The Wheel of Practices for Better Living: A Strategy and Tool for Promoting Maternal Health and Preventing Chronic Under-nutrition
"The power of the Wheel and its implementation strategy lies in that it was conceived as a process that actively involves the participation of 1,000 Day families and the community, individually and collectively, rather than serving as a passive didactic tool."
In order to address some of the multiple causes of chronic malnutrition in Guatemala, the United States Agency for International Development (USAID) Community Nutrition and Health Project - Nutri-Salud developed the Wheel of Practices for Better Living strategy in collaboration with the Guatemalan Ministry of Health (MOH). Formally adopted in 2015, this material and its use by the family and during home visits comprised one of the MOH's official health promotion strategies in 2015 and 2016. This document from University Research Co., LLC (URC) describes this social and behaviour change communication (SBCC) strategy from its design through implementation, seeking to capture its uniqueness and impact through the voices and experiences of its diverse stakeholders. The purpose of the document is to explore the challenges and accomplishments of The Wheel of Practices strategy, sharing some of the lessons learned and best practices derived from this experience.
In the country's Western highlands, poverty rates for the indigenous population are estimated at 76%, and two of every three children under five are chronically malnourished. Chronic malnutrition is so common in the region that most people there are unaware of the condition. Since 2012, Nutri-Salud has endeavoured to support the Guatemalan MOH to address this situation in the Western Highlands. The project had three broad aims: to improve the nutritional status of women of reproductive age and children under five by implementing the seven essential nutrition actions, focusing on "the first thousand days" (i.e., during pregnancy and the first two years of life); to strengthen essential maternal, neonatal, and child health care and family planning services at the community level; and to engage communities in active solutions to their health care needs through community mobilisation, SBCC, and links to local government structures. This project operated under the broader umbrella of USAID's Western Highlands Integrated Program (WHIP), a framework designed to promote the collaborative implementation of US-government-funded programmes in 30 municipalities in five departments in the Western highlands (see Related Summaries, below).
Guided by a behaviour-centred programming approach, Nutri-Salud (2012-2017) focused its strategic approach on preventive actions that could be taken at the household and community level and on improved delivery of quality health services at the primary level. Designing the SBCC strategy and the development of the Wheel tool and accompanying counseling cards was a long and multi-phased process involving a number of actors. For example, a literature search undertaken by a consultant anthropologist revealed that among the principal weaknesses of previous projects had been lack of sufficient knowledge and understanding of the Mayan worldview related to key maternal and child health topics and ideas such as prevention. Displaying the desired behaviours in a Wheel came after thorough analysis of barriers and how to overcome them, as well as the recognition of the need to design ways to involve whole families, communities, and local-level organisations, not just caregivers, in changing behaviours.
The final version of the Wheel - available here in PDF format - developed over almost a full year of pretesting, vetting, and development of implementation details, was a large vinyl poster distributed to health practitioners to be given and explained to families to hang in their homes. It presents an illustrated set of 19 practices, divided into colour-coded sections that correspond to different phases of the 1,000 days: pink for five practices during pregnancy, green for seven practices for children from birth through age two, and blue for seven "daily practices". The format was selected because of its resemblance to the Mayan calendar and the fact that it presents all of the key practices and "holds them in place", in the words of one of the designers. During 2013, the Wheel was validated in the field in all the priority geographical areas, using three alternative versions, in order to determine its potential utility based on such criteria as didactic clarity, aesthetic appeal and attractiveness, cultural acceptability, and persuasiveness.
One component of the strategy used the Wheel as the centrepiece of home visits by community health workers, who, after reviewing the Wheel's practices with the family, discuss, for example, a commitment with the pregnant mother to integrate one to three of the key pregnancy practices into her life that she might not currently be doing or doing optimally. The project developed key support and guidance materials for health workers to ensure the most effective use of the Wheel, including: counseling cards and operational guides for the home visits; training materials for capacity-building for implementers, and recording and monitoring tools for tracking program coverage as well as progress on the selected practices. The other two strategy components seek to connect the key actors who affect health outcomes at the local level: other family and community members and community leadership. Other family and community members are engaged through interactive group sessions that familiarise the participants with the key 19 practices and allow discussion of how people have modified their practice and with what effect. And community meetings and smaller working sessions with community leadership serve as a mechanism to ensure that health is seen as a community issue, as well as strengthening the ties of health workers to the community. (See an entire section of the document on the role of community action in health and nutrition.)
In June of 2015, the Wheel was officially adopted as a key policy of the MOH, with a focus on significantly expanding the Wheel strategy with the objective of reaching 41,000 (later expanded to 55,000) families in six priority Health Areas (Huehuetenango, Quiché, Totonicapán, San Marcos, Ixil, and Quetzaltenango). The MOH recognised that implementing the Wheel strategy meant more than distributing the Wheels. Multiple home visits are a critical feature of the Wheel's strategy and, given the extreme shortage of community-level health promoters, the MOH and Nutri-Salud needed to devise a functioning model of alliances with other local partners that could shoulder some of the responsibilities of integrating the Wheel into primary-level health-care programming. The number of partners rose to 19 by January of 2017. At a March 2017 conference, representatives of the partner organisations discussed the challenges and benefits of implementing the Wheel, seeing it as a strategy that allows them engagement with the families in a systematic and straightforward way.
Seeing the need to reinforce the Wheel behaviors broadly, in 2017 Nutri-Salud launched a radio campaign with short spots on 11 of the 19 behaviours. Broadcast in Spanish and local languages, these spots address common doubts about some Wheel practices. For example, in Huehuetenango, Radio Mass and Radio Kayros, covering largely rural areas, are broadcasting the spots to popularise, reinforce and deepen understanding of the key practices. These spots will also be broadcast in waiting rooms of health centres.
Between October 2015 and April 2017, the programme grew from 2,264 participating families to over 55,000 in the WHIP area. By the final months of 2016, those with a Wheel for more than 6 months had a follow-up visit and many families had multiple visits. The Wheel was generally well received by the local-level health staff who carry out the home visits; most health staff see it as an important mechanism to improve health outcomes and strengthen the bond, often fragile, between the community and health services. Many health promoters and other local health workers share the sense that the materials play a strong motivational role, both for health staff and for families.
A series of case studies was carried out with families in two distinct regions, looking at percentages of families who say they were following the 19 practices when they got the Wheel (at the first visit) with the percentage that said they were following the practices after a year or 2-3 follow-up visits. One finding (see page 13 for more results): Comparing initial practice for the seven "everyday" behaviours to practice after a year's exposure to the Wheel, uptake of the behaviours improved across the board, usually with 7-10% more families reporting following the practice.
Challenges to implementing the Wheel strategy have included: the chronic shortage in human resources to carry out the family visits; the socio-economic situation of the families (some practices on the Wheel place real financial challenges on families and necessitate community action); circumstances where domestic violence, alcohol abuse, or mental illness are at the root of highly dysfunctional families; and the potential disillusionment by families when those practices promoted by the Wheel that urge to visits to health services do not always result in receiving the desired service.
The document concludes that, while "the sustainability of efforts to expand coverage and participation of communities in the Wheel strategy over the last years has faced some uncertainty due to shifts in MOH policy, there are a number of initiatives and ways in which Nutri-Salud and local MOH departments have deepened ownership of the Wheel over time, suggesting that it has roots to sustain it and can continue to bear fruit....Nutri-Salud's policy of alliances and partners was a crucial and necessary step in 2015-2016 to help ensure the expansion of coverage of the Wheel...As the Nutri-Salud project comes to a close, some analysts...argue that the Wheel strategy now has its own 'legs' and has proven itself to be an invaluable tool and best practice, with the flexibility to be used under different circumstances. They argue that the Wheel has already set in motion important processes for tens of thousands of families, and that even if progress is slow, results will be seen over time..."
Click here for the 24-page document in English (PDF).
Click here for the 24-page document in Spanish (PDF).
You might also be interested in La Guía de Uso de la Rueda de Prácticas Para Vivir Mejor (User Guide for the Wheel of Practices for Better Living), a companion guide (in Spanish) to La Rueda de Practicas Para Vivir Mejor (the Wheel) [PDF]. It is designed to support community health workers in their home visits to families.
Emails from Mike Favin and Anna Kark to The Communication Initiative on July 6 2017 and July 14 2017, respectively; and URC website, July 7 2017. Image caption/credit: Family visit. Nutri-Salud photo archive