behaviors that impacted nutrition (e.g., hand washing). The significant decreases in stunting and underweight in

0-5 month old children reflects the Project’s success in increasing the practice of exclusive breastfeeding for this

age group, validating the project’s strategy of utilizing Self-Help Groups, support groups for lactating mothers,

and Care Group Volunteers to both monitor and encourage this behavior at the household level. Thus, it appears

that the CBIO+Care Groups methodology, combined with the PD/Hearth intervention for empowering

communities to improve child feeding practices with their own available and affordable resources, can produce

significant improvements in child nutrition over time, particularly in stunting. Limitations. The statistically significant differences in the data for underweight and wasting between the

June 2015 Final KPC Survey and the November 2014 final anthropometric census (barrido) may call into

question the accuracy of one or both of the data sources. That said, the 7-month time difference between the final

measures of the two data sources may render them not comparable and, therefore, not mutually confirmable.

The Baseline KPC survey was done in January, the cold dry season when there is a seasonally lower incidence

of diarrhea, which contributes heavily to underweight due to water and nutrient loss. The Final KPC was done in

June, during the rainy season, when there is a seasonally higher incidence of diarrhea, increasing underweight.

The project’s 2015 Final KPC Survey anthropometric data is not sufficiently comparable with the

corresponding data for the 2013 WHIP household survey because the project weighed and measured under-two

children while the WHIP survey weighed and measure under-five children.

Recommendations. 1) Develop rigorous standardized anthropometry training and quality control tools; 2)

continue doing bi-annual anthropometric censuses; 3) the moderately high levels of wasting detected by the

Final KPC Survey call for further investigation to confirm these results, ascertain the causes, and respond with

treatment and prevention; 4) conduct Barrier Analyses and other qualitative research to identify the specific

barriers to the consistent practice key nutrition-related behaviors and tailor interventions that address those

barriers; 5) secure more evidence that behavior change and the use of locally available and affordable foods can

make unnecessary the expensive programs of food supplementation; 6) capitalize on the MSPAS nutrition

initiatives and on the post-election change in administration to secure MSPAS logistical and financial support for

the CBIO+Care Groups+PD/Hearth approach to nutrition; and 7) secure project partner NGOs with expertise in

both community-based agronomy and in micro-enterprises for women to help families produce nutritious foods

and to give women the skills to produce their own income to improve the nutrition of their children.

2. Background

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A huge challenge to improving the health of under-5 children in the rural indigenous (Maya) population of

Guatemala has been combating a very high prevalence of stunting and underweight. According to the most

recent Guatemala DHS survey (2008/09), in the department of Huehuetenango, with an overwhelmingly rural

Maya population, 64.7% of under-five children are stunted; 30.4% are underweight; and 0.7% suffer from

wasting.4 A more recent (2013) survey conducted by the Western Highlands Integrated Project (WHIP) in 20

rural municipalities of the predominantly Mayan western highlands, which includes Huehuetenango department,

revealed that 67.4% of under-five children were stunted; 17.2% were underweight; and 0.8% were wasted.5 This

malnutrition compromises immune systems and underlies the high under-five child mortality in the rural

indigenous population. According to the 2008/9 DHS survey, the under-five mortality rate for indigenous

children was 52 per 1,000 live births vs. only 33 for the non-indigenous population.6 Contributing to this

situation are food insecurity, lack of nutritional skills and knowledge, endemic poverty, and a stubborn devotion

to maize and the belief that it alone is sufficient nutrition. The Maya call themselves “the people of maize.”

Therefore the operational research of the Community-Based, Impact-Oriented Child Survival Project in

Huehuetenango, Guatemala included the following research question:

Does de CBIO + CG methodology produce significant improvements in the nutritional status of children

compared to a control/comparison area (Project Phase 2 communities) and compared to selected municipalities

of Huehuetenango department and/or the rural population of Huehuetenango department (after four years of

Project implementation)?

The Project devoted 30% of its level of effort to address the moderate acute malnutrition and high prevalence

of underweight and stunting in the under-2 population with a prevention focus through regular growth

monitoring, improved knowledge of and skills in appropriate child feeding practices, and improved access to

preventive nutrition services. A Community-Based Growth-Promotion approach was utilized, in which staff

Educadoras (Health Educators) and community health workers known as Community Facilitators (CFs) properly

trained in anthropometric techniques, regularly measured height/length and weight of under-2 children, utilizing

CBIO community registers and maps to locate, visit and identify as early as possible children with insufficient

growth progress in order to target them and their caretakers for additional nutritional counseling and problem

solving. The Educadoras and Community Facilitators weighed and measured every under-2 child during a home

visit when the child turned 3, 6, 12, 18 and 24 months of age. The visits included nutrition counseling, and

Vitamin A supplementation and deworming with albendazole for the child accordingly to the MSPAS-prescribed

schedule. Mothers of stunted and underweight children were targeted for either support groups for breast-

feeding women (Círculos de madres lactantes ) or workshops (talleres hogareños) to learn proper

complementary feeding practices. Their children were then closely monitored for improvement. Cases of

wasting were referred to MSPAS health posts or clinics for provision of nutritional supplementation and medical

attention. These interventions were implemented in the 91 communities of project Phase 1 from March 2012

through May 2015, and in the 89 communities of project Phase 2 from October 2013 through May 2015.

Crucial to this strategy was the integration of Care Groups and the Positive Deviance/Hearth methodology.

The Care Group training cascade was utilized to bring nutritional skills and knowledge to every mother with an

under-five child. The staff Educadoras trained in each village a Community Facilitator, who in turn trained a

cadre of 5 to 10 volunteer mother peer educators, known as Comunicadoras. Each Comunicadora was assigned

10-15 mothers of under-five children in her community, and collectively they covered 100% of this target

population. Through home visits and twice-monthly meetings known as Self-Help Groups, and utilizing

participatory lessons for non-literate adult audiences, they brought to their assigned women BCC messages

emphasizing exclusive breastfeeding for six months followed by complementary feeding that included a diverse

diet of locally available and affordable foods rich in protein, iron, and vitamins and with sufficient caloric

content. Other BCC lessons taught that impact nutrition include hand washing at critical moments, proper point

of use water purification and storage, and proper feces disposal to reduce diarrhea and its impact on nutrition

from weight and nutrient loss. Other nutrition-related lessons encouraged Vitamin A supplementation for

children, and prompt care-seeking for children with symptoms of pneumonia/ARI. Importantly, the

4 Encuesta Nacional de Salud Materna-Infantil 2008/9. Ministerio de Salud Pública y Asistencia Social. Guatemala: 2009.

5 Monitoring and Evaluation Survey for the Western Highlands Integrated Project-Baseline 2013. MEASURE Evaluation.

University of North Carolina, Chapel Hill, NC: August 2014. 6 Encuesta Nacional de Salud Materna-Infantil

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Comunicadoras monitored compliance with these behaviors, particularly for exclusive breastfeeding, reporting

to the Community Facilitator their observations, which were included in the project’s M&E data.

The locally available and affordable nutritious foods were identified utilizing the Positive Deviance/Hearth

methodology. A household survey of 288 mothers of under-two children conducted in September 2012 in 30 Phase 1 communities in all three municipalities established baseline levels for stunting, underweight, and

wasting. The survey data was also utilized to identify “positive deviants”- the children who were at or above the

normal weight and height for their age. The mothers of these children were then interviewed to discover what

and how they were feeding their children. It was found that they were using locally available and affordable

foods that included cheap vegetable oil, garden vegetables, wild greens, fruits, eggs, and legumes. The

Curamericas Guatemala Educadoras then designed a two-week menu cycle built around the traditional

maize/tortilla dietary base, but strongly supplemented by these additional nutritious foodstuffs. Then, assisted

by the Community Facilitators, they utilized the Self-Help Groups to implement talleres hogareños (“hearth

workshops”), held in the kitchens of Community Facilitators or Comunicadoras, in which the mothers in the

Self-Help Groups received hands-on instruction and practice in preparing the foods of the two-week menu cycle.

Supplementary food (Nutributter) was also provided to beneficiary communities for children 6-18 months

through PY2 as part of a partnership with Guatemalan NGO, Wuku’ Kawoq, that donated a temporary supply of

the nutrient-dense food supplement.

The results of these interventions were monitored via the routine home visitation for growth monitoring, and

by conducting periodic barridos (literally, “sweepings”), during which the Educadoras, assisted by the

Community Facilitators, conducted an anthropometric census, weighing and measuring every under-two child in

the project service area, locating the children using the CBIO community registers and maps. Table 1

summarizes the inputs, activities, and outputs of the project’s nutrition intervention.

Table 1: Inputs, activities, and outputs of the project’s nutrition intervention

Inputs Activities Outputs

- Manual for Care Groups - Manual for Positive Deviance intervention -Community registers and maps - Personnel: 26 Educadoras, 3 Educadora Supervisors, 3 Municipal Coordinators, 149 Community Facilitators, 779 Comunicadoras, 3 SIAS Ambulatory Nurses, 5 SIAS Auxiliary Nurses, 17 SIAS Community Facilitators -Scales for weighing children -Measuring boards for children

-Training of Educadoras, Community Facilitators, and Comunicadoras in nutrition - Establishment of Care Groups and Self-Help Groups -Training of staff in Positive Deviance intervention and anthropometry - Care Group meetings - Self-Help Group Meetings -Positive Deviance Intervention: weighing/measuring; survey of positive deviants; design of menu and workshops -Talleres Hogareños (community workshops on complementary feeding) -Growth monitoring of children 0-23 mos.

-26 Educadoras, 149 CFs and 779 Comunicadoras trained in EBF, complementary feeding, anthropometry, and Positive Deviance -5,698 children 0-23 months evaluated for stunting, underweight, acute malnutrition during barridos. -31 children referred to health facilities/SIAS staff for acute malnutrition -7,960 household visits for child growth monitoring and Vitamin A dosing -736 home complementary feeding workshops (talleres hogareños) -8,080 mothers educated in EBF and IBF and in proper complementary feeding practices

3. Methodology

To analyze the results achieved by the nutrition intervention the following sources of data were reviewed:

a) KPC and household survey results:

i. Baseline KPC Survey of 599 mothers of under-two children conducted in January 2012 in 30 Phase 1

communities (n=299) and 30 Phase 2 communities (n=300) randomly selected from all three municipalities

utilizing stratified cluster sampling. The youngest under-two child of every interviewee was weighed by

trained interviewers but not measured, so this data included only anthropometry for underweight. Of the 599

children weighed, 310 (51.8%) were male and 289 (48.2%) were female.

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ii. Household survey of 288 mothers of under-two children conducted in September 2012 in 30 Phase 1

communities randomly selected from all three municipalities utilizing stratified cluster sampling. The

youngest under-two child of the interviewee was both weighed and measured by staff Educadoras trained in

anthropometry. Anthropometry looked at both weight and height and so included data for underweight,

stunting, and wasting. Of these 288 children weighed and measured, 145 were male (50.3%) and 143 female

(49.7%).

iii. Final KPC Survey of 600 mothers of under-two children conducted in June 2015 in 30 Phase 1 communities

(n=300) and 30 Phase 2 communities (n=300) randomly selected from all three municipalities utilizing

stratified cluster sampling. The youngest under-two child of every interviewee was both weighed and

measured by trained interviewers. Anthropometry looked at both weight and height and so included data for

underweight, stunting, and wasting. Of the 600 children weighed and measured, 290 (48.3%) were male and

310 (51.7%) were female.

For each survey data set, the data was first analyzed with EpiInfo 7 using z-scores to detect and eliminate

outliers (results <>6SD for underweight and stunting (wfa and lfa) and <>5SD for wasting (wfl)): 1 (from Phase

1 communities) for the January 2012 KPC survey; 13 (all from Phase 1 communities) for the Sept 2012

household survey; and 12 (6 from Phase 1 communities and 6 from Phase 2 communities) for the June 2015

KPC survey. Then the data sets for each survey, without outliers, were exported into Excel tables. Each entry

was then reviewed for correct classification and corrected as necessary utilizing the WHO reference tables for

underweight (weight for age), stunting (height for age), and wasting (weight for height). 7 Then underweight,

stunted, and wasted records that were <-2SD were counted and malnutrition rates calculated. These results were

corroborated by two separate independent researchers.

Final KPC Survey anthropometric results for the children from the Phase 1 communities were compared with

the Baseline KPC Survey results for underweight and with the September 2012 household survey results for

underweight, stunting, and wasting for the children from Phase 1 communities. Final KPC Survey results for

the children from the Phase 2 communities were compared with the Baseline KPC Survey results for

underweight for children from Phase 2 communities. Final KPC Survey results for the children from Phase 1

communities were compared with the Final KPC Survey results for the children from Phase 2 communities for

underweight, stunting, and wasting. P-values (Fisher mid-point) were calculated for all of these comparisons

utilizing WinPepi.

b) The data from the project’s anthropometric censuses, known as barridos (see Background, above). Beginning

in June 2013 in the Phase 1 communities and August 2014 in the Phase 2 communities, an attempt was made to

measure and weigh every under-two child in the project service area two or three times per year, with the last

census/barrido in both Phase areas occurring in November 2014 (Table 2). This effectively was an

anthropometric census since the coverage of children <2 years old ranged from 93% to 100% (Table 2).

Educadoras, assisted by Community Facilitators, weighed and measured every under-two child in their

assigned communities during a home visit, and utilizing the WHO weight-for-age (wfa), height-for-age (hfa),

and weight-for-height (wfh) references tables, identified all children <-2SD for wfa (underweight), for hfa

(stunting), and for wfh (wasting). Curamericas Guatemala M&E staff then aggregated the Educadoras’ data into

Excel spreadsheets, aggregated by Phase and by municipality, and reviewed every record, verifying, and

correcting, if necessary, the anthropometric classifications and then computed the prevalence of stunting,

underweight and wasting. For the children from the Phase 1 communities, November 2014 census results were

compared with the June 2013 census results for underweight, stunting, and wasting. For the children from the

Phase 2 communities, November 2014 census results were compared with the August 2014 census results.

Final November 2014 census results for the children from Phase 1 communities were compared with the

November 2014 census results for the children from Phase 2 communities. P-values (Upton's "N - 1" chi-square)

were calculated for all of these comparisons utilizing WinPepi.

Table 2: Coverage of anthropometric censuses (“barridos”) by Phase area

7 WHO population reference tables. Available at http://www.who.int/childgrowth/standards/en/

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Date of census

No. of children 0-23 months of age who were weighed and measured

Total population of children 0-23 months of age

(per CBIO Community Registers)

Pctg of children 0-23 months of age who were

weighed and measured

Phase 1 communities

Phase 2 communities

Phase 1 communities

Phase 2 communities

Phase 1 communities

Phase 2 communities

June 2013 2,093 0 2,093 NA 100% NA

Sep 2013 2,093 0 2,093 NA 100% NA

Jan 2014 2,197 0 2,197 NA 100% NA

Aug 2014 2,401 2.198 2,548 2,215 94% 99%

Nov 2014 2,194 2.051 2,367 2,147 93% 96%

c) The project’s Operational Research also called for comparing the final anthropometric results for the Phase 1

communities with selected municipalities of Huehuetenango Department or with the rural population of the

Department. Unfortunately, we were not able to obtain recent comparable anthropometric data for the

Department, as the most recent national DHS Survey is still in process and the previous survey contained old

data from 2008. We therefore utilized for our comparison the anthropometric data from the 2013 baseline

Monitoring and Evaluation Survey for the Western Highlands Integrated Program (WHIP). The WHIP is a

multi-sectorial USAID-funded project led by URC LLC and its in-country partner, Guatemalan NGO Nutri-

Salud, with the goal of achieving sustainable improvements in health and other development indicators in 30

prioritized municipalities located in the five departments of the Western Highlands (which includes

Huehuetenango Department). These 30 municipalities are very comparable to the Child Survival Projects’ three

municipalities, exhibiting very similar health and socio-economic indicators, and with similar rural mountainous

terrain, indigenous Mayan population, and poor access to health care and health facilities. The WHIP survey

interviewed families from 4,007 households in the 30 municipalities between July and November 2013 and

collected anthropometric data for 3,312 under-five children and calculated the prevalence of stunting,

underweight, and wasting in this sample. These data were compared with the corresponding data from the June

2015 Final KPC Survey for children from Phase 1 communities and p-values (Upton's "N - 1" chi-square)

calculated using WinPepi for these comparisons.

4. Findings

Table 3 presents the anthropometric results for all three surveys for the under-2 children who were weighed

and measured who were from Phase 1 communities.

Table 3 – KPC and household survey anthropometric data for under-2 children from the Phase 1 communities

Anthropometric Indicator and Data Source

Phase 1 Communities

p-value Num Denom Pctg

95% Confidence Interval

Underweight - children <2 yrs old who are <-2SD below normal weight for age per WHO reference population

Jan 2012 Baseline KPC Survey 48 298 16.1% 12.1, 20.8% 0.240 (Jan 2012) 0.009 (Sept 2012)

Sept 2012 Household Survey 82 275 29.8% 24.5, 35.6%

June 2015 Final KPC Survey 59 294 20.1% 15.6, 25.1%

Stunting - children <2 yrs old who are <-2SD below normal height for age per WHO reference population

Sept 2012 Household Survey 205 275 74.5% 69.0, 79.6% 0.000


Wasting -children <2 yrs old who are <-2SD below normal weight for height per WHO reference population

Sept 2012 Household Survey 13 275 4.7% 2.5, 7.9% 0.385


11

We see a significant change in stunting (p=0.000) which fell from 74.5% for the September 2012 survey to

39.5% for the Final KPC Survey. For underweight, we see no significant change from Baseline to Final KPC

Surveys, but a significant change from the September 2012 household survey (29.8%) to Final KPC Survey

(20.1%) (p=0.009). We see no significant change in wasting, with a prevalence of wasting detected that is rather

high (3.1%). Table 4 presents the anthropometric results from the KPC Surveys for the under-2 children weighed and

measured who were from Phase 2 communities. Note that there is data for stunting and wasting only for the June

2015 Final KPC Survey. We see no significant change in underweight from the Baseline to Final KPC Surveys.

We also see here a relatively high prevalence of wasting (4.4%).

Table 4 – KPC survey anthropometric data for under-2 children from the Phase 2 communities

Anthropometric Indicator and Data Source

Phase 2 Communities

p-value Num Denom Pctg



Jan 2012 Baseline KPC Survey 59 300 19.7% 15.3, 24.6% 0.918



June 2015 Final KPC Survey 152 294 51.7% 45.8, 57.5% NA


June 2015 Final KPC Survey 13 294 4.4% 2.4, 7.4% NA

Table 5 compares the anthropometric results from the June 2015 Final KPC Survey of the children from the

Phase 1 communities with the results for the children from the Phase 2 communities. We see a significant

difference in the Final KPC Survey results only for stunting, with 39.5% of the children from the Phase 1

communities classified as stunted vs. 51.7% of the children from the Phase 2 communities (p=0.004). Table 5 – Underweight, stunting, and wasting in under-2 children from Phase 1 communities compared to

children from Phase 2 communities – data from the June 2015 Final KPC Survey Phase area of children weighed

and measured Num Denom Pctg


p-value


Phase 1 communities 59 294 20.1% 15.6, 25.1% 1.00

Phase 2 communities 59 294 20.1% 15.6, 25.1%


Phase 1 communities 116 294 39.5% 33.8,45.3% 0.004



Phase 1 communities 9 294 3.1% 1.4, 5.7% 0.515


Table 6 presents the anthropometric data from the anthropometric censuses (barridos) for the under-2

children weighed and measured from the Phase 1 and Phase 2 communities. Because these were censuses with

93% to 100% coverage of the population of under-2 children (see Table 2, above), no confidence intervals are

presented. For the children in the Phase 1 communities, comparing the results from the June 2013 census with

the final November 2014 census, we see significant declines in the percentage that were stunted, from 53.1% to

39.8% (p=0.00); in the percentage that were underweight, from 23.2% to 10.9% (p=0.00); and in the percentage

that were wasted, from 1.9% to 0.3% (p=0.00). For the children in the Phase 2 communities, we see a significant

decline from August to November 2014 only for underweight, from 20.1% to 15.5% (p=0.00).

Comparing the results of the final anthropometric census of November 2014 for the children from the

communities of the two Phases, we see significantly lower prevalence of stunting, underweight, and wasting in

12

the children of the Phase 1 communities: 39.8% stunting vs. 52.2% for the children from Phase 2 communities

(p=0.000); 10.9% underweight vs. 15.5% for the children from the Phase 2 communities (p=0.00); and 0.3%

wasting vs. 0.8% for the children from the Phase 2 communities (p=0.027).

Table 6 - Results of anthropometric censuses (barridos) of under-two children weighed and measured from

Phase 1 and Phase 2 communities

Month/year of Barrido

No. children weighed

and measured

Stunting- No. children

<-2SD hfa

Pctg Stunted

Underweight-No. children <-2SD wfa

Pctg, Underweight

Wasting- No. children <-2SD wfh

Pctg

Wasted

Under-two Children from Phase 1 Communities

June 2013 2,093 1,112 53.1% 486 23.2% 40 1.9%

Sept 2013 2,093 871 41.6% 328 15.7% 28 1.3%

January 2014 2,197 1,032 47.0% 331 15.1% 18 0.8%

August 2014 2,401 1,106 46.1% 320 13.3% 10 0.4%

November 2014 2,194 874 39.8% 239 10.9% 7 0.3%

Under-two Children from Phase 2 Communities

August 2014 2,198 1,203 54.7% 442 20.1% 24 1.1%

November 2014 2,051 1,071 52.2% 317 15.5% 17 0.8%

Figure 1 (below) shows the changes detected in the percentage of under-2 children from the communities of

both Phases who were classified as stunted (<-2SD height for age), combining the data presented above from the

KPC and September 2012 household surveys and the data from the anthropometric censuses (barridos). We see

a clear corroboration of the results of the two data sources, with almost identical results from the Final KPC of

June 2015 and the final census (barrido) of November 2014. The final census data thus confirms the significant

decline in stunting from 74.5% to 39.5% detected by the Final KPC Survey in the Phase 1 communities.

Figure 1- Changes in percentage of under-two children classified as stunted, by Phase of community,

between January 2012 to June 2015, data from KPC and Household Surveys and from anthropometric censuses


both Phases who were classified as underweight (<-2SD weight for age), combining the above data from the

KPC and September 2012 household surveys and the anthropometric censuses (barridos). Here we see a

discrepancy between the final results of the two data sources, with significant differences between results of the

Final KPC of June 2015 and the final census of November 2014: 20.1% vs. 10.9% (p=0.00) for the children from

Phase 1 communities and 20.1% vs. 15.5% (p=0.044) for the children from Phase 2 communities. While the

74.5%

39.5% 51.7%

53.1%

41.6% 47.0% 46.0%

39.8%

54.7% 52.2%

0%

20%

40%

60%

80%

Jan 2012

Sept 2012

June 2013

Sept 2013

Jan 2014

Aug 2014

Nov 2014

June 2015

Changes in Stunting

Phase 1 communities - KPC and Household Surveys Phase 2 communities - KPC Surveys Phase 1 communities-Barridos Phase 2 communities-Barridos

13

final November 2014 census shows a significant decline in underweight for the children of both Phases, as noted

above, the Final KPC Survey detected no significant change in underweight from the Baseline KPC Survey in

the children of the communities of either Phase.

Figure 2 - Changes in percentage of under-two children classified as underweight, by Phase of community,

between January 2012 to June 2015, data from KPC and Household Surveys and from anthropometric censuses


both Phases who were classified as wasted (<-2SD weight for height), combining the above data from the KPC

and September 2012 household surveys and the anthropometric censuses (barridos). Here, again, we see a

discrepancy between the results of the two data sources, with significant differences between results of the Final

KPC of June 2015 and the final census of November 2014: 3.1% vs. 0.3% (p=0.00) for the children from Phase

1 communities and 4.4% vs. 0.8% (p=0.00) for the children from Phase 2 communities. While the final

November 2014 census shows a significant decline in wasting from the June 2013 census for the children in

Phase 1 communities, the Final KPC Survey detected no significant change in wasting from the September 2012

household survey for the children from Phase 1 communities, and indicated persisting high prevalence of

wasting in the communities of both Phases.

Figure 3 - Changes in percentage under-two children classified as wasted, by Phase of community, between

January 2012 to June 2015, data from KPC and Household Surveys and from anthropometric censuses

16.1%

29.8%

20.1% 19.7% 20.1% 23.2%

15.7% 15.1% 13.3%

10.9%

20.1%

15.5%

0%

5%

10%

15%

20%

25%

30%

35%

Jan 2012

Sept 2012

June 2013

Sept 2013

Jan 2014

Aug 2014

Nov 2014

June 2015

Changes in Underweight

Phase 1 communities - KPC and Household Surveys Phase 2 communities- KPC Surveys Phase 1 communities-Barridos Phase 2 communities-Barridos

4.7%

3.1%

4.4%

1.9% 1.3%

0.8% 0.4% 0.3%

1.1% 0.8%

0

0.02

0.04

0.06

Jan 2012

Sept 2012

June 2013

Sept 2013

Jan 2014

Aug 2014

Nov 2014

June 2015

Changes in Wasting

Phase 1 communities-KPC and Household Surveys

Phase 2 communities - KPC Surveys

Phase 1 communities-Barridos

Phase 2 communities- Barridos

14

Significant decreases were detected in stunting and underweight in 0-5 month old children of the Phase 1

communities (Figures 4 and 5). Stunting dropped from 26.9% in June 2013 to 14.6% in November 2014

(p=0.00); and underweight from 12.3% to 3.0% (p=0.00). Consequently, the stunting and underweight

prevalence in the 6-23 month age group were higher than those for the entire 0-23 month population. These

changes were to a great extent due to an increase in the percentage of 0-5 month children who were exclusively

breastfed. In San Sebastian Coatán exclusive breastfeeding increased from 16% coverage in May 2014 to 48% in

November 2014 (p=0.00); in Santa Eulalia, from 35% in May 2013 to 60% in April 2014 (p=0.00).[No data

currently available for San Miguel Acatán].

Figure 4- Changes in percentage under-two children from Phase 1 communities

classified as stunted per anthropometric census, by age group

Figure 5- Changes in percentage under-two children from Phase 1 communities

classified as underweight per anthropometric census, by age group

Table 7 (below) compares the anthropometric results of the June 2015 Final KPC Survey for the children of

Phase 1 communities with the corresponding anthropometric measures for the children from the 2013 WHIP

26.9% 26.9% 27.6%

18.3% 14.6%

62.9%

47.1% 53.4% 55.6%

48.0% 53.1%

41.6% 47.0% 46.0%

39.8%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

June 2013 Sept 2013 Jan 2014 Aug 2014 Nov 2014

Changes in stunting by age group- children from Phase 1 communities

Stunting 0-5 months of age Stunting 6-23 months of age

stunting 0-23 months of age

12.3% 12.3% 8.4%

6.0% 3.0%

27.3%

16.9% 17.3% 15.8%

13.4%

23.2%

15.7% 15.1% 13.3%

10.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

June 2013 Sept 2013 Jan 2014 Aug 2014 Nov 2014

Changes in underweight by age group - children from Phase 1 communities

Underweight 0-5 months of age



15

baseline survey.8 Note that the WHIP survey weighed and measured 3,312 children under-five years of age,

while the Final KPC Survey weighed and measured 294 children under-two years of age (not counting outliers).

Table 7 – Comparison of anthropometric data of under-5 children from the WHIP 2013 Baseline Survey with

similar anthropometric data of under-2 children from the Project’s June 2015 Final KPC Survey

Data Source Num Denom Pctg 95% Confidence

Interval

p-value

Stunting - children <-2SD who are below normal height for age per WHO reference population

WHIP 2013 Baseline Survey (children <5 yrs old) 2232 3312 67.4% 62.7, 72.1%

0.000 June 2015 Final KPC Survey (children <2 yrs old from Phase 1 communities)

116 294 39.5% 33.8, 45.3%

Underweight - children <-2SD who are below normal weight for age per WHO reference population



59 294 20.1% 15.6, 25.1%

Wasting - children <-2SD who are below normal weight for height per WHO reference population



9 294 3.1% 1.4, 5.7%

The WHIP survey detected a prevalence of 67.4% for stunting, 17.3% for underweight, and 0.8% for wasting

among under-five children in the sampled population in the project’s Zone of Influence (ZOI) (area where

project was planned to be implemented) (Table 7). This compares with 39.5% stunting, 20.1% underweight, and

3.1% wasting detected in Final KPC Survey among the under-2 children from the Phase 1 communities.

Compared to the children from the WHIP survey, the children from the Phase 1 communities showed

significantly less stunting (p=0.00), comparable underweight (no significant difference), and significantly more

wasting (p=0.00).

5. Discussion

The data from Final KPC Survey and final November 2014 anthropometric census supports our hypothesis

that the CBIO+Care Groups methodology produced significant improvements in the nutritional status of children

in the Phase 1 communities compared to a control/comparison area (i.e., the Project Phase 2 communities) after

four years of Project implementation. The Final KPC Survey shows significantly lower stunting at end of project

in the children of Phase 1 communities compared to those of Phase 2 communities, and the November 2014

anthropometric census shows significantly lower end-of-project stunting, underweight, and wasting in the

children of the Phase 1 communities.

Less clear is if the CBIO+Care Group methodology produced significant improvements in children in the

Phase 1 communities compared to selected municipalities of Huehuetenango department and/or the rural

population of Huehuetenango department (after four years of Project implementation) as we were unable to

obtain truly comparable data for children of the under-2 age group.

The data from the surveys and from the anthropometric censuses concur that the project’s nutrition

intervention succeeded in significantly reducing the prevalence of stunting in under-two children in the

communities of Phase 1. No such change was noted for the communities of Phase 2. Given that stunting is a

relatively slow-to-change nutritional indicator, it appears the longer project intervention in Phase 1 communities

produced the desired dose-response effect in the successful reduction of stunting in young children.

Less clear is if the project’s nutrition intervention was successful in also lowering the prevalence of

underweight and wasting. There are statistically significant discrepancies the final anthropometric data for

underweight and wasting between the two prime data sources, the surveys and the anthropometric censuses.

While the final November 2014 census indicates significant declines in both underweight and wasting for the

8 Monitoring and Evaluation Survey for the Western Highlands Integrated Project-Baseline 2013

16

children of Phase 1 communities (and in underweight for those of Phase 2 communities), June 2015 Final KPC

Survey shows effectively no change in these indicators.

That said, underweight and wasting can be relatively volatile and thus the time difference between November

2014 (the time of the last census) and June 2015 (the time of the Final KPC survey) – 7 months – could also

account for this discrepancy. Note that the two data sources agreed for the stunting measures: stunting is a more

gradual cumulative process that may not show significant changes over 7 months, while underweight and

wasting can change rapidly in that timeframe under the influence of food insecurity and increased child disease

incidence (particularly pneumonia/ARI and diarrhea).

There is some evidence to support the hypothesis that underweight and wasting may have increased

significantly between November 2014 and June 2015 as a result of a general deterioration in the local health

system during that same time period, which the project could not overcome. This time frame coincided with

severe disruptions in the Guatemalan government, riven by corruption and mass resignations and arrests of high

government officials. This was felt at the local level, with government clinics in the project area forced to close

at times when staff had not been paid for months. Worse, the Extension of Coverage (PEC) program of MSPAS,

which brought ambulatory nurses into the communities to provide critical preventive and treatment services such

as treatment of sick children and immunizations, was abruptly ended by the government in October 2014,

leaving families without affordable and accessible health services for sick children. The effect of the termination

of PEC is reflected in the Final KPC Survey, which shows significant drops in the coverage of key PEC-

provided services (e.g., immunizations and supplementation of Vitamin A). In addition, the project’s vital events

registration system showed during this very same period, between October 2014 and June 2015, a sharp rise in

infant mortality that coincided with the loss of PEC and this possible parallel spike in underweight and wasting.

These possibilities will need further investigation.

The successful integration of the Positive Deviance/Hearth (PD/Hearth) intervention into the CBIO+Care

Group service platform must be noted. The CBIO community registers and maps and CBIO’s use of routine

home visitation enormously facilitates the identification of both the positive deviants and the malnourished

children needing follow-up attention. The Care Group training cascade provides a ready community

infrastructure and volunteer labor force for the implementation of the hearth workshops (talleres hogareños).

The project’s PD/Hearth intervention also confirmed that there are locally available and affordable nutritious

foods and that extremely costly food supplementation programs with their warehousing, logistics, and

distribution challenges, may not be necessary (barring natural and made-man disasters).

The contribution of the Care Groups also must be noted, and goes beyond the talleres, revealed by the

statistically significant increases from Baseline KPC Survey to Final KPC Survey in the communities of both

Phases in key household behaviors that impacted nutrition, which included proper Infant Young Child Feeding

(IYCF) (percentage of infant and young children 6-23 months fed according to a minimum of appropriate

feeding practices); prompt care seeking and treatment of children with symptoms of pneumonia/ARI; use by

child caretakers of Oral Rehydration Therapy (ORT) during a diarrheal episode; appropriate point-of-use

treatment and storage of water; and hand washing at critical moments (after defecating, after cleaning a child,

before preparing food, and before feeding a child).

The significant decreases in stunting and underweight detected by the censuses in 0-5 month old children

confirms the Project’s success in increasing the practice of exclusive breastfeeding for this age group and

validates the Project’s strategy of utilizing Self-Help Groups, support groups for lactating mothers (Círculos de

madres lactantes) and Comunicadoras to both monitor and encourage this behavior at the household level.

Thus, it appears that the CBIO+Care Groups methodology’s combination of routine home visitation guided by

community registers and maps, the Care Group training cascade for bringing skills and knowledge and life-

saving behavior change to every door, combined with the PD/Hearth intervention for empowering communities

to improve child feeding practices with their own available and affordable resources can produce significant

improvements in child nutrition over time.

17

6. Limitations

The statistically significant differences in the data for underweight and wasting between the June 2015 Final

KPC Survey and the November 2014 final anthropometric census (barrido) may call into question the accuracy

of one or both of the data sources. That said, the 7-month time difference between the final measures of the two

data sources may render them not comparable and, therefore, not mutually confirmable, as underweight and

wasting can change significantly in that time frame.

The Baseline KPC survey was done in January, the cold dry season when there is a seasonally lower incidence

of diarrhea. The Final KPC was done in June, during the rainy season, when there is a seasonally higher

incidence of diarrhea, which contributes heavily to underweight due to water and nutrient loss.

The project’s 2015 Final KPC Survey anthropometric data is not sufficiently comparable with the

corresponding data for the 2013 WHIP household survey because the project weighed and measured under-two

children while the WHIP survey weighed and measure under-five children.[Note that the latest DHS Survey data

for Huehuetenango, had it been available, would also provide anthropometric data for uner-5 children]. Given

that the development of stunting is a cumulative process over the course of a child’s growth, if sufficient

nourishment is not provided from ages 2 to 5 we would expect higher prevalence of stunting in under-five

children than in under-two children, and so this calls into question the comparison for stunting.

7. Conclusion and Recommendations

The operational research evidence supports the hypothesis that the CBIO+Care Group methodology –

particularly when integrated with the PD/Hearth methodology- can produce superior results over time in

changing key nutrition-related behaviors and in reducing malnutrition in young children in the rural indigenous

population of Guatemala, particularly stunting.

Recommendations:

1) Develop and implement rigorous standardized anthropometry training and quality control curriculum and

evaluation tools to ensure accurate weighing and measuring of children by staff implementing growth

monitoring, anthropometric censuses, and household surveys. Consider developing with MSPAS an official

anthropometric skill certification to be required of all data collectors and project staff performing anthropometry

on young children.

2) Continue doing anthropometric censuses, but less frequently, to ease the strain on human and other resources

that are required. Consider a bi-annual census – one done during the cold/dry season (December through March)

and a second during the wet/rainy season (June through October), with the first census triangulating the baseline

KPC Survey data and the last triangulating the Final KPC Survey data.

3) The moderately high levels of wasting detected by the Final KPC Survey are alarming and call for further

investigation to confirm these results, ascertain the causes, and respond quickly with treatment and prevention.

4) Conduct Barrier Analyses and other qualitative research to 1) identify the specific barriers to the consistent

practice key nutrition-related behaviors (such as exclusive breastfeeding) in order to tailor interventions that

specifically address those barriers; and 2) to better understand and respond to the socio-economic and cultural

factors that impact child nutrition, such as traditional customs and belief systems, and male dominance and

control of family resources.

5) Perform further operational research for the effectiveness of PD/Hearth integrated into CBIO+Care Groups to

secure more hard evidence that behavior change and the use of locally available and affordable foods can resolve

the endemic malnutrition among the rural indigenous population in Guatemala, making unnecessary expensive

programs of food supplementation which, besides their great cost for warehousing and distribution, distort

agricultural markets and family behaviors, as does the UNICEF/MSPAS bolsa solidaria through which many

18

families intentionally keep young children malnourished so they can continue to qualify for a free monthly

package of food.

6) Capitalize on the MSPAS nutrition initiatives Pacto Cero Hambre (Zero Hunger Pact) and La ventana de

1,000 días (The Window of 1,000 Days) and on the post-election change in administration to secure MSPAS

logistical and financial support for the CBIO+Care Groups+PD/Hearth approach to nutrition, ideally through

integration with the Extension of Coverage Program if and when it is re-instated.

7) Secure a project partner NGO with expertise in community-based agronomy and animal husbandry who can

utilize the CBIO+Care Groups service platform to help families locally produce nutritious foods, such as through

family kitchen gardens (huertos familiares), raising chickens and rabbits, and raising goats for milk and meat.

Also secure a project partner NGO with expertise in implementing projects for micro-loans and micro-

enterprises for women to give women the skills to produce their own income which they can utilize to improve

the nutrition of their children.

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