|Guidelines for Training Community Health Workers in Nutrition (WHO, 1986, 128 p.)|
After studying this chapter, taking part in discussions, and doing the exercises, a community health worker should be able to:
· Collect information that will help to show what are the nutritional and nutrition-related problems and needs of the community.
· Decide which social groups, families, and individuals are at special risk of nutritional problems. These people are sometimes referred to as the "target population". Help should be given to this group in particular.
· Identify the nutrition problems, and, with the help of the supervisor, plan the actions or tasks to deal with these problems.
· Identify people and the organizations in the community that can help with the nutrition problems and prepare a list of what they can do, how they can help, and how to build an understanding with them. People who can help in various ways are sometimes called "resource persons".
· Decide which people are seriously ill and should be referred to the nearest health centre or medical supervisor.
Why should we know the community?
In order to help a community we must know what are its "actual" needs and what are its "felt" needs with respect to nutrition. The things a community wants, or thinks it needs (its "felt needs'), may not always be the same as the "actual needs"-the things that are really necessary. If we do not know the hopes and desires of a community it may be difficult to help the people. The "felt" needs and the "actual" nutritional needs should both be satisfied if a programme to improve nutrition is to succeed.
Services which are intended to help people will be most effective when the people themselves help in their planning and implementation. But first the people must realize that there are solutions to their problems. They must also have confidence in their own capabilities.
If they feel that a programme is being forced on them, they may oppose it and it will fail.
If you live in a community you may think you already know all about it. But to help a community to help itself, it is necessary to study it in detail. It is essential to know most of the people, and not simply the ones who live near you or the ones who appear to be important. It is essential to know their problems and what causes them. It is essential to know what people and what organizations can help in different ways. This requires a systematic study and the desire to understand and help people. The sections below consider the different things the community health worker needs to learn about a community.
Information that will help to find out the nutritional needs of the community
Good nutrition and good health go together. Malnutrition is a sign of poor health. Young children grow rapidly; therefore, their nutritional needs are great. A child who does not get enough food or the right mixture of food stops growing or grows Slowly. Growth failure is the first and most important sign of malnutrition. The growth of children is an important indicator of the whole community's nutritional status; it is considered in detail in Module 2.
One can learn about the nutritional problems of a community by finding out which children fail to grow properly and why. This can be done by carrying out a nutrition survey of all the children in the community. Every child who is below the age of 5 years is weighed and, if possible, his height is also measured, and this information is related to the child's age. This procedure will be further described in Module 2.
Grading of malnutrition
With the above information it is possible to divide all children below the age of 5 years into three categories:
· Well nourished
· Moderately malnourished
· Severely malnourished.
Additional information about each child
In order to understand why there is growth failure, it is important to collect some additional information about each child.
· Sex (male or female)
· Family's community group (religion, class, caste, etc.)
· Size of the family. How many children have been born in the family? Are child-spacing devices used?
· Health status of the family. Have any children in the family died? Is anyone in the family ill?
· Occupation of parents. What work does each one do?
· Child's food. What milk (breast milk or other) does the child drink? What foods and how many times a day does the child eat?
· Child's health. Has the child had any illness? Is he well now?
· Immunizations. Has the child been immunized? If yes, against what disease or diseases and at what age?
On the basis of this information it will be possible to see which major factors are associated with growth failure and malnutrition in the children in the community.
Information about the community
In addition to the information on children and their families, there are other factors that relate to the nutritional statue of the community. The community health worker can investigate these factors by finding answers to the questions listed below:
· How poor or how rich are the majority of the families in the community?
· Who owns the land in the community? (This applies particularly to rural communities).
· What are the patterns of work of the people?
· Is clean water readily available for drinking and washing?
· What are the community's beliefs and practices about food in disease and in health?
· What is the influence of seasonal changes on the availability of clean water and food, and on the health and economic status of the community?
This information can be obtained by careful observation, informal discussions with community members, and planned interviews. A detailed discussion of how each of these factors affect nutrition follows.
Economic status and education
The economic status of a family (whether it is rich or poor) is perhaps the most important factor affecting nutrition. It relates to things such as the ability to buy food or land or animals which produce food. One can tell the economic status of people by looking at their houses, furniture, clothes, etc. Such observation is important because people often do not like to discuss their financial matters. Education is another important factor affecting nutrition. The level of education of an individual can often be judged by talking to him. Education also depends on the family's economic status. Children in poor families start working instead of going to school.
In rural communities, the majority of the population are often farmers. The question of who owns the land becomes important in considering the nutritional problems. Often the landowners do not live in the community. Most farmers in such communities are landless labourers who have no say in what crops should be grown. The landowners may prefer cash crops (sugar-cane, tobacco, coffee, etc.) to food crops (wheat, rice, maize, etc.) because they bring in more money. This considerably reduces the amount of food that could be available in the community. Landless farmers are mostly paid low wages in cash, often insufficient to buy food from the open market.
In communities where the people own much of the land themselves, the following questions need to be considered in judging the community's nutritional status. Is the land that the family owns extensive enough to supply the family's food needs? Is the land irrigated? In many countries, most farmers do not own enough land to produce sufficient food to meet a family's need for a whole year. They have also to sell some of their produce to get cash money for other needs.
In communities where women also work, the following questions need to be asked. Can women take their very young children with them to work so that they can breast-feed them during the day? If the children have to stay at home, who looks after them? At what times of day or periods of the year do the mothers have more time or less time to look after their children?
Seasonal fluctuations in the availability of work, food, and water are common in some communities. Often different seasons are associated with epidemics of diseases such as diarrhoea, malaria, and measles. Landless labourers suffer most nutritional problems during the non-farming season when they have no work.
Information about the kind and amount of food available in a community is essential in considering nutritional problems. In many village communities small farmers and farm labourers have staple food grains which last only 4-5 months after harvest. After this they eat tuber roots, cereal gruels, and purchased food. Some families are partly starved as a result of this. In some areas, too, foods such as fish, milk, beans, and fruit are seasonal. When cash crops are grown instead of food crops, not only is the food production reduced but money may also be diverted to alcoholic drinks and to nutritionally inferior processed foods and drinks that cause nutritional problems. In some countries, the consumption of imported brands of aerated soft drinks is causing nutritional problems. The community health worker should discourage the consumption of such drinks because they are always expensive and have little nutritional value. Money spent on such drinks could be used to buy more nutritious foods. Regular home visits and market visits during different seasons of the year give information about the availability and cost of foods. The "hungry season" is a regular occurrence in many communities.
Food distribution within the family
The dietary habits and methods of food preparation are important. How and how often is the food prepared and for how long is it stored? How many meals are eaten each day, and are the children given any snacks? Are any special foods prepared for children? Within the family who eats what, who is served first, are the children fed separately and from their own plates? These factors influence how much nourishment a young child receives.
Beliefs about foods
There are important beliefs associated with food in all communities. These traditions and habits have a strong influence on what food is eaten. Some foods are of high prestige, others of low prestige, and some are for special occasions. Some foods are considered to be "hot" or "cold" in many countries because they are believed to heat or cool the body. Certain foods are forbidden in some families (e.g., animal foods among vegetarians). At different ages and stages of life particular foods are considered to be harmful; for example, certain fruits are believed to induce abortions in pregnant women, and other foods are thought to influence the development of the child in the uterus. The community health worker must know what people in the community believe about different foods. Only then will she be able to advise them appropriately.
In all communities there will be people who are ready to help. Their influence should be put to good use. Some people have special skills in the fields of art, music, poetry, or drama that can be used to spread messages about good nutrition habits. Some people in the community may have fears about health and nutrition programmes, especially when surveys are done and inquiries made about people's way of life and property. Excessive use of alcohol can be a major problem in some areas. The community health worker must know about all these matters and should be sensitive to people's feelings.
The methods commonly used in the collection of information are: review of available records, planned interviews using questionnaires, informal discussion, and observation.
How to decide who is at special risk of nutritional problems
Certain groups in the population are specially vulnerable to nutritional problems. These are children between the ages of 6 months and 3 years, and women who are pregnant or lactating. Families with pregnant mothers and young children can again be divided into groups at high and low risk by using information from the nutrition survey described earlier.
Children in developing' countries in the following categories are known to be at risk of becoming malnourished.
(1) All infants who have not been breast-fed for at least the first 5 6 months of life.
(2) Infants with low birth-weights, below 2.5 kg.
(3) Twin or multiple births.
(4) Children high in the birth order, i.e., 5th, 6th, or subsequent children in large families.
(5) Children in a family in which an older brother or sister died in the first year after birth.
(6) Children with illnesses, particularly measles, whooping cough, or repeated diarrhoea, especially in the early months of life.
(7) Children of poor families.
(8) Orphans or children with only one parent or those with an indifferent step-father or step-mother.
(9) Children whose growth curve does not slope upwards, as explained in Module 2. (10) Children who are cared for by older children because their mothers go out to work.
(11) Children with congenital defects, e.g., cleft-palate.
Certain groups of women are also at risk of malnutrition. This can affect not only their own health and capacity to work, but also that of their children. They are:
(1) Women who are wasted or grossly underweight at the beginning of a pregnancy.
(2) Women who gain too little weight (less than 6 kg) during the course of pregnancy.
(3) Women who have too short an interval (less then 6 months) between the end of one pregnancy and the beginning of the next pregnancy.
(4) Women who become pregnant before the age of 15 years.
(5) Women who have had more than five children.
(6) Women who have previously given birth to babies with a low birth-weight (less than 2.5 kg).
There may be special risk factors for women and children among different groups in the community. Hence, it is important to observe all social groups carefully.
Many nutrition programmes do not have enough resources: trained personnel or money. Therefore it is essential to concentrate the nutrition activities on those at greatest risk. It is known that concentrating in this way on a relatively small group of children and mothers can make a significant difference to the number of malnourished children and the number of deaths from malnutrition in a community.
How to identify nutritional problems and plan appropriate action
Once the information on nutrition in the community has been gathered, the community health worker and supervisor must analyse it. The main causes of malnutrition can be found by examining the social, economic, and health status of the high-risk groups. The problems of the community will be many and varied-from poverty to bad feeding habits-and so will the solutions to these problems. Health workers can do relatively little about poverty; probably the most they can do is to give their full support to community development programmes, and help poor families to use whatever they have more efficiently. But in the case of problems related to bad feeding practices, the community health worker can and should be able to do a lot.
A community health worker cannot solve all problems of the community-she must select those problems that she can do something about.
Problems related to poor feeding practices should be listed in the order of their importance, and of how common they are in the community. This should be done in consultation with supervisors and others who have experience in treating and preventing malnutrition and who also know the community well. Each problem should be considered separately to see if a solution is possible. A list of priority solutions can then be made. Selection of priority solutions will depend on the answers to the following questions.
· How easily can the activities be undertaken by the community health worker and community? How manageable are these activities?
· Are the necessary resources readily available, or can they be easily mobilized?
· How important is the solution to the community? (Ask the opinion of the community leaders.)
· How important is the solution to the community health worker?
· How frequent (i.e., common or prevalent) is the problem to be solved?
For each selected solution the community health worker specifies the tasks she has to perform and the activities the community will participate in. She also identifies the resources she needs. Finally, the plan of action is completed by specifying the schedule of tasks and activities. The community health worker should give priority to the problems that she can do something about, even if they do not seem very important by comparison with other problems in the community. Overcoming poverty may be the biggest problem for instance, and giving nutrition advice to the community may appear much less important, but it is Something practical that the community health worker can actually do. The priority list should be made up of tasks that are both important and feasible.
How to get to know and work with people and organizations that can help with nutritional problems
When finding out about the nutritional needs of the community the community health worker will meet many people who can help in solving nutritional problems. Such people will include "formal" leaders: the local religious heads, educated people like schoolteachers, postmasters, local doctors, landowners, heads of small industries, heads of women's or farmers' clubs, civil servants, and political leaders. It is also important to contact the "informal" leaders. These are people who do not hold any formal position in the community but are nevertheless influential and helpful. These people must be told about the importance of nutritional problems. They must understand how they can help, and their cooperation must be won. Their support will be essential in influencing the community.
The community health worker should seek the help of any government or private organizations working in the community. These will mostly include community development programmes and national nutrition supplementation programmes. The community health worker should have close contact with the schools in the community.
All community health workers will have a supervisor who may be a resident of the community or who may visit the community at regular intervals. The supervisor should be consulted about all the problems. In addition, if the community health worker is not herself a traditional birth attendant or traditional healer, she should seek the cooperation of such people. They know the people and have the confidence of the community, and they have much knowledge about common ailments and have provided health care for years.
There may also be programmes to increase the food production in the community, e.g., poultry and dairy farming development programmes, and those for improving fish ponds and home gardens. The community health worker should work closely with these. Other programmes that help indirectly include programmes for improved sanitation and water supply, and those for the control of infectious diseases and for family planning. She should also work closely with those working for an immunization programme, if there is one in the community.
Getting to know people is the first step towards working together with them. Some useful steps on how to know and work with the community are given below.
· Find out where the nearest health centre is so that difficult cases can be referred to it. Alternatively, such cases can be referred to the supervisor.
· With the assistance of the head of the community prepare a list (if one is not already available) of the organizations, formal and informal leaders, and personnel of both government and private organizations. Against each name write out their functions. It will also be useful to indicate what resource (finance or special skill or knowledge) each of them represents.
· Find out when the highest community body (this may be community council or some other equivalent body) meets. With the help of the village head, arrange to attend one of their meetings. If the community health worker comes from outside the community, this gives her an opportunity to be formally introduced to its leaders. It also provides an opportunity for her to explain her purpose and role in the community, and to present the findings (i.e., problems and solutions) of her nutritional survey. In this way she can learn the reactions of the leaders and seek their support. On this important occasion, she may be accompanied by her supervisor.
· If there is no such meeting, the community health worker arranges for individual meetings with the community leaders and personnel of community development organizations for the same purpose. An alternative and faster step is to be introduced formally to the people by the village head through a community meeting or assembly.
· Arrange for periodic exchange of information between the community health worker and the community. This can be done through periodic meetings with community leaders, and personnel of community development organizations. Such meetings also provide an occasion for discussing the progress of the work of the community health worker, the problems encountered, and the results expected. It is important to make the community feel that the programme belongs to it.
Deciding which people are seriously ill and should be referred to the health services
Some patients, especially small children, may quickly become seriously ill and die. These "high-risk" patients should be referred at once to the medical supervisor or sent to the nearest health centre. Some danger signs of illness will be described in Modules 6, 7 and 8.
This is a list of some high-riak patients who should be referred immediately to the nearest health centre:
· Small newborn infants who weigh less than 2.5 kg
· Infants or young children who lose weight during 3 successive months in spite of regular advice to the parents on what to feed the child
· Children with acute diarrhoea who do not improve with the special fluid within 1-2 days, and those with signs and symptoms of dehydration
· Severely malnourished children with other complications like fever, cough, and rapid distressed breathing
· Very anaemic (pale) women who are very thin or who have swollen legs.
1. Lecture: Training content.
2. Community survey: Collection of information on the nutritional needs of the community.
3. Group discussion: Results of the community survey.
Exercise 1. The food pathway-a problem analysis exercise
Ask all trainees to describe the pathway in the community between the production of food and its consumption by man (i.e., preparing ground for cultivation-planting-weeding-irrigating-harvesting-transporting-storing-selling-cooking-serving-eating-digesting ).
This path will have many local variations. In some communities food transport and food shops may be unknown.
Next, ask trainees to describe the different problems that can occur in the food pathway. Discuss with the trainees how the problems can affect the nutrition and health status of a community and how they might be overcome.
Exercise 2. Information collection and analysis
In this exercise trainees can work in groups of 2-5. Each group plans a simple nutritional survey, stating and preparing the following:
-the purpose of the survey
-specific information to be collected
-how the information will be collected
-questionnaires or special forms to be used in the survey.
If possible, the groups should use different methods for collecting the information.
Ask each group to carry out the prepared survey plan and put together the collected information. Each group should then present its findings and an analysis of the collected information. Now discuss the problems encountered in collecting and interpreting the information. Suggest solutions that could have been undertaken. Ask the trainees to discuss what they consider to be the advantages and disadvantages of the different methods used in the surveys.
Exercise 3. Preparing a plan of action
In this exercise the trainees should work in pairs. From the information collected in Exercise 2 ask the trainees to select one nutritional problem in the community and write out answers to the following questions:
1. What is the problem? Why was it selected? What factors caused it?
2. Which group in the community is the target population? Give a brief account of its social and economic conditions.
3. How can the problem be solved?
-What action has to be taken?
-What will be the result of taking that action?
-What resources are needed to take that action (what manpower, money, materials, space, time)?
-What is the timetable for the different steps in the plan of action?
-When and how is the progress of the action reviewed?
Each pair of trainees presents its plan of action. Discuss the advantages and disadvantages of each solution and how these could be improved.