HEALTHY HOMES PROJECT: Cook stove construction

We invited the groundskeeper of the health post to serve as our Master Builder during the construction phase of the project because he had participated in a training session that I coordinated within the previous year.  

Happy mom with her new AMIGA Design improved cook stove

In the photo, you can see the opening where firewood is placed inside the tunnel underneath the iron cooking surface.  If the cook is not using all of the holes (on which the pots are placed) they should be covered and the smoke gets forced through the tunnel and into the chimney at the end of the tunnel.

The base of the cook stove serves several purposes: to make the cooking surface higher, which saves the cook from back strain when bending over a fire, and it reduces the chances that the kids will come into contact with burning firewood. Inside the base is sand filler, but directly underneath the tunnel (inside the base) are ingredients that help maintain a consistently high heat: broken glass and one kilo of salt and one kilo of sugar.

Months prior I had presented a list of materials with costs included to the local municipal government to request support for the project.  I spoke directly with the Gerente (Comptroller) of the municipality who assured me that there would be sufficient funds to buy the materials when we were ready to begin building.  It was no surprise that months later the funds had run out and we were left wondering how to pay for the materials to build the cook stoves.

Altogether, the cost of the materials to construct 35 stoves and pay the master builder adds up to about 8,000 soles (under $3,000).  I increased the number of cook stoves to 35 to include stoves for the seven volunteer health promoters who had worked diligently to conduct house visits and complete the monitoring forms.  At this point in the project, two participants had voluntarily dropped and no longer wished to participate, leaving us seeking funds to purchase materials for the remaining 28 participants and 7 health promoters.

Luckily, Peace Corps has a small grants program and is able to fast-track grant applications through several U.S.-based funding sources.  Unfortunately, there were no small grants available for health projects.  But, there were funds available for environmental projects, so I added an environmental education component and tree planting activity, and I successfully argued that the stoves reduce deforestation because they utilize less firewood.  It creates more work for me, but it’s worth the pain in order to get the necessary funding.

With the grants funds burning a hole in my bank account, I negotiated the welding of the metal cooking surface and the conical hat that rests atop of the chimney from a welder in Chulucanas, recommended by Peace Corps’ cook stove consultant.  A local welder in La Union made the iron chimney support, and I ordered 3,000 bricks from a local brick maker in Monte Redondo.  All of the other outstanding materials I was able to purchase from local hardware stores in La Union.   Purchasing the materials was challenging, but it was not the hardest part.  The real challenge was to arrange for transportation of the welded materials from Piura, and the bricks from La Union.

Given that the municipality was not paying for any of the materials that they had originally agreed to purchase for the project, it seemed fair that they could at least provide transportation for the materials.  Arranging transportation turned out to be a challenging and frustrating task.  First, I submitted a request to the Mayor for transportation of the materials.  My request was approved, but in order for the logistics manager to arrange transport, I needed a document from the municipality stating the exact dates and specifications of what would be provided.  Weeks later I finally was able to obtain the proper documentation that would allow me to bring the welded materials from Piura to my community.  The second half of my transportation dilemma was still unresolved, and it took a full month for the municipality to transport the mountain of bricks from the brick maker 10 minutes away to the health post in my town.

In June we were finally able to begin construction!  In preparation, the master builder and I built a model stove and discovered that the number of bricks needed would be much higher than we anticipated.  The recommended number of bricks to use to construct the “Amiga” style stove is 200, but with the measurements we were provided (80cm wide x 70cm tall x 180cm long) there would be no way to build it to those dimensions with only 200 bricks.

The master builder and I decided to shorten the design to 140cm long, cutting off 40cm length and saving 50-60 bricks.  Additionally, we decided to fill the base of the stove with dirt to save precious bricks.  These design changes allowed us to build each stove with as little as 220 bricks.

I should add that the Peace Corps recommendations are to ask the participating families to purchase bricks or make mud bricks using locally available (free) ingredients.  The people in my community do not use mud bricks for historical reasons and when asked about the possibility of making mud bricks or buying traditional bricks every family responded negatively.   In the 1970s there was a devastating flood that occurred in my community and everything was lost or destroyed, except that which was made from brick or cement, hence everything is reluctant to build anything with mud.   Furthermore, the participants of the project do not have the funds to buy bricks, so the responsibility to provide them fell to the project coordinators.

All of the materials were brought to the health post and the families were notified that they should collect the materials from the health and bring them to their homes at least one day prior to their specific build date.  The master builder, who is also the groundskeeper at the health post kept track of the materials and communicated with the families to arrange for pick-up.

Building a stove is backbreaking work for someone who is more accustomed to working in front of a computer.  I exercise almost every day (to the amazement of people in my community) but shoveling mud and hauling bricks for 3-4 hours was almost beyond my physical capacity.  Even though we had a helper from each family, and often one or two younger family members helped out, it was still quite demanding work.  

Click here to read about the project challenges.

HEALTHY HOMES PROJECT: Challenges

The challenges to properly managing the Healthy Homes project were numerous, but clearly not insurmountable.  The professional isolation was the most difficult aspect of the project for me because the responsibility to drive interest and participation in the project among community members and health workers fell completely on my shoulders.  This was not an easy task, given that the profession of public health does not exist in Peru and prevention work was an entirely new concept for my Peruvian colleagues.  I introduced them to the idea of setting goals and objectives, and measuring progress toward them.  I taught them about proper data collection and analyzing the results to identify trends and determinants of health.  I showed them how to develop programmatic interventions, organize educational sessions and evaluate the programs’ effectiveness.  Not easy tasks, given that the health center staff were often overwhelmed with patients and last-minute urgent requests from the regional health department and from the local municipal government.  Meetings were often cancelled and nothing happened until very last minute, but the project was completed on time, under budget, and with outstanding results.

 There were additional unforeseen issues to tackle.  One involved the unfortunate passing of my main contact at the Municipality only a few short months after my arrival.  Losing my biggest cheerleader at the Municipality created a vacuum of support for my funding request, which was denied.  I was provided with material support for the educational sessions, but no financial support to purchase the necessary materials to construct the improved cook stoves.  I scrambled to quickly find funding, as the delay in moving forward with the project could have pushed it past the deadline.  Fortunately, my grant application for small project assistance funds from USAID was approved and the project continued with only a short delay.

Another challenge arose when the Municipality launched an initiative very similar to my Healthy Homes project which competed for funding and resources with my project.  My project utilized a group of volunteer health promoters to organize educational sessions and conduct house visits.  The municipal initiative also utilized the health promoters to organize educational sessions, some of which covered the same topics as mine.  The overlap stretched thin the health promoters’ ability to properly organize and attend all sessions, and I had problems with health promoters not following through and not showing up.  In addition, there was confusion among the participants of my project, some of which were obligated to attend the other educational sessions, and they didn’t understand why it was necessary to attend two sessions.  I worked very closely with the health promoters to avoid overlap and confusion, and I notified participants of the change.

After completing the four educational sessions, we reviewed the attendance records of the educational sessions and discovered that only about one-third of participants had completed the requirements of the program.  After discussing with my colleagues, we decided to repeat the four sessions a second time and offer a second chance for participants to complete the program.  After repeating the sessions, we reached 83% attendance.

Please continue reading to find out the results and discover the exciting conclusion of the Healthy Homes Project.

HEALTHY HOMES PROJECT: Results

The results of the final evaluation show that the program was a great success, despite the many challenges. 

Before launching the behavior communication intervention, the knowledge and behaviors of mothers in the five categories were measured using the Baseline Survey. After participating in the project, the knowledge and behaviors of participants were measured for a second time, using the Final Survey (an adaptation of the Baseline Survey).  The results of the surveys were compared to determine the degree to which participating mothers had adopted knowledge and attitudes that serve as the foundation for a healthy home.

Results of the final evaluation showed improvements among participants on 18 of 22 behavioral indicators, including the following notable results:

Indicator	Before intervention (baseline)	After intervention (final)
Mothers demonstrate the correct manner to wash hands	48%	78%
Mothers drink safe water	88%	100%
Mothers maintain water receptacles clean and covered	48%	89%
Place to wash hands exists in the home near the kitchen and/or the bathroom	24%	97%
Mothers know the correct ingredients (and quantity) to prepare ORS	24%	75%
Mothers mentioned at least 2 new practices adopted in the previous few months to maintain a healthy home	n/a	66%
Mothers exclusively breastfed child until at least 6 months of age	92%	100%
Mothers name foods high in protein	67%	84%
Mothers recognize the symptoms of pneumonia	53%	81%
Mothers use improved cook stove every day	n/a	68%
Mothers engage children in activities to stimulate early childhood development	44%	80%
Mothers mention at least 3 improvements in the physical or mental development of their child	N/A	97%

Most importantly, 17% of participating children who were underweight or under height for their age prior to launching the program had recuperated weight and/or height to fall within the normal range by the end of the program.

The results are impressive, but we must consider the confounding effects that influenced these results due to the overlap of some mothers who were also enrolled in concurrent projects mandated by the regional government.  All 30 families had also participated in the JUNTOS program and five families had also participated in the Familia Feliz program.

The JUNTOS program coordinated with the health promoters to organize compulsory lectures on various topics related to the health of the family and maintenance of the household.  Some topics presented to the participants of the JUNTOS program overlapped with the topics presented in the Healthy Homes program.  While this overlap caused confusion among participants, and burdened them to comply with similar requirements of two programs, it may have provided the benefit of reinforcing the same message across programs.  The repetition of key messages and additional opportunities to practice new behaviors may have improved recall and sustainability of behavior changes.

The Familias Feliz program was focused entirely on showing mothers how to engage their children in activities that stimulate early childhood development and its narrow focus allowed them to delve deeper into techniques than we were able to do with the Healthy Homes program.  The five families enrolled in the Familias Feliz program (that were also enrolled in the Healthy Homes program) received much more in-depth guidance and training than the other participating families and likely benefitted from the additional intervention.

The only way to separate the effect of the additional interventions by other programs on the results of the Healthy Homes program was to compare the families in the Healthy Homes program who had received the intervention with families in the Healthy Homes program who had not received the intervention, but were enrolled in the JUNTOS and/or Familias Feliz programs.

Fortunately, we had three families that had received a cook stove but had not participated in the educational sessions nor the house visits, which meant that these families received the incentive to change behavior but did not have opportunities to gain knowledge or practice new behaviors through the Healthy Homes program.  If new knowledge and behaviors were adopted, it would have resulted from participation in the JUNTOS or Familias Feliz programs.

Because these families did not receive the intervention they can serve as a control group to participants in the Healthy Homes program. By comparing the knowledge and behavior of the group that received no intervention against the group receiving the intervention, we can determine with certainty that improvements in knowledge and behavior reflected by the Healthy Homes participants that were not reflected by the control group were the result of the Healthy Homes intervention.

The comparison showed that the eight indicators listed below were the result solely of the Healthy Homes intervention:

• Mothers hold water containers clean and covered

• Households that have a hand washing station

• Mother named at least two practices to prevent diarrhea

• Mother mentioned at least two new practices adopted in recent months to maintain a healthy home

• Mother named at least two signs or symptoms of a parasitic infection

• Mother named high-protein foods

• Mother engaged child in activities to stimulate mental and physical development

• Mother named three changes in the development noticed in your child

The remaining 14 indicators were most likely the result of the combination of effects from participation in the Healthy Homes, JUNTOS and Familias Feliz programs.

The health center staff has indicated a high level of interest in replicating the program, which will allow more families to gain the benefits of participating and hopefully lead to a greater community impact.

Please click here to read about the program benefiting adolescents in the same community.