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close this book Community Nutrition Action for Child Survival
close this folder Part I - Community nutrition problems and interventions
Open this folder and view contents Unit 1 - The nutrition of women and children
Open this folder and view contents Unit 2: Measuring and monitoring growth in young children
Open this folder and view contents Unit 3: PROMOTING BREASTFEEDING
Open this folder and view contents Unit 4: Introducing weaning practices in the community
Open this folder and view contents Unit 5: Preventing diarrhea
Open this folder and view contents Unit 6: Immunization
Open this folder and view contents Unit 7: Family planning and nutrition

Part I - Community nutrition problems and interventions


Unit 1 - The nutrition of women and children


SESSION 1: What is Malnutrition?

SESSION 2: Focus on the Nutrition of Women and Children

SESSION 3: Important Causes of Malnutrition in Women and Children

SESSION 4: Community Nutrition Action for Child Survival

Session 1: What is malnutrition?

Most trainees will have been exposed to basic nutrition principles in their work. This introductory session is intended as a review; however, it may include information new to some trainees. You should develop the session content based on a pre-training assessment of the trainees' knowledge about the nutrition of women and children.


Participants will discuss general nutritional requirements for growth and development. Inadequate diet and illness will be defined as the primary causes of malnutrition in individuals.

Time: 1-3 hours


- Flipchart and marking pens

- Slides and projector or posters showing the symptoms of severe malnutrition

- Handout - "Malnutrition"


1. Read the statement below to the group, or substitute statements about malnutrition in your country. Ask trainees to think about the statement for a few seconds.

"About 17 million of the world's children under five years old died last year; more than 12 million died from diarrhea, pneumonia, and contagious infections. Malnutrition was an underlying cause in all of these deaths. " UNICEF, A Child Survival Revolution, 1983

2. Ask trainees: "What is malnutrition?". Write the answers on the flipchart. Encourage as many answers as possible. The list will often include effects and causes, as well as definitions of malnutrition.

3. Referring to the trainees' answers in 2. above, give the definition of the term "malnutrition" as it will be used throughout the workshop:

Example: "Malnutrition is the physical and mental disability that results when the human body does not get the nutrients it needs to grow and function properly. "

4. Review the basic nutrient requirements for growth and development. Explain the classification of foods according to their primary functions in the body

(use the Basic Three Food Groups or the system of classification used in your country). In groups without nutrition background, conduct an exercise in which trainees practice classifying local foods or pictures of local foods according to their primary functions in the body, e.g., Basic Three Food


5. Ask: " Why do people become malnourished?"

Trainees will give a variety of answers. List their answers on the flipchart; then summarize by saying:

"We can see that there are many reasons people become malnourished. We will be talking about many of the causes of malnutrition during this workshop. In this session, let us begin by talking about the biological causes of malnutrition in the individual. "

6. Explain that the physical causes of malnutrition are:

- inadequate diet

- not eating enough food; not eating enough of certain kinds of food (e.g., foods from each of the three food groups);

- illness.

7. Explain how illness can cause malnutrition by:

- reducing the amount of food eaten;

- reducing the intestine's ability to absorb (use) the food eaten;

- increasing the body's demand for available nutrients.

Describe the body's reaction to specific illnesses (i.e., diarrhea, measles and parasitic infections) and how they affect food intake and use by the body.

8. Draw the cycle of malnutrition-infection to illustrate the following points.

- Malnutrition weakens the body, making it more susceptible to illness, so people who are malnourished get sick more often.

- Illness often reduces nutrient intake at a time when the body needs more nutrients than normal to fight infection.

- Repeated illness complicates and intensifies malnutrition.


9. Ask trainees to brainstorm the signs and symptoms of malnutrition. When they finish, add any additional physical signs and divide the signs into those related to Protein Energy Malnutrition (PEM) and those related to specific vitamin and mineral deficiencies. You may wish to illustrate the signs of severe malnutrition using slides or posters.

Remind trainees that these different types of malnutrition often occur together.

10. Summary

"In this session we have seen that malnutrition is the result of:

- not eating enough food;

- not eating enough of certain kinds of foods;

- illness.

In the next activities, we will be analyzing the nutrition problems of women and young children and identifying community activities that address the immediate causes of malnutrition."

Distribute the Handout - Malnutrition" as a reference.



Malnutrition has been identified as one of the world's most serious health problems and a major cause of death in infants and young children. Last year 17 million children under five years of age died throughout the world: 12 million of them died from diseases directly related to malnutrition. (UNICEF, A Child Survival Revolution, 1983)

What is Malnutrition?

Malnutrition is the physical and mental disability that results when the body does not get the nutrients it needs to function and grow. The body gets nutrients from foods. Foods contain different combinations of nutrients, so the body needs different kinds of foods to meet its nutrient requirements. The functions of food in the body can be divided into three categories building and repairing the body's tissues, providing energy and strength, and maintaining or protecting the body from illness.

The Basic Three Food Groups

In order to understand the combinations of foods necessary for growth and health, we often divide the foods according to what they do in the body. A common system for classifying foods is the Basic Three Food Groups. (There are also systems for classifying foods by function and nutrient content that include four, five and six classifications.)

The Basic Three Food Group System divides foods into Body-Building, Energy and Protective categories.

Body-Building Foods (protein) are used by the body for growth and repair of tissue. These foods are very important for everyone, but they are most important for young children who are growing very rapidly and for pregnant and breastfeeding mothers who are nourishing growing babies as well as themselves. The Body-Building Foods include milk, eggs, legumes, fish, meat, poultry, nuts, etc.

Energy Foods (carbohydrates and fats) are those that help us do all of the things we must do every day, i.e., work, walk, play, etc. These are very important foods and they usually make up the bulk of the diet. Energy Foods include cereal grains, roots and tubers, fats and oils, sugars, etc.

Protective Foods (vitamins and minerals) are those that help keep the body free from sickness and functioning properly. These foods include fruits and vegetables, especially dark green and yellow vegetables and fresh fruits.

The body needs some of each of these kinds of food every day to stay healthy. There are also special times when the body needs more food than normal to grow and stay healthy. These include periods of rapid growth, sickness and heavy physical labor.

What Causes Malnutrition?

When the body does not get enough of the foods it needs; when it does not yet the right combinations of food; or, when illness affects the body's ability to use foods properly, a person may become malnourished.

Diets may be deficient in the quantity and the quality of food consumed. This means that the amount of food eaten and/or the nutritional value of the food is below the daily human requirement. The minimum nutrient requirement varies according to the age, size and reproductive status of the individual.

Protein Energy Malnutrition (PEM), one of the most serious nutritional problems, is caused by inadequate intake of body-building and/or energy foods and is usually accompanied by nutritional anemia. Kwashiorkor and marasmus are two types of PEM.

Vitamin and Mineral Deficiencies also cause malnutrition. Anemia (iron), xerophthalmia (vitamin A), rickets (vitamin D) and goiter (iodine) are related to vitamin or mineral deficiencies. Some of these vitamin and mineral deficiencies also occur with protein energy malnutrition.

Illness affects the body's ability to digest and use food, as well as the amount of food eaten. Diarrhea is a good example of an illness that causes malabsorption as well as reduced intake of food. When diarrhea occurs, the intestine is unable to absorb many of the nutrients contained in the food. If the person with diarrhea is feeling unwell, or if there is vomiting, there will also be less food eaten than normal. In some cultures, children with diarrhea may also be taken off food during bouts of diarrhea. Because the body actually requires more nutrients than normal to fight infection, illnesses like diarrhea have a double impact on nutrition status.

What are the Effects of Malnutrition?

Malnutrition causes growth failure, increased risk of infection, physical changes in the body, illness, disability and death. Malnutrition impairs the body's defense systems for fighting infection, meaning that the malnourished become sick more often and suffer more from their illnesses than the well-nourished. This vicious cycle of malnutrition and infection leads to reduced productivity of workers, high drop-out and repeater rates among school children, a greater demand for health and hospital care, high expenditures by the government and waste of human life.






Hair changes

Lack of Body


"Flaky paint" rash

Building and


Swelling (edema)

Energy Foods








Lack of total


"Old man" look

food intake




Skin hanging on bones



Night blindness

Lack of


Bitot's spot

vitamin A






Pale conjunctiva ( eye)

Lack of iron






Pale mouth and tongue


Notched ribs

Lack of


Bowed legs

vitamin D


Enlarged thyroid

Lack of








* These are signs of severe forms of malnutrition. In most cases, people showing these signs have been malnourished for a long time. Although they may not have had visible physical signs of malnutrition, they may have experienced fatigue and sickness. In children, the first sign of malnutrition (PEM) is failure to grow.

Session 2: Focus on the nutrition of women and children


To describe critical events during pregnancy, breastfeeding and weaning that place women and children at high risk of malnutrition. To illustrate the relationship between malnutrition, infection and child spacing.

Time: 1-2 hours


- Newsprint and marking pens or chalkboard and chalk

- Wall chart - "Stages of Fetal and Infant Growth"

- Handout - "Stages of Fetal and Infant Growth"

- Handout - "Focus on Women and Children"


1. Ask trainees: " Who suffers most from malnutrition?" List their answers on the flipchart. Then explain that poor women and children under three years suffer most from malnutrition in both normal and disaster situations because of their special nutritional needs and susceptibility to diseases that can lead to malnutrition.

2. Display the chart - "Stages of Fetal and Infant Growth." Review the characteristics of pregnancy, early infancy and weaning in terms of the nutritional requirements and common illnesses and problems at each stage.

Use the table on the next page to prepare your presentation.




Nutritional Requirements

Common Symptoms


- 350 extra calories per day or about ½ extra plate of food each day*
- green leafy vegetables and meat to prevent anemia
- weight gain of at least 12.5 kg

- anemia
- inadequate weight gain
- low birth weight(<2500 grams)
- premature delivery
- maternal depletion

(0-6 months)

- 550 extra calories per day or about one extra plate of food each day
extra liquids for the breastfeeding mother
breastfeeding should begin immediately after birth (give colostrum)
- breastfeeding should be on demand
- breastfeeding for 4-5 months without supplements

- early introduction of foods other than breast milk leading to diarrhea and decreased production of breast milk
- early termination of
- use of feeding bottles leading to diarrhea and other infections

Weaning/ Breastfeeding
(6 months -2 years)

- begin giving semi- solid food by 6 months
- give 4-6 small meals per day from 6 months to 2 years
- continue breastfeeding
- high energy/mixed diet

- inadequate weight gain
- diarrhea
- measles
- other infections

* Calculation of additional caloric requirements are for a woman weighing 50 kg. Normal daily requirement is 2,000 calories; in pregnancy, calorie requirement increases to 2,350 calories; during the first six months of breastfeeding, it increases to 2,550 calories per day. Calculations for extra plates of food are based on the assumption that women eat three meals per day, under normal circumstances.

During the presentation, encourage trainees' participation in the following ways:

3. Emphasize the importance of a woman's health and nutrition to the health and survival of her child. Ask trainees to tell the group about cases of women they know who have been sick during pregnancy and how this affected the child.

4. Ask trainees: "What happens when an infant is not breastfed during the first year of life? Why do women stop breastfeeding?" Emphasize the role of maternal nutrition in successful breastfeeding. (This topic will be discussed in greater detail in a later session.)

5. Discuss the incidence and the effects of illness, especially diarrhea and measles, during the weaning period. Trainees should understand the need to deal with both illness and feeding habits to improve the nutrition of women and children.

6. Draw the chart below - Effects of Birth Spacing on Child Survival. Ask trainees to brainstorm reasons why large, poorly spaced families are more likely than smaller families to have malnourished children and children who die.

Effects of Birth Spacing on Child Survival

7. To summarize this session, divide trainees into small groups (four-five persons) and ask the groups to agree on one important rule to improve nutrition for each of the topics discussed during this session:

- Pregnancy

- Breastfeeding

- Weaning

- Illness

- Birth Spacing

Each rule should improve some aspect of the nutrition status of women and/or children.

8. When groups finish, ask them to present their rules for improved nutrition. Rules might look like this:

- Eat one extra plate of food every day during pregnancy.

- Begin breastfeeding immediately after birth.

- Do not give foods besides breast milk to infants under four months.

- Breastfeed to prevent diarrhea.

- Allow at least three years between the births of your children.

9. Close the session and bridge to the next:

"In this session, we reviewed the reasons for increased risk of malnutrition during pregnancy, early infancy and wearing. As managers, we are concerned with using our limited resources to produce the best results possible. In order to do that, we must decide who needs our help the most and who will benefit the most from it. In nutrition and health care, we emphasize the needs of mothers and children and strategies for working with them because they are the ones who suffer the most from malnutrition."

Distribute the Handout - "Focus on Women and Children" as a reference.

Stages of fetal and infant growth




Nutritional Requirements

Common Symptoms


- 350 extra calories per day or about ½ extra plate of food each day*
- green leafy vegetables and meat to prevent anemia
- weight gain of at least 12.5 kg

- anemia
- inadequate weight gain
- low birth weight(<2500 grams)
- premature delivery
- maternal depletion

(0-6 months)

- 550 extra calories per day or about one extra plate of food each day
extra liquids for the breastfeeding mother
breastfeeding should begin immediately after birth (give colostrum)
- breastfeeding should be on demand
- breastfeeding for 4-5 months without supplements

- early introduction of foods other than breast milk leading to diarrhea and decreased production of breast milk
- early termination of
- use of feeding bottles leading to diarrhea and other infections

Weaning/ Breastfeeding
(6 months -2 years)

- begin giving semi- solid food by 6 months
- give 4-6 small meals per day from 6 months to 2 years
- continue breastfeeding
- high energy/mixed diet

- inadequate weight gain
- diarrhea
- measles
- other infections

* Calculation of additional caloric requirements are for a woman weighing 50 kg. Normal daily requirement is 2,000 calories; in pregnancy, calorie requirement increases to 2,350 calories; during the first six months of breastfeeding, it increases to 2,550 calories per day. Calculations for extra plates of food are based on the assumption that women eat three meals per day, under normal circumstances.

Session 2: Focus on women and children

Women and young children are more likely than most other groups to become malnourished because of the events in their lives that increase their nutritional requirements. The body demands extra food during periods of growth, physical work and illness. Women and young children often experience two or three of these conditions at the same time. In many communities, their needs for extra foods are not met.

The period of greatest nutritional demand on women and children begins at conception and continues through the fetal and infant periods until about three years of age. The periods that demand greatest food intake and the problems associated with them are:


Pregnancy increases a woman's need for food. She is eating for two people, herself and the baby growing inside of her. If she does not eat the foods she needs, her baby may be born weak and sickly, and her own body and health may suffer. Even under optimal conditions after birth, infants who have been retarded in growth during fetal life sometimes continue to grow slowly for many years. They may also show a tendency towards poorer intellectual performance, compared with infants who grew normally before birth.

Mothers from poor sectors of society frequently have only an inadequate diet available and have very limited opportunities for proper antenatal care, including the prevention and treatment of anemia, malaria and other infections. This largely explains why lower birth weights are found in these groups. Poor diet may be caused by low income, inadequate food production, lack of knowledge about nutrition or food taboos imposed during pregnancy. Also, a woman's activity rarely decreases during pregnancy. Many women continue to till the soil, carry wood and water, and take part in other strenuous jobs until delivery.

To insure the best fetal growth and give every child a good start in life, it is important to prevent and treat infectious diseases and high blood pressure during pregnancy, and to make the mother and father understand the importance of a good and sufficient diet during pregnancy. In addition, both parents should understand the need to slow the mother's work pace, and so allow her to have sufficient rest before delivery.


Research has confirmed the universal superiority of mother's milk both nutritionally and from an anti-infective point of view. Breastfeeding is also valued for child-spacing and emotional bonding between mother and baby.

Breastfeeding should begin as soon after birth as possible. Colostrum, the first milk produced by the breasts after birth, provides important protection against infection as well as nutrients for the growing infant. To insure adequate breast milk production and growth of the infant, Breastfeeding should be "on demand. " Breast milk alone is sufficient for an infant from birth through four to six months of age. Breastfeeding should continue as long as possible (2-3 years) to provide continued protection from illness and important nutrients for growth and development.

Good maternal nutrition is important during the Breastfeeding period. Additional food and liquids should be consumed as in pregnancy. If the Breastfeeding woman's diet is inadequate, she may become weak. The quality of breast milk also depends on the adequate nutrition of the mother and, of course, the quality of breast milk affects the growth of the infant.

The declining pattern of Breastfeeding is one of the world's most serious nutrition problems. It has been estimated that some 10 million cases of infant marasmic diarrhea occur in developing countries each year, many as a result of early termination of Breastfeeding and introduction of feeding bottles and breast milk substitutes.


From six months to two years of age, Breastfeeding should continue, but a growing child also needs to eat other foods in sufficient quantities to meet his body's requirements. This is called the weaning period when new foods are gradually added to the infant's diet. It is a critical period in the life of the child, because new foods and exposure to contaminated foods, water and utensils mean that weaning age children are more likely to become sick from diarrhea and other infections. This is also a period of rapid physical and mental development. If children are not given sufficient amounts of food and a diet rich in body-building, energy and protective foods during these critical years, they will stop growing. They may become sick more often than well-nourished children, and some will die. Those who live, but have been severely malnourished during this period, may never reach their physical and mental potential during life.

Infection and Malnutrition

One of the greatest dangers of the weaning period is the change from sterile breast milk to animal milk, semi-solid and solid foods, which are often acquired, stored and fed in unsanitary conditions. The weaning process is associated with the highest rate of infection, particularly of the gastrointestinal tract, that the child will experience in its entire lifetime. Infections, in turn, prepare the way for malnutrition and increase the negative effects of an inadequate diet.

Diarrhea is the most common infection of the weaning period; it is also the disease that kills more children in the world today than any other. A malnourished child will get diarrhea an average of four times as often and is also more likely to die from a diarrhea! infection than a well-nourished child.

Measles, tuberculosis, malaria, whooping cough and parasitic infections also have very detrimental effects on young children during infancy and weaning. These illnesses are both made more serious by malnutrition and can contribute to malnutrition. Immunization and improved nutrition are the keys to preventing measles, tuberculosis, whooping cough and other serious childhood illnesses that can cause and make malnutrition worse.

Child Spacing and Malnutrition

The amount of time between births is very important for the health of women and children, as is the total number of births in a woman's lifetime. Infants are more likely to survive if at least three years are allowed between births. This gives a woman's body the chance to rest after pregnancy and breastfeeding, before beginning this demanding cycle again. Adequate spacing between births helps to avoid depletion of the woman's body and deprivation of the growing fetus.

Spacing also reduces the total number of births and increases each child's share of family resources, especially food. Children from smaller families with several years allowed between births are generally better nourished, better educated and more productive than those from large, poorly spaced families.

Session 3: Important causes of malnutrition in women and children

In Sessions 1 and 2, we discussed the biological causes of malnutrition and the special nutritional risks of women and young children. We know that a few simple practices (i.e. improved feeding, immunization, treatment of diarrhea and child spacing) could improve nutrition and save many lives. However, it is not always easy to spread and gain acceptance for these practices. Malnutrition is the result of complex socio-economic causes within the family and the community. Before we can promote improved nutrition practices, we must understand more about how and why people do things the way they do at present.


To explore the social, economic and cultural causes of malnutrition in women and young children.

Time: 2 1/2 hours


- Flipchart and marking pens

- Handout _ "A Story About Malnutrition"

- Handout - "Causes of Malnutrition in My Region"

- Trainer's Reference "Socio-Cultural Causes of Malnutrition"


1. Distribute the Handout - "A Story About Malnutrition." Read the "Story About Malnutrition" slowly, asking trainees to follow along as you read.

2. Ask trainees to re-read the story; then, ask them to list on a sheet of paper as many causes of malnutrition in the story as they can.

3. Now, ask trainees to state one cause at a time. List the mentioned causes on the flipchart. List each cause only once. Continue asking participants for causes until no new causes are given.

Expect the following causes of malnutrition:

- Family has rocky/infertile land

- Family is large - five births/four living children

- Elizabeth fed only starchy energy foods

- Mother believes eggs are bad for children

- Mother only takes children to health center when they are very sick

- Health care is far away from the village

- Mother does not know that lack of food is a reason for Elizabeth's sickness

- Belief that "evil eye" causes malnutrition

- Mother and grandmother have little time to care for young children

- Births have been spaced less than three years apart

- Drought sometimes destroys crops

- Frequent diarrhea

Explain that there are many interrelated reasons why women and children become malnourished.

Note: If the causes given by trainees are too general or vague, ask, "Why is that a problem?" until the answer given refers to a specific action, belief or condition causing the malnutrition.

For example:

- "People are poor" is a very general cause of malnutrition. It does not describe a situation that one could hope to change in a short period of time. "Ignorance" is another general reason that does not give us enough information.

- Two specific causes might be:

"Body-building foods (eggs, legumes) are produced in the village, but people sell them and use the money to buy rice, a less expensive staple food."

"Families do not know that their children's illnesses are caused by lack of food."

4. Invite a resource specialist to discuss the common causes of malnutrition in your country. Make sure the causes mentioned in the Handout - "Socio-Cultural Causes of Malnutrition" - are discussed.

5. Distribute the Handout - "Causes of Malnutrition in My Region. " Ask trainees to answer the questions on the handout about the causes of malnutrition in their own regions. Facilitators should assist participants during this exercise.

6. Hold a question and answer summary of this activity in which the resource specialist responds to questions from trainees about the causes of malnutrition in their regions.

7. Summary

"Before we can introduce changes in nutrition practices in the community, we must understand how people perceive nutrition problems and the constraints they have to accepting new practices. Constraints are forces against change. If we understand the constraints to improved nutrition, we will be better able to develop educational messages and activities that community members can understand and accept."



This story is told by (Maria), a 30-year-old woman from the village of (__). (Maria) is married to (John) and they have four small children. Last year (Maria's) fifth child died only a week after it was born. Now, (Elizabeth), the three year old, is sick with fever and a cough. Maria is very worried.


When my husband and I first came to (village) to live with his family, we had only one child, our oldest son (Peter). Now, (Peter) is nine years old, and he and his younger brother, who is seven, are studying in the village school. The two youngest children, (Jane) and (Elizabeth), are still very small. (Jane) is five and (Elizabeth) will soon be three.

Life has been difficult for us here in (village). Our land is rocky, and there are years when the rains come late and our crops fail. This year, my husband has been lucky to get work on a plantation about 40 km from (village). The money he earns on the plantation is little but with it we will buy rice this winter and seeds for next year's planting. While my husband is away, my mother-in-law and I must manage the house and the farming.

Today, I am very worried about my youngest daughter (Elizabeth). Poor little (Elizabeth), she has always been so thin and small. Now, she is coughing and coughing and she feels so hot. It seems as if God does not want her to stay with us for very long.

Last month, I took (Elizabeth) to the health center because she had very bad diarrhea. The health center is far and we must walk most of the way. I only take the children there when they are very sick and our own cures do not make them well.

At the health center, the nurse gave me some packets for the diarrhea. She also told me that (Elizabeth) needed to eat more food and that I should give her eggs and milk or meat every day. The nurse was very nice, but what she told me did not make any sense. Where am I to get these special foods for (Elizabeth)? The only time my family eats meat is at feast time when a goat is slaughtered. The milk the old cow gives is very little and if I do not sell it, who will pay the school fees for my sons?

I have a few chickens, but I am afraid to give their eggs to (Elizabeth). Is it not true that eggs are very strong food for such a small child? They will certainly make her stomach hot and cause more diarrhea.

I do not understand why (Elizabeth) needs such special foods. The other children are thin but they are not sick like (Elizabeth). They eat the same foods we have always eaten, (rice and soup) in the morning and the evening.

My mother-in-law says that (Elizabeth) has been bewitched. I am beginning to believe that what she says is true. Next week, I will arrange a cure for (Elizabeth) with (Don Miguel). (Don Miguel) is our village healer; he is very wise and will know what to do to make (Elizabeth) healthy.

To the Trainer:

Adapt or rewrite this story based on the most common causes of malnutrition in your country or region.

Discussion Starter:

List as many possible causes of malnutrition in this story as you can.



List all of the factors (beliefs, practices, social and economic conditions, etc.) that you feel are causes of malnutrition in women and children in your area. Be specific!



Factors affecting food availability and use within the family will determine how we go about introducing new ideas and practices to improve nutrition.

1. Traditional Beliefs and Food Habits

Every culture in the world has beliefs about food and certain practices that affect the foods people eat. Some of these beliefs and practices help people to stay healthy; others can be harmful.

A belief or practice promotes good nutrition if it encourages people to eat a food which is good for them. For example, in many countries it is common for women when pregnant and after birth to follow food taboos that encourage them to drink additional liquids and eat body-building foods like chicken or meat. In Africa, one traditional practice involved abstinence from sexual intercourse until a child could walk to his father carrying a plate of food (two-three years). This allowed the child to benefit from his mother's attention and, most importantly, from breastfeeding. It was also an effective method of family planning. It is important to remember that even if a belief seems to be unscientific, if it means extra food for someone who needs it, then the belief and practice should be encouraged.

Beliefs or practices which block foods from women and children are harmful and should be discouraged through education and example. These include any beliefs or practices that restrict foods or liquids from:

- pregnant and breastfeeding women;

- anyone with diarrhea, especially a young child;

- weaning-age children;

- anyone who is sick.

Some specific examples include:

- Trying not to eat during pregnancy so that the baby will be small and the delivery easy

- Not giving colostrum to newborn infants

- Withholding specific foods from children because they are believed to result in an illness like worms or a change in character

- Withholding food and water during diarrhea

- Feeding men and boys first or feeding them the largest portions

It is interesting to note that most food restrictions apply to those who need food the most - women, young children and people who are sick. These are the groups who most often become malnourished.

Beliefs about the causes of malnutrition in children also affect how families treat malnourished children and whether or not they will accept advice from outsiders. Most cultures have beliefs about what causes severe forms of malnutrition, and they often have a special name for the disease. Some groups believe that malnutrition comes from "the evil eye"; others believe an unfaithful husband or wife has caused it; still others believe that malnourished children have been contaminated by pregnant women or another malnourished child.

A thorough understanding of local food habits and beliefs is the key to working successfully with any community on nutrition problems. Remember:

- A belief or practice is considered helpful and should be supported if it encourages giving extra food and liquid, even if it is not based on scientific fact.

- Harmful beliefs and practices are those that restrict foods from the vulnerable groups.

- It is always best to encourage positive traditional beliefs and practices while trying to change harmful practices through education and example.

2. Food Supply

In rural areas, the amount and quality of a family's land, its income and its equipment affect the foods available for child feeding. The knowledge of farmers also affects the variety of foods they grow and their harvests. Environmental factors (i.e., rainfall, insects, etc.) have an effect on food supply, as does the demand for certain types of cash crops in the marketplace. In many areas, the switch from subsistence crops to cash crops has had a very negative effect on the amount and the kinds of food available in rural areas. A regular "hungry season" each year before the harvest can also be a serious problem. In urban and increasingly in rural areas, cash income is an important factor in a family's ability to buy food for child feeding that it does not produce.

3. Early Termination of Breastfeeding, Use of Feeding Bottles

This has become a problem in developing and developed countries in recent years. Urban areas, as well as some rural areas, are increasingly bombarded with advertising promoting the use of feeding bottles and infant formulas. Middle- and upper- class women who have tended to accept this advertising are poor role models for their rural and less advantaged "sisters." The lack of financial resources needed to purchase breast milk substitutes, the lack of clean water in most areas and poor environmental hygiene combine to make bottle feeding a deadly practice. All mothers should be encouraged and helped to breastfeed their infants; those who cannot breastfeed should be taught hygienic practices and the use of cup and spoon for feeding their small children.

4. Time Available for Child Care and Feeding

This is one of the factors that is often overlooked when thinking of child health and nutrition. In most societies, the mother is the individual responsible for the care and feeding of the family's young children. She is often responsible for a variety of other tasks at home, in the fields and in the marketplace as well.

We know that young children must eat more frequently during the day than older children and adults (four-five meals per day). If family meals are normally prepared only twice each day, it may be difficult for a mother who is working in the fields, gathering firewood and food for the animals or fetching water to feed her young children as many times each day as she should. To save time she may feed the baby foods that are of the same consistency as those of the adults, or the baby may be given to an older sister who is sharing a bowl with the rest of the children while trying to feed herself and the baby.

5. Women's Health

It is estimated that about half of non-pregnant and two-thirds of pregnant women in the developing world suffer from iron-deficiency anemia (WHO 1979). Anemia affects a woman's ability to care for herself and her young children because it makes her feel tired and weak. Anemia during pregnancy and breastfeeding can have serious effects on unborn or breastfeeding infants. Other common conditions that affect a woman's ability to care for herself and her young children include malaria, gastro-intestinal disorders and parasitic infections. The availability of health care services can be critical not only to the health of women but also to the health and nutrition of their children.

6. Women's Status and Education

Attitudes toward women's roles in the family and in society affect all aspects of their lives, including diet, work, education and access to health care. Increasing women's education and income can have very positive effects on their decision-making roles in the family and on the nutrition and health of their children.

7. Large Families, Poorly Spaced Births

All of the problems of food availability and time for child care are worsened when there are many children to feed and care for. In addition, a woman who has had many pregnancies (more than five) has a good chance of being sick herself, with little energy to meet the demands of her family.

Traditional beliefs play an important role in determining family size and spacing of births. Attitudes toward male and female roles, the value of male children and children as security in old age are important. Competition between wives in polygamous situations also affects family size.

8. Accessibility of Health Information and Services

Preventive and curative health care facilities are often located at a distance from the rural village, implying a long walk and/or transport costs. Women may have little time to participate in the activities of the health center even when activities and health workers are located at a reasonable distance. Health information may not be available to families for the same reasons given above or because ethnic and class barriers make it difficult for them to seek and understand such information.

Session 4: Community nutrition action for child survival


To introduce six community-appropriate nutrition and health interventions that can reduce malnutrition and improve child survival through growth monitoring, promotion of breastfeeding, improved weaning practices, oral rehydration therapy, immunization and family planning.

Time: 1/2 hour


- Handout - "Community Nutrition Action for Child Survival "

- Trainer's Reference - "Estimates of Child Survival through Intervention"

- Newsprint and marking pens

Note: This session can be used as an introduction to the following units in Part I of this module.


1. Introduction: In the previous sessions we discussed the many causes and effects of malnutrition in women and children. What can be done to improve nutrition and thus, the survival and quality of life for women and young children? There are probably as many ways to improve nutrition as there are causes of malnutrition. Some interventions are more expensive and more time consuming than others. Some require highly trained "experts." Many, however, can be carried out by community members and families if they are given only a little training and support.

What are these community nutrition interventions?

2. Distribute the Handout - "Community Nutrition Action for Child Survival." Review each of the six interventions with the trainees. These interventions and the roles that community members can play in their introduction will be covered in detail in the following units.

3. Use the UNICEF estimates of child lives that could be saved each year to demonstrate the dramatic effect that these simple interventions could have on child survival.






No. of Deaths
Per Year

Lives that
Could Be Saved

Community Interventions

Low birth weight

3 million

1 million

- Growth monitoring
- Maternal nutrition
- Breastfeeding
- Improved weaning
- Family planning

Immunizable diseases

3.3-5 million

3-4.5 million

- Immunization


5 million

2.5-3.5 million

- Oral rehydration therapy


13 million

9 million



Adapted from UNICEF. "A Child Survival and Development Revolution. "

Assignment Children. Geneva, 1983, p. 51.



American Public Health Association. Mothers and Children. Quarterly Newsletter, various editions.

Cameron, M. and Hofvander, Y. Manual on Feeding Infants and Young Children. Oxford University Press, 1983.

Center for Population and Family Health. Family Planning: Its Impact on the Health of Women and Children. Columbia University, 1981.

Hamilton S., Popkin, B. and Spicer, D. Women and Nutrition In Third World Countries. Praeger, New York, 1984.

Jelliffe, D.B. Child Nutrition in Developing Countries. U.S. Agency for International Development, Washington, D.C., 1969.

United Nations International Children’s Emergency Fund. "A Child Survival and Development Revolution." Assignment Children. Geneva, 1983.

World Council of Churches. Contact. "The Nutrition of Mothers and Children" 50. Christian Medical Commission, April 1979.

World Federation of Public Health Associations. Improving Maternal Health in Developing Countries. Washington, D.C., 1984.

___ . Maternal Nutrition. Washington, D.C., 1983.

___. Oral Rehydration Therapy. Washington, D.C., 1983.

World Health Organization. Guidelines for Training Community Health Workers in Nutrition. WHO Offset Publication No. 59. Geneva, 1981.

___. Towards a Better Future, Maternal Child Health. Geneva, 1980.


Unit 2: Measuring and monitoring growth in young children

SESSION 1: Measuring Growth

SESSION 2: Arm Circumference

SESSION 3: The Road To Health Chart

SESSION 4: The Thinness Chart

SESSION 5: Choosing A Growth Monitoring System

SESSION 6: Counseling Referral and Follow-up of Malnourished Children

Session 1: Measuring growth


Trainees will review the measurements of growth in young children and their usefulness for identifying children at "high risk" of malnutrition.

Time: 1/2 hour


- Flipchart and marking pens

- Handout - "Measuring the Growth of Young Children"


1. Introduce this unit by reminding trainees that:

"Community managers must look for ways to benefit the greatest number of people with their often limited resources. One way we do this in nutrition activities is by clearly identifying and focusing our efforts on children at "high risk" of malnutrition and death. "

2. Ask trainees how they would define and identify "high risk" children.

Responses may include:

- Malnourished children

- Children from poor families

- Children whose mothers or fathers are absent

- Children who have physical signs of malnutrition

- Children who are sick

Summarize trainee responses by saying that there are many conditions and circumstances that may make children nutritionally "high risk." Growth failure is one of the most useful indicators we have for deciding whether children are at high or low risk of malnutrition.

Growth failure is the first sign of malnutrition

3. List and discuss common measurements of growth appropriate for community use. Use the Handout "Measuring the Growth of Young Children" to prepare and guide your presentation.

4. Explain why these measurements are compared with standard measurements for reference populations with normal and sub-normal nutrition status.

5. Explain the difference between single growth measurements and serial (repeated) measurements on the same child. Discuss the advantage of using serial measurements for early detection of growth failure.

6. Close the session by telling trainees that managers must choose which growth measurements and growth monitoring instruments are the best for use in their projects. A manager's choice often depends on the kinds of malnutrition common in an area, the workers' or volunteers' skills and the resources available for training and supervision.

In this module, three instruments for measuring and monitoring growth are presented:

- The three-color arm circumference measuring tape

- The Road to Health Chart

- The Thinness Chart

These instruments have been used successfully in communities worldwide to identify "high risk" children. Besides providing useful measures of growth, they also promote the active involvement of parents and community leaders in the identification of "high risk" children and the causes of malnutrition in their communities.



Measuring a child's growth is one way of detecting malnutrition before the visible signs and symptoms of severe PEM become apparent. Healthy children grow very rapidly, especially in the first few years of life. Failure to grow is the first sign of malnutrition. If we can find children in the community who are not growing normally, we can take action to improve nutrition and prevent serious illness and, in some cases, death.

Growth can be measured and compared in several different ways:

Weight is the most reliable indicator of growth in young children. Changes in the weight of a healthy child can be detected every month from 0-5 years of age. To measure growth, we can (1) compare a child's weight gain over time, (2) classify a child's weight for his age, and (3) compare this measurement to a standard weight for children of the same age.

Height increases more slowly than weight in young children, but comparisons of height-for-age and height-for-weight can be useful measures. Height-for-age tells us about the past nutrition status of a child. Children who are "stunted, " or shorter than normal children their age, have probably been chronically undernourished. Children who are too thin for their height when compared to normal children of the same height are "wasted" or currently malnourished.

Arm Circumference, or the distance around the middle of the upper arm, is another measurement of growth in children from 1-5 years old. In healthy children, arm circumference remains fairly constant between one and five years. When a child is malnourished, the arm circumference is reduced. By measuring arm circumference and comparing it to a standard for normal children, we can detect children who are currently malnourished, or "wasted."

In this module we focus attention on three growth assessment instruments that can be used by the community to identify children who are "in danger" of becoming malnourished and those who are currently malnourished and in need of immediate assistance. These are the:

- Three-color arm circumference tape

- Road to Health Chart

- Thinness Chart

Session 2: Arm circumference


Trainees will be able to make and use a three-color arm circumference measuring tape to identify moderately and severely malnourished children. They will discuss the advantages and disadvantages of arm circumference as an indicator of growth and the use of the three-color tape as a screening tool in the community.

Time: 1/2 hour (1 hour if arm tapes are made during the session)


- Handout - ''Measuring Arm Circumference"

- Materials to make three-color arm circumference tapes(X-ray film; plastic or any other material that will not stretch; scissors; ruler; green, yellow and red marking pens or paint; pencils)

- Flipchart and marking pens


1. Distribute the Handout - "Measuring Arm Circumference" and explain that mid-upper arm circumference is a good indicator of malnutrition in children 1-5 years of age, because the size of the arm in a healthy child changes very little during this period. If the mid-upper arm becomes thin, this is a sign of malnutrition.

2. Distribute three-color arm tapes to the trainees and explain the reasons for the length of the colored areas on the tape. Or, help trainees make their own tapes following the instructions on the handout.

3. Demonstrate the correct method for measuring arm circumference using the tape. It is best to recruit a small cooperative child for the demonstration. Trainees should practice on a number of small children either during or after the session. Observe each trainee and correct any mistakes made using the tape.

4. Ask trainees to list the advantages of using arm circumference and the three-color tape in community nutrition action programs. These include:

- Simple, fast

- Easy for the community to understand and use

- Good where people cannot read or write

- Requires little training

5. Point out that the arm circumference tape:

- is an excellent tool for finding out about the present nutrition status of children 1-5 years;

- can only be used to detect malnutrition in children 1-5 years old;

- does not tell us about past malnutrition;

- while telling us which children are already malnourished, it is not a good tool for finding "high risk" children before they become malnourished.



Mid-upper arm circumference is a useful indicator of the nutritional status of children 1-5 years old

How to Make a Three-Color Arm Circumference Measuring Tape

1) You will need a strip of material that does not stretch (plastic is best).

2) Cut the strip about 20 cm long and 2 cm wide.

3) Mark the strip with fine vertical lines at 12.5 cm and 13.5 cm from one end of the strip.

4) Color the strip red from the end to 12.5 cm (use paint or felt pen that will not come off easily ) .

5) Color the strip yellow from the 12.5 cm mark to the 13.5 cm mark.

6) Color the strip green from the 13.5 cm mark to the other end.

Three-color arm tapes are available in some countries through UNICEF. They can also be ordered from the Voluntary Health Association of India, C-14 Community Center, SDA, Opp. IIT Main Gate, New Delhi 110 016, India. Insertion tapes marked in centimeters, instead of cut-off points, are also available.

Three-Color Arm Circumference Measuring Tape

How to Use the Three-Color Tape to Find "High Risk" Children

1) Only use the three-color strips with children 1-5 years old.

2) Place the strip around the middle part of the child's deft arm. Find the middle of the upper arm by using the top of the arm and the tip of the elbow as the end points.

3) Which color is touched by the red end of the strip? Green, Yellow or Red?

What Do the Colors Mean?

Green - The child is well nourished .

Yellow - The child is " in danger" of becoming severely malnourished.

Red - The child is severely malnourished and in need of immediate attention.

What to Do for "Yellow" and "Red" Children?

Children with yellow and red arm circumference should be fed extra food every day, and they should be treated for any existing illness.

Children with red arm circumference are in danger of death. They need more food in 5-6 small meals a day. In these children, treatment of illnesses that may be causing or complicating malnutrition is extremely important. Families of severely malnourished children may also need temporary assistance to care for and feed their sick children.

Following-Up Malnourished Children

Arm circumference slowly increases as a child's nutrition improves. Use the three-color strip to monitor and evaluate the progress of malnourished children by comparing their monthly arm circumference measures.

Who Can Use the Arm Circumference Tape to Find and Help Malnourished Children?

Health workers, community leaders and parents can be taught to use the tape for screening and monitoring the growth of children in the community.

The three-color arm circumference strip is easy to use and understand. Because it can be used with both literate and non-literate groups, it is a useful tool for involving parents and the community in the health and nutrition of their children.

Session 3: The road to health chart

Many different types of growth charts are available for screening young children. The one presented in this session is the WHO Road to Health Chart which has been adapted for use in many parts of the world. The Road to Health Chart is an effective tool for monitoring a child's weight gain over time where regular weighing (monthly or bi-monthly) is possible. The purpose of the chart is early identification of growth failure so that action can be taken to prevent severe malnutrition. *

* The WHO chart does not allow classification of nutrition status (i.e., normal, moderate and severe malnutrition). Charts using the Gomez or Harvard standards of weight for age are available for this purpose.


Trainees will practice completing and using the Road to Health growth chart to identify children with growth failure. They will also discuss probable causes of growth failure for different age groups.

Time: 2-3 hours


- One sample Road to Health Chart for each trainee

- Wall-sized flannel graph or drawing of the Road to Health Chart (TALC)

- Road to Health Workbook for each trainee

- Weighing scale (a portable hanging scale with 100 or 500 gram divisions is best for community use)

- Several cooperative young children


1. Introduce this session by telling trainees that changes in weight are the most sensitive indicators of growth and nutrition status in young children. Distribute a Road to Health Chart to each trainee. Explain that the Road to Health Chart is a screening tool that allows us to monitor a child's weight gain in order to find children who are becoming malnourished before they develop severe malnutrition.

2. Describe the features of the Road to Health Chart pointing them out on the wall-sized chart. (See Workbook, page 2)

3. Distribute a Road to Health Workbook to each participant. Use the workbook to complete the following steps:

a. Regular Weighing: In order to use the Road to Health Chart for growth monitoring, we must weigh and record the weight of a child regularly (monthly, bi-monthly). Demonstrate how to weigh a young child using a portable scale that can be purchased or obtained locally. Review the points on page 5 of the Road to Health Workbook "Accurate Weighing is Important."

b. Calculating Age: Weight is plotted together with age on the Road to Health Chart. It is only necessary to find out the child's age once, when the chart and the calendar are first filled out. In some areas, mothers do not know the ages or the birth dates of their children. Where this is true, a local-events calendar can be made relating events that people are likely to remember (i.e., festivals, holidays, political events, disasters, etc.) and seasons (summer, winter, rainy, maize, harvest, etc.) to specific months and years. Workbook Exercise 1 - "A Local-Events Calendar" should be completed by trainees during or after the session.

c. Recording Weight for Age on the Road to Health Chart: Using the wall-sized chart, demonstrate each step in completing a Road to Health Chart for the first time and for repeat weighings. Use page 9 of the workbook to guide the demonstration.

Ask trainees to practice recording weights on the Road to Health Chart by completing Exercise 2 in the workbook. When they finish, help them correct their charts by drawing the growth curves as they should appear on the wall-sized chart. Watch for and correct the following common errors:

- The calendar is not filled in completely or it is filled in incorrectly

- The first month written on the calendar is not the month of birth. The most common mistake is to write January (or the first month of the local year) or the month the child is first weighed instead of the birth month in the first box of the calendar

- The dot for weight is on the wrong weight or in the column for the wrong month

Practice plotting different weights and ages until most trainees can successfully record weights and ages on the chart.

d. Interpreting the Growth Curve: Record one weight on the wall- sized chart under the lower reference line. Record another weight for a child of the same age between the lines. Explain why we cannot say that one is healthy and the other "high risk" without more information.

Draw growth curves for the six months prior to the weights given for each child as in the following example.

Growth Curve

* This example shows that unless a child's weight falls far below the bottom line we cannot be sure he is malnourished. Some children will be smaller than others for genetic reasons or because of past malnutrition. The important thing is that a child is gaining weight every month.

+ Likewise, it is not always safe to assume that a child is well nourished if his weight is between the two reference lines. He could be at "high risk. because of recent weight loss.

Draw the arrows below on the flipchart and explain the significance of the directions of different growth curves.

Directions of different growth curves.

Use the example on page 13 of the workbook to further explain the directions of the curve.

e. Looking for the Causes of Growth Failure: When growth failure occurs, the first thing to do is to find out what is causing it. Explain that illness, a change in feeding habits, separation of mother and child, etc., will cause sudden weight loss.

Trainees should complete Workbook Exercise 3, Interpreting the Growth Curve. This can be done in small work groups or individually. When they finish, discuss each of the five growth curves mentioning the common causes of growth failure for each age group.

4. Write on the flipchart:

"Interpreting the growth curve and taking action to correct growth failure are the most important steps when using the Road to Health Chart."

5. Summarize this session by reviewing with trainees:

- Purpose of the Road to Health Chart - early identification of malnourished children

- Resources Required - Road to Health Charts, weighing scale set, trained literate workers, space, time

- Frequency of Weighing - monthly or every other month Location - community, clinic, homes.

Road to health workbook

A. The Growth Chart

B. Accurate Weighing is Important

C. How to Find the Age of a Child if the Mother Does Not Know

D. Recording Weights on the Growth Chart

E. How to Interpret the Growth Line

Adapted and excerpted from World Health Organization. Guidelines for Training Community Health Workers in Nutrition. Geneva, 1981.

(Trainers should select growth charts available in their regions. These growth charts should be substituted for the growth charts used in figures and exercises in this workbook. If charts with more than two reference lines are used, the description and instructions for recording and interpreting weight will also require modification.)

A. The Growth Chart

A Growth Chart is basically a graph on which a child' weight is shown at different ages. There are many types of growth charts, but most of them have the same basic features. Fig. 5 shows a typical growth chart. It should be printed on card or paper sufficiently strong to be used to some years. The horizontal lines in this chart represent weight in kilograms. The vertical lines represent age in months. The weights are marked against each horizontal fin' on the left-hand side of the chart. The vertical lines for 12 columns for each year, corresponding to the months of the year. The month names can be written in the 12 boxes below the columns. The first box on the left-hand side of the chart is for the month of birth. This box has thick line around it. The first column for each year also has a box with thick lines around it. This is to identify the beginning of each year of age. The year of birth is marked by the side of the box for the month of birth (i.e., the first box with thick lines around it).

Across the graph are printed two growth reference lines These lines give the general direction of growth in health children. They are not the target for the growth of all children. If a child's weight is much below these grows! reference lines there is some reason for concern, but it is the direction or angle of a child's own growth line that is much more significant than any weight recorded below the lower reference line.

Some other important features of the growth chart are given below:

- Information about the child and family. This is written on the back of the graph. The family address and name, the number of children, and their state of health are all recorded (Fig. 6).

- Immunizations. There is a space for recording the different dates of immunizations. This also serves as a reminder of when the next immunizations are due.

- Medical history. It is convenient to write the illness suffered by the child on the side of the chart that shows the weight graph. The name of the disease can be written vertically in the month in which it occurs. This makes it easy to see ho, a disease such as measles seriously affect. growth.

- Additional information. The same chart can also be used for recording additional information. For example, if a nutritional supplement programme is being carried out and vitamin A is given every 6 months, a large A can be written at the bottom of the column of the month in which it was given. If food supplements or antimalarial drugs are given monthly a tick can be marked in the column for the appropriate month. Parents are advised to space their children as this permits each child to have a maximum of care and nourishment; if they have been advised, or have accepted some form of contraception, it is good to record this on the chart as well.

- Reasons for special care. Certain social, economic and health factors are associated with a high risk of malnutrition. The chart has a space to record these factors; it is headed "Reasons for special care." This makes it easy to identify quickly the priority children.

If parents are made to understand the significance of the information on the chart, and then allowed to keep the chart themselves, they will feel more involved and responsible for the child's health care. This encourages community participation. It saves the time and space needed for storing charts in a health centre. Also the charts can be taken with a child during visits outside the community (e.g. to the grandparents' home), or to any health centre. The charts should be put in plastic (polyethylene) covers to help parents keep them clean and dry. Another advantage of keeping cards with the parents is that the community health worker does not have to carry them when making home visits. In the case of children who are at a special risk. however the community health worker should keep duplicate growth charts at the health centre.






Follow these steps

Accurate weighing is important. A community health worker can learn how to weigh a child quite easily by following the instructions given below.

1. Hang the scale up securely, keeping the dial at eye-level so that the weight can be read easily.

2. Adjust the pointer to zero before placing the child in the sling or basket. Most scales have a knob or screw to make this adjustment.

3. Undress the child with the help of the mother. It is better to weigh the child naked if it is not too cold and if local customs permit.

4. Place the child in the sling or basket with the help of the mother. Ask the mother to stand nearby and talk to the child. The mother should not hold the child and the child's feet should not touch the ground when the weight is being read.

5. Read the weight on the scale. If the child is struggling, try to calm him with the help of the mother and when he stops moving read the weight quickly.

6. Record the weight in figures, for instance 3.5 kg.

The most common spring scale (often called a Salter scale, although many other brand names exist) has a face which looks like a clock. The weights are marked in kilograms around the dial. Some dials also show 100-gram divisions between kilograms, but the simplest scales only have kilograms marked by bold lines and 500 grams marked by thin lines. Such scales are convenient for workers with limited education because these lines are similar to those which are drawn on the most widely used growth charts (Fig. 4)


Marking on the spring scale

Spring Scale

Source: Appropriate Health Resources and Technologies Action Group, (AHRTAG),

London, UK.

Spring Scale

Dial-Shaped Spring Scale

Source: Teaching Aids & Low Cost

Dial-Shaped Spring Scale

A Single Beam Scale for Clinic Use

Source: CMS Weighing Equipment, Ltd.,

London, UK

Single Beam Scale

Philippine Bar Scale

Source: Nutrition Center of the Philippines,

Manila, Philippines

Philippine Bar Scale

C. How to find out the age of a child if the mother does not know

There are two important factors in measuring growth weight and age. It is very important, therefore, to know the correct age of a child. Often mothers do not remember the dates of births of their children. In such cases the community health worker can estimate the age of a child by Asking the mother certain questions and by using a local events calendar.

The first simplest way to find out the age of a child is to look up the local official register of births, baptismal certificate book, or similar record. Often mothers forget or are not aware of the existence of such records.

If the child is not registered or if no such records exist, the community health worker should first try to find out the year of birth of the child. This can be done by asking the mother if the child wee born a few months before or after another child in the neighborhood. The community health worker should then find out if the date of birth of that child is known. If the mother of the second child knows the date of birth of her child, the year of birth of the first child can be easily estimated. The year of birth can be easily determined in this way for children up to 4 years of age. In the case of older children the year of birth becomes difficult to estimate correctly; however, with older children, it is not so important to be absolutely accurate.

The next step is to determine the month of birth. This can be done by the use of a local-events calendar. A local-events calendar shows all the dates on which important events took place during a past 3-5 year period. It may show the different seasons, months, phases of the moon, local festivals and events in the agricultural cycle. (Fig. 1). National and local occurrences of importance are also marked on it, these include storms and cyclones, political elections, the opening of nearby roads, cinemas, shops, etc. Each community health worker should make his own local events calendar.


EXERCISE 1: A Local Events Calendar

Develop a calendar of key events in your area during the past four years, to help parents recall the approximate birth months of their children.



Festivals and Events







D. Recording weights on the growth chart

The weight of a child should be recorded on the chart according to the instructions given below.

1. Write the name, address and information about the child and the family on the back of the chart. It is important to do this at once to show whose record it is and to avoid recording one child's weight on another child's chart.

2. Write the month of birth in the box below the first vertical column (the first box which has thick lines around it). Near the box write the year of birth. This is September 1978 in the example in Fig. 7.

3. Note that there are 5 sets of 12 columns. Each set is for one year of the child's life. Beginning with the month of birth (see instruction 2), write out the following months of the year in the following boxes. When you reach January, write the year near that box exactly as you wrote the year of birth (see instruction 2) near the box for the month of birth.

4. Record the weight by putting a big dot on the line corresponding to that weight in kilograms. For example, if the weight of a child is 6 kg in a given month, find the horizontal line representing 6 kg and put a dot at the point on that line where it meets the column for the month in which the weight is being taken. This is January 1979 in the example shown in Fig. 7.

5. The position of the dot within a column can be adjusted. The purpose of this is to indicate when (early in the month, in the middle of the month, or late in the month) the child is being weighed. If the child is being weighed early in the month, put the dot towards the left side of the column. Put the dot in the middle of the column if the weight is being taken in the middle of the month. If the weight was taken late in the month, put the dot towards the right side of the column.

The above instructions should be followed each time you record the weight on a chart. An example of weight chart showing 3 weights of a child taken on 3 different occasions is shown in Fig. 8. Notice that the three weight dots are joined by a line. This is the line of growth. It is very important.

Notice too, that the chart in Fig. 8 is for a different child from the one in Fig. 7. The child in Fig. 8 was first seen and weighed in September 1977 by a community health worker, who questioned the mother about when the child was born. The month of birth (June 1977) was written in the first box on the chart and the weight record was placed in the fourth column (September).




Recording the weight on a growth chart



Example of a growth line

Exercise 2: Recording Weights

Recording Weights

Complete the growth chart for this child:

1) John was born in March 1982. His mother brought him to the clinic in May 1982 when he was weighed for the first time. His weights during 1982 and 1983 were:




- 5 kg


- 7.5 kg


- 5.5 kg


- 7 kg


- 6 kg


- 7.5 kg


- not weighed


- 8 kg


- 6.5 kg


- not weighed


- not weighed


- 8.5 kg


- 7 kg


- 8.5 kg


- 7.5 kg


- 9 kg



- not weighed



- not weighed



- 10 kg



- 10 kg

Exercise 2: Recording Weights

Recording Weights


Guillermo Gomez was born 20 December 1982. He was first weighed at a community weighing day in June 1983. His weights during the next 12 months were:


- 7 kg


- 7.5 kg


- 7.5 kg


- 8 kg


- 8 kg


- 8.5 kg


- not weighed


- 9 kg


- 8.5 kg


- 8 kg


- 8.5 kg


- 9 kg


E. How to interpret the growth line

Look carefully at the growth line in Fig. 8. Note that the line is going upwards left to right, from 5.5 kg in September to 6.5 kg in November and then to 7 kg in January 1978. Remember that when the line is going up, the child is growing; this is good. If the line is horizontal or going down the child is not growing well, and this is not good. Some charts have examples of the direction of growth curve printed below the chart. This is to remind health workers that the direction of growth, upwards, horizontally or downward, is very important.

In the first 6 months of life a levelling off or a downward movement of the growth line is a serious matter. After 2 years a small variation over one or two months is not so serious.

The importance of the direction of the growth curve is illustrated in Fig. 9. Arrows A, B. C, and D have been drawn on the growth chart parallel to the growth curve for different periods. The growth curve parallel to Arrow A is good. The growth curve parallel to Arrow B is not satisfactory and action should have been taken. When the growth curve fell, parallel to Arrow C, the child was in a dangerous condition and urgent action was needed. Any child who does not gain weight for three months should be referred to the supervisor or health centre. When the growth curve returned to the direction of Arrow D, the child's growth became normal again.

Remember that it is the direction of the growth curve that is more important than the position of the dots on the curve. The dots parallel to Arrow B are above the lower reference line, but the growth curve is levelling off and this is a matter for concern. The dots parallel to Arrow D are below the reference line, but the direction of the growth line is once again upwards and therefore the mother is congratulated for her good care.


Direction of the growth curve

The direction of the growth curve is more important than the position of the dots.

Exercise 3: Interpreting the Growth Curve

When a child begins to lose weight or does not gain weight for several months, it is a sign of problems. Analyze the growth of the children in the next five charts:

1. Describe the growth of each child.

2. What questions would you ask to find out the possible causes of growth failure in each case?

3. What advice would you give each mother at the most recent weighing session?

Analyze the growth of the children (A)

Analyze the growth of the children (B)

Analyze the growth of the children (C)

Session 4: The thinness chart

The Thinness Chart was developed for use in maternal child health clinics in Nepal by Save the Children (UK). The Thinness Chart uses two measures, weight and height, to assess the nutrition status of young children. A large multi-colored wall chart is first attached to the wall. Children are weighed and then placed standing in front of their weights on the chart. Height is then measured by placing a flat hand on the head and marking the point where the hand touches the chart. Nutrition status can be measured either in terms of percentages of standard weight for height or by using color-coded cutoff points indicating high, potential and low risk. Age is not required for this method. Graphing of weight is accomplished simultaneously with the measurement of height on the chart.


In this session, trainees practice using the Thinness Chart to classify the nutrition status of young children. The advantages of the Thinness Chart for community action projects are discussed.

Time: 1 hour without practice


- The Thinness Chart, available from TALC - Teaching Aids at Low Cost

- One copy of the booklet, "The Thinness Chart - How You Use It" for each trainee

- Chalkboard and chalk

- Several willing young children


1. Introduce the session by telling trainees that one way to identify children who are presently malnourished or at high risk of malnutrition is by comparing their current weight to their current height. By comparing a child's weight and height to standards for well-nourished and malnourished children, we can identify those children who are growing well as well as those who are malnourished and in need of additional counseling and medical attention.

2. Display the Thinness Chart. Explain that weights are shown on the vertical lines of the chart and heights on the horizontal lines. The colored bands across the chart tell the health or nutrition workers whether a child is healthy (green), in danger of malnutrition (yellow), malnourished (lower red) or severely malnourished (upper red). In contrast to the Road to Health Chart, the higher a child falls on the chart's curve, the more malnourished he or she is.

3. Distribute copies of the booklet "The Thinness Chart, How You Use It." Demonstrate steps for using the chart as presented in the booklet.

4. Practice: Arrange a practice session in which trainees weigh and assess several children using the Thinness Chart. Observe trainees and correct problems to improve their skills where necessary.

5. Ask trainees to brainstorm the advantages and disadvantages of the Thinness Chart as a tool for nutrition assessment at the community level. These might include:


- Does not require calculation of age. Can be used by people with minimal literacy skills.


- Mothers can participate.


- Colored bands make assessment easy and understandable


- Requires special chart and weighing equipment.


- Wall and adjoining floor must be flat.


- Difficult to make children stand still in front of chart.


- For children under one year, a measuring board is also required.


6. Summarize by reviewing the purpose and steps in using the Thinness Chart for nutrition assessment.

Note: The Thinness Chart is being used in two of the countries where CEDPA's training workshops have been held, Nepal and Senegal. The chart is generally easier to use and interpret than the WHO Road to Health Chart because it does not require graphing numerical measurements and assessing their position on the graph. Instead, the wall chart combines the measurement of height with the assessment of normal or abnormal growth. The Ministry of Health of Senegal is currently attempting to adapt the chart for use by non-literate village workers, who would use color coded weighing scales and wall charts to assess nutritional status of young children.


How you use it

Thinness chart

Developed by the Save the Children Fund with the London School of Hygiene and Tropical Medicine. The Thinness Chart is available from: TALC, P.O. Box 49, St. Albans, Herts, ALl 4AX, UNITED KINGDOM.

- Put the chart near your scales.

- The chart goes on the wall. The wall must be even.

- The bottom of the chart must touch the ground.

Scale and chart

- Weigh the child.

Weigh the child

- Note the weight to the nearest half kilo (kg).

Note the weight

- Find the weight on the chart with your finger.

Find the weight

- Ask the mother to put her child under your finger.

- The child must be in the correct place.

The child must be in the correct place

CHECK THAT: 1 the middle of the child's head is under his weight on the chart.

The middle of the child's head

CHECK THAT: 2 the child's shoulders and feet are against the chart.

The child's shoulders and feet

CHECK THAT: 3 the child's heels are against his weight at the bottom of the chart.

The child's heels

THEN: Put the palm of your hand on the child's head.

Touch the chart with your finger.

Which colour does your finger touch?

Your hand on the child's head

Is the child in the:





Where is the child?

You can darken the upper red section yourself. This will show you if the child is extremely thin.

This child is in the UPPER RED.

He is extremely thin (wasted).

You must help him urgently.

Child in upper red.

This child is in the LOWER RED.

He is very thin (wasted).

You should help him quickly.

Child in lower red.

This child is in the YELLOW.

He is thin.

You must watch him regularly.

Child in yellow.

This child is in the GREEN.

He is well nourished.

Child in green.

Session 5: Choosing a growth monitoring system


To compare the advantages and disadvantages of three growth monitoring tools: the three-color arm circumference tape, the Road to Health Chart and the Thinness Chart.

For use in training managers who will choose their own systems for measuring and monitoring the growth of young children.

Time: 20 minutes


- Handout - "Choosing a Growth Monitoring Systems"

- Wall-sized version of the handout


1. Distribute the Handout - "Choosing a Growth Monitoring System." Ask participants to use information from Sessions 2-4 to answer the questions on the chart.

Note: A copy of the completed handout is provided with this session for the trainer's reference.

2. Complete the wall-sized handout as a group activity. Use this as a time to review important points about each growth monitoring system.

3. Remind participants that the following criteria determine which growth monitoring system is appropriate in a given situation:

- Characteristics of malnutrition in the area

- Number of workers and their skills

- Resources available for training and supervision

- Resources available for assistance to "high risk" children










Mid-upper Arm

- Distance Around Mid-upper Left Arm

-Severe Malnutrition in Children 1-5 Yrs.

- Tape Marked either with Three Colors or in CM Divisions

- Minimal Training Required to Teach Health Workers, Mothers and Other Community Members How to use

- Only Useful with Children
- Measures Malnutrition that is already Severe

- Quick, Easy to Use
- Portable, Can Be Used Anywhere
- Easy to Understand
- Detects Improvements in Nutrition Status

Road to Health Chart

- Monthly Weights
Age at First Weighing

- Past and Present Malnutrition
- Most sensitive with Children Under 2 Yrs.

- Weighing Scale
- Road to Health Chart

- Extensive Training And Supervision Required

- Age is Often Difficult to Determine
- Workers Must Be Literate
- Equipment Expensive

- Sensitive to Early Changes in Nutrition Status
- Weighing Activity is Popular in the Village

Thinness Chart

- Weight
- Height

- Present Malnutrition
- Wasting

- Thinness Chart
- Weighing Scale
- Measuring Board

- Training and Supervision Required

- Requires Flat Wall and Floor
- Difficult to Make Children Stand
- Chart must be Purchased or Produced Locally
- Equipment Expensive

- Easier to use Than the Road to Health Chart
- Can Be Used by Semi-literate Workers
- Colors Make it Easy to Understand and Use
- Weighing Activity is Popular

Session 6: Counseling, referral and follow-up of malnourished children


In this session, trainees practice explaining the significance of children's growth measurements to their parents. Actions that should be taken in cases of severe malnutrition and early growth failure are discussed.

Time: 2 hours


- Role Plays - containing growth charts and mother's instructions for three situations (In this exercise, trainees use the Road to Health Chart as the tool for assessing the nutrition status of several children. Arm circumference measures or measures from the Thinness Chart can be substituted.)

- Handout - "Community Action with Malnourished Children" (This should be developed locally. An example is included.)


1. Introduce the session with a discussion of the critical role parents play in monitoring and taking action to improve the growth of their children.

2. Divide into work groups of three people. Work groups will conduct three role plays each. The characters in the role plays are a "community nutrition worker," the "mother" of a malnourished child and an "observer." Work group members will rotate the roles so that each member plays all three roles.

3. Give group members different situation sheets and instruct them to remove the " Instructions to the Mother" for their own reference. In each situation, the "mothers brings her child's Road to Health Chart to the Community nutrition worker." The "worker's" job is to:

- explain the Road to Health Chart and the child's growth curve to the "mother";

- discover the causes of growth failure by asking the questions about the health, eating habits, etc., of the child;

- help the "mother" plan what to do to improve the growth of her child.

The "observer" should note how the "worker" uses the Road to Health Chart to explain the child's situation and the need for action.

Allow about five minutes per role play situation.

4. Discuss the role plays by asking trainees to answer the following questions based on their experience in the roles of "mother," and "community nutrition worker" and


- How did the "community nutrition worker" use the Road to Health Chart to explain a child's nutrition status? - What questions did you ask to find out why the child had stopped growing?

- Did the "community nutrition workers" tell the "mothers" what they should do, or did they plan together how to improve the child's growth? Which do you think is more effective?

5. Counseling and education of parents are two community interventions to improve the nutrition of children identified during growth monitoring activities. Ask participants: "What other actions can/should be taken in the community with "high risk" children?" Write their responses on the flipchart.

6. Distribute the Handout - "What to Do When Children are Malnourished." Explain that each community nutrition program must decide what the community/clinic or agency will do for the malnourished children identified in growth monitoring activities. This handout gives a basic list of appropriate community interventions. Review them with the trainees and encourage them to add others that they feel would be necessary and feasible.

7. Review the basic steps in measuring growth and taking action to improve the nutrition of "high risk" children:

- Measure and assess the growth of all children under five regularly.

- Counsel the parents of "high risk" children. Visit them at home if possible.

- Refer or treat malnourished and sick children for illness.

- Follow up and evaluate the progress of each child.


Situation #1

Situation #1

Instruction to the Mother:

You brought the baby to the weighing activity because she is sick and has gotten thin.

You stopped breastfeeding her in September, at 4 months, because she "didn't like" your milk.


Situation #2

Situation #2

Instruction to the Mother:

You work on a tea plantation all day and leave this child with your 8-year-old daughter. Your husband left in August to find a job in the city. You are breastfeeding in the morning and at night. During the day the baby eats rice from the morning meal.


Situation #3

Situation #3

Instruction to the Mother:

You stopped breastfeeding this child in August when he was 16 months old because you became pregnant again. He refused to eat much for the next few weeks. Then he got the measles in November. Since then he has had frequent diarrhea.



To the Trainer:

This handout should be developed by each program based on the nutrition assessment instruments they use, their resources and established guidelines for intervention.


In a CEDPA-supported nutrition program, Community Nutrition Volunteers use arm circumference and weight gain to identify "high risk" children.

If a child has:

The Community Nutrition Volunteer:

Yellow Arm Circumference
(>12.5 cm <13.5 cm)
No weight gain for two months

- Counsels the parent(s)
- Teaches the mother to make improved foods for child feeding
- Refers the child to the nearest clinic if he is sick
- Follows up after one month

Red Arm Circumference
(<12.5 cm)
No weight gain for three months

- Counsels the parent(s)
- Refers for immediate medical treatment
- Gives food supplement
- Visits home one week later to teach mother how to make improved foods and how to treat diarrhea with ORS
- Follows up monthly until arm circumference is green

All children

- Teaches the mother to prepare improved weaning foods
- Teaches the mother how to make and give ORS to treat diarrhea
- Discusses the importance of and methods for child spacing



American Public Health Association. Growth Monitoring. 1981.

Morley, D. and Woodland, M. See How They Grow Monitoring Child Growth for Appropriate Health Care in Developing Countries. Oxford University Press, New York, 1979.

Nabarro, D., Verney, J. and Wijga, A. The Weight-for-Height Chart Project. Evaluation Report. 1982-1984.

World Health Organization. Guidelines for Training Community

Health Workers in Nutrition. WHO Offset Publication No. 59. Geneva, 1981.



SESSION 1: The Importance of Breastfeeding

SESSION 2: Helping Mothers Breastfeed

SESSION 3: Case Study: Breastfeeding Information for Kenyans

Session 1: The importance of breastfeeding


In this session, trainees list the advantages of Breastfeeding and the dangers of bottle-feeding and breast milk substitutes. Rules for successful Breastfeeding are presented and discussed.

Time: 1 hour


- Handout - "Breastfeeding Self-Test" plus answer sheet

- Handout - "Rules for Successful Breastfeeding"

- Flipchart and marking pens


1. Distribute the "Breastfeeding Self-Test" and ask trainees to complete it individually. When they finish, tell them that you will discuss the test at the end of the session.

2. Ask trainees to brainstorm the advantages of Breastfeeding for mothers and infants. List their responses on the flipchart. Then, ask trainees to brainstorm the dangers of bottle-feeding and early introduction of foods other than breast milk. List these on the flipchart. Add any advantages or dangers that you feel trainees have missed.

Summarize: "Breastfeeding has many advantages for mothers and infants. Breastfed infants are generally healthier than infants fed with bottles and breast milk substitutes. This is especially true in low income families because breast milk is a clean, nutritious and low cost food for infants. Breast milk also contains anti-infective agents that help breastfed infants fight against infection. Infants who are not breastfed and those who are given foods other than breast milk during the first months of their lives are very often malnourished and at "high risk" of sickness and death."

3. Distribute the Handout - "Rules for Successful Breast-feeding." Discuss each of the rules and the reasons why each one encourages successful breastfeeding.

4. Discuss the importance of giving colostrum. In many countries, women believe that colostrum should not be given to newborn infants. This is not true! The composition of colostrum is different from the milk produced by the mother 3-5 days after birth. Colostrum contains large amounts of protein substances (including secretory immunoglobulin) which helps prevent infection in the newborn. It is a good idea to put the infant to the mother's breast immediately after delivery since frequent sucking is necessary to establish lactation.

5. Summarize this session by asking the trainees to repeat the self-test taken at the beginning of the session. After they finish, review the correct answers to each of the questions and compare scores before and after the session. Leave some time for additional questions and answers.



























Answer the following questions TRUE or FALSE.




1. Breast milk contains all the nutrients an infant needs until he/she is four months to six months of age.


2. Women with small breasts will have difficulty breastfeeding.


3. Colostrum has no nutritional value. It should be discarded.


4. Breastfeeding should be on a schedule.


5. After birth, it is best to wait 24 hours before putting an infant to the breast.


6. Malnourished women cannot breastfeed their infants successfully.


7. Most women can breastfeed successfully.


8. Pregnancy should be avoided while the youngest child is still breastfeeding.


9. Frequent breastfeeding will increase milk production.


10. Women who are breastfeeding should eat extra food and drink plenty of liquid every day.


11. It is advisable to give an extra bottle of milk or formula if an infant appears to be hungry after breastfeeding,




1. Breastfeed as soon after birth as possible.

The infant's suckling at the breast stimulates milk production. It also insures that the infant receives colostrum, the first yellowish liquid produced by the breast. Colostrum contains concentrated anti-infective agents that help protect the infant against sickness.

2. Breastfeed frequently (on demand).

The production of milk is stipulated by the baby's suckling so the baby should be fed on demand rather than according to a schedule. The more an infant breastfeeds, the more milk the breast will produce.

3. If possible, eat extra food every day.

During breastfeeding, the caloric needs of the mother are increased. It is estimated that an additional 500 calories per day are needed by the mother. If these calories are not available, the mother's fat supply will be used for milk production. Most women, even in countries where chronic malnutrition is prevalent, are able to breastfeed their infants exclusively for 4-6 months. Research has found that breastmilk from undernourished mothers contains amounts of protein and lactose similar to those of well-nourished mothers. Emphasis should be placed on improving maternal diet before supplementing the diet of the breastfeeding infant.

4. Relax.

Breastmilk is released by the ejection or let-down reflex. It can be temporarily inhibited by tension or anxiety.

5. Do not give other foods and liquids until the infant is at least four months old.

Do not give other foods and liquids until the infant is at least 4-6 months of age. Breastmilk alone is generally sufficient until this age. Supplemental foods reduce the amount of time the infant sucks on the breast and therefore reduces the amount of milk the mother produces.

6. Avoid bottle feeding!

When the infant is 4-6 months of age, foods in addition to breastmilk can gradually be added to the infant diet. A cup and spoon should he used.

Session 2: Helping mothers breastfeed


In this session, trainees analyze some common reasons given for termination of breastfeeding and use of breast milk substitutes. They also discuss activities to promote successful breastfeeding in the community.

Time: 1 hour


- Handout - "Helping Mothers Breastfeed"

- Trainer's Reference - Breastfeeding Case Examples

- Flipchart and marking pens


1. Read Breastfeeding Case Example #1 to the group. Ask the following questions:

- Why was the woman in this example weaning her daughter? (new pregnancy)

- Is this a common problem in your area?

- Is it necessary to terminate breastfeeding once you become pregnant?

2. Summarize the discussion. Although there are many taboos and cultural beliefs against breastfeeding when a mother becomes pregnant again, breastfeeding is not an uncommon practice during pregnancy in many developing countries. Beliefs in changes in breast milk volume or composition associated with a new pregnancy have not been confirmed by factual observations, nor have any ill effects been detected for either mother or infant. The main concern in such situations is that the mother's additional nutritional requirements are met. They will not be significant during the first trimester of pregnancy, a time when most lactating women would not even be aware of a new pregnancy.

3. Ask one of the trainees to read Case Example #2 to the group. In this example, the infant is not growing properly even though the mother is breastfeeding. Ask trainees to list the reasons why this infant might not be growing.

Responses should include:

- Giving other food decreases the suckling time at the breast, decreasing milk production

- Other foods may be contaminated and cause infections

4. Ask trainees what advice they might give the mother in Case Example #2. This can be done in a role play with discussion about the advice given.

5. The case examples describe several common reasons that women give for terminating and/or supplementing breastfeeding. Ask trainees: "What are some of the reasons given by women in your region who stop breastfeeding?" List these on the flipchart.

6. Discuss each of the reasons listed. You may wish to proceed with the following steps:

- Distribute the Handout - "Helping Mothers Breastfeed". This handout lists common problems that can cause a woman to stop breastfeeding. Review each of the problems and the suggested solutions, referring back to the list generated by the trainees.

- Identify the reasons on the list that are related to false beliefs or misconceptions. Give the facts. Discuss ways to change beliefs and dispel rumors through education and example.

- Review the rules for successful breastfeeding. (Session 1)

- Summarize: Most women can breastfeed successfully if they have access to information and support from their family and community. Only in rare cases will breastfeeding not be possible.

7. Divide into small work groups. Ask each group to brainstorm a list of activities that community groups and community program managers could organize to promote successful breastfeeding. Allow 10-15 minutes, then ask each group to present its list of ideas. These might include:

- Provide information and support for pregnant and breastfeeding women

- Education of community leaders especially women to promote breastfeeding

- Training of health workers and traditional healers, especially TBAs

- Acting to stop the misleading promotion and sale of infant formulas and feeding bottles

- Support for legislation for policies that support breastfeeding, such as maternity leave, creches, nursing breaks, etc..

8. Summarize the session by emphasizing the important role that community members, especially women, can play in providing information and support to breastfeeding mothers.





Medical Practices that Promote Bottle Feeding: Hospital procedure may require separation of mother and infant at birth.
Sugar water or formula maybe given during this period thus interfering with the beginning of breastfeeding and milk production in the breasts. Health workers may also be poorly informed, recommending that a woman stop breastfeeding unnecessarily

Promote rooming-in at hospitals. Eliminate bottle feeding of fluids to the infants.
Talk to hospital officials about changing outdated practices that undermine breastfeeding
Train health workers to provide correct information to breast-feeding women.

Social Forces:
The use of infant formulas and feeding bottles by upper class women, promotion by formula companies, and Western attitudes toward breasts and sexuality have resulted in an increase in bottle feeding among poor women.

Educate community leaders, women and men.
Provide support and encouragement for breastfeeding women.

Insufficient Milk:

Encourage the mother to breastfeed the baby more often. If possible the mother should eat more food every day and drink lots of liquids.

When a woman finds she is again pregnant, she may stop breast- feeding .

Do not stop breastfeeding abruptly. A health woman can continue breastfeeding while pregnant gradually weaning her child. Encourage her to eat additional body-building, energy protective foods.

Temporary Separation of Mother and Infant: If the infant is breast- feeding less often, less milk will be produced.

Breastfeed frequently when reunited.
Express milk manually during the separation.

Working Outside the home:
Undernourished women produce less breast milk.

Encourage women to breastfeed at night and frequently when with their infants.
Educate employers. Promote the passage and enforcement of labor regulations that encourage breastfeeding such maternity leave, legislation, creches, and nursing education.

Maternal Illness:

Breastfeeding is contraindicated only in cases of severe maternal illnesses, for example in the case of heart failure, or severe kidney, liver or lung disease. Most common illnesses in mothers are not in themselves reasons not to breastfeed.

Low-Birth Weight Infant:
A large proportion of low-birth weight infants (below 2500 g) are born at term and behave as fully matured infants.

They can and should be breastfed.
If the infant is pre term and unable to suck properly, the mother can express her milk and feed her child manually. The food of choice for preterm infants is breastmilk.



To the Trainer: Develop your own examples to illustrate the most frequent causes of early termination of breastfeeding and inadequate milk production. Examples can also be developed as role plays or dramas.

1. An example from Kenya

A healthy 12 month old girl came to the monthly village weighing activity with her mother. The nutrition worker congratulated her on how well her daughter was growing and encourages her to continue what she is doing. The mother is concerned because she has found out that she is pregnant and must stop breastfeeding. In Kenya, it is common for women to stop breastfeeding as soon as they find out they are pregnant again.

2. An example from Nepal

A three-month-old baby boy was brought to the village clinic with diarrhea and vomiting. The baby was pale and thin. When asked if she was breastfeeding, the mother said she was breastfeeding but that she did not have enough milk. To supplement her own milk she started giving buffalo milk in a bottle and porridge made from ground maize when the baby was about two months old. She said the baby had been sick with diarrhea three times in the last month and that he was getting thinner and thinner despite her efforts to feed him. The mother also looked pale and thin.

Session 3: Breastfeeding information for Kenyans


In this session, trainees discuss the experience of a unique Kenyan organization, Breastfeeding Information Group (BIG), started in 1978 by Breastfeeding mothers to promote Breastfeeding in their country. Educational materials produced by BIG for use with health workers, mothers and fathers are provided for review and comment.

Time: 1 hour


- One copy of the case study "Breastfeeding Information for Kenyans" for each trainee

- Multiple copies of educational materials developed by BIG and other organizations to promote successful Breastfeeding

- Flipchart and marking pens


1. Distribute the case study "Breastfeeding

Information for Kenyans" to each trainee. Ask them to read the case study individually.

2. Divide trainees into small work groups of 5-7 persons each. (It is best to form homogeneous groups of people from, the same regions, organizations, countries, etc. Groups will be discussing whether a project like the one in the case study could be organized in their own areas.) Ask each work group to discuss and answer the questions at the end of the case study.

3. Conduct a discussion based on the groups' answers to the case study questions.

4. Display or distribute copies of educational materials developed by the Kenyan Breastfeeding Information Group and other organizations. Encourage trainees to examine and/or copy materials that could be adapted for use in their areas.

5. Summary: Ask trainees to summarize the most important information presented in this session and/or unit. (You may also want them to state their impressions of the content and the methodologies used.)



Volume 3, Number I

January 1983

ISSN 0272-69 17

Breastfeeding Information for Kenyans by the Breastfeeding Information Group, Nairobi.

A widely circulated myth in Kenya holds that ''African women all breastfeed." While it is true that almost all Kenyan mothers start breastfeeding (97% in 1977) old traditions of exclusive breastfeeding for the first months give way to social pressures and the ready availability of commercial products, Early supplementation has become the custom among many families.

A mother attending a clinic with her three-month old may say, ' Oh, yes, I am breastfeeding," while a bottle of formula mixed hours before peeps from her basket. There is no intention to deceive. only the fact that for many mothers today, "breastfeeding" automatically is taken to mean breast-plus-bottle. The bottle may be filled with water a fruit-flavored drink or vitamin preparation, a glucose drink, or some kind of milk feed.

Few parents understand how this recent custom interferes with lactation. Often the health workers themselves do not realize this. In many cases the top-up bottle of glucose water for formula is started soon after delivery. In a nationwide study, researchers from the Breastfeeding Information Group and Ministry of Health found that 97% of the maternity unit nurses and midwives surveyed felt that babies should have pre-lacteal supplements of glucose water or formula, and 95% actually give them. (Veldhuis, Nyamwaya, et al, 1982). This routine once established is continued at home.

"Unfortunately I was never advised about breastfeeding before my baby was born. However, after I hod the baby these was advice from of sides to breastfeed. I hove tried my best in this effort but the baby is not satisfied. She is 15 days old and keeps crying when she is hungry until I feed her the formula milk. Please advise. "Mrs. P.K. (Kisumu)

With this pattern widespread, it is not surprising that mothers who are sincerely trying to do their best for their babies experience two very common problems: "I don't have enough milk to satisfy my baby," and "the baby refuses my breast and prefers bottles.''

The Breastfeeding Information Group (BIG) was started quite informally by a group of seven women to provide help with these kinds of breastfeeding problems. At first we discussed what we knew about breastfeeding. problems we had observed end experienced, and what activities might be useful in Kenya. By late 1978, we had decided to register officially as a voluntary society with a constitution and officers, and to offer advice directly to mothers and also through posters and leaflets on breastfeeding topics.

Parents have responded enthusiastically to talks we have given at clinics, meetings of women's troupe, and also to our printed materials. Our attempts to hold special breastfeeding mothers discussion meetings outside the clink atmosphere have not, on the other hand, drawn more than a handful of participants. In Kenya, breastfeeding help on a mother-to-mother basis seems best given through existing social communities.

We use every medium we can to reach people. The letters quoted in this article were selected from 42 responses to a 'Letter to the editor' which appeared in the Kenya Daily Notion in September 1982. Such publicity reaches a far wide; pubic than the clinics do and draws a varied response.

We answer all inquiries individually. We have responded to frequent questions by developing leaflets. For example, Kenyan men have frequently asked what they can do so we wrote a leaflet called, "Please help your wife to breastfeed." This leaflet is now being translated into Swahili. It joins a number of other leaflets for parents, and a booklet for health worker. Funds for publishing and for the free distribution of our materials were provided by UNICEF and OXFAM.

Answering letters, working on publications and giving talks are frequently done by volunteer temporarily resident in Kenya who can donate substantial time to the breastfeeding Information Group. Increasingly, Kenyans are taking active roles, even though most of them have full time jobs and families to look after. Among our approximately 40 active members in Nairobi, many donate between five and fifteen hours per week to our work. Although we always use breastfeeding mothers to work directly with other mothers, we also value active members who are men, single women, and mothers who could not breastfeed due to lack of information. Throughout the country. we have between 200-250 paying members, including many health workers and teachers. For their yearly membership fee, (about U.S. $1.50) they receive our bi-monthly newsletter. The majority of our officers and members are Africans, but Kenya's Asians and whites also participate.

Through reading and discussion classes, we provide training to our volunteers, end we also maintain a library they can use. Thanks to a grant from OXFAM we can now pay two Kenyan counselor to work with Swahili-speaking mother. Our policy has always been to give help where we are asked, and this means that we work with every sector of Kenyan society from the busy attorney in her Peugeot, to the illiterate mother struggling to support her children alone; from the well-to-do homes of business people to the disadvantaged urban squatters. In the next few years, we expect to strengthen and expand our outreach into the rural areas through existing women's groups, and the rural health service networks.

On a typical day, one of our members might give a talk to patients waiting for treatment at the Mathare Valley Baptist Clinic, in one of Nairobi's poorest areas, and then go on to nearby Pumwani Maternity Hospital where about 100 women crowd the antenatal clinic. In this city-run hospital, the management of breastfeeding is good, but nurses are usually too rushed to discuss mother' questions in detail. So the counselor explains the superiority of breastfeeding, how to have plenty of milk, when to add other foods, and the like. She hands out simple leaflets in Swahili for women whose reading skills may be newly acquired.

Today at the Kawangware-Kabiro Clinic, there is a weaning food demonstration using common local foods to make a nutritious low cost porridge. The clinic is located in a peri-urban, low-income area and is headed by one of our members. The mothers at the clinic have been actively discouraged from the use of supplementary bottles. If a mother comes to the clinic with a feeding bottle, she usually agrees with the nursing sister to exchange it for a cup, and instructions on how to feed with cup and spoon.

In another part of the city, in a private hospital with poor breastfeeding practices (timetable feeds, no rooming in, top-up bottles, and a formula gift pack for every new mother), an expatriate counselor sits with a group of 15 to 20 mothers who have recently delivered. She emphasizes how the home pattern of breastfeeding should differ from the hospital routine. Developing a good milk supply, promoting the let-down reflex, and preventing breast refusal dominate the discussion, and the points made are reinforced with this very literate group by a set of homemade teaching posters. In this hospital, with its well-educated private patients, most will be returning to jobs soon.

"I am expecting my first baby this year and I am a working mother. I will be allowed two months maternity leave. What advice would you give to a working mother who would love to breastfeed but is unable to do so since she is away most of the day?" Mrs. A.D. (Nakuru)

"I am a young mother of one child aged four months. I really find it difficult to cope up with breastfeeding since I work in an office far away from home. I would be very grateful if you could send me your leaflets on increasing one's breast milk, and managing a job and breastfeeding." Mrs. G.I. (Nairobi)

For most urban women in Kenya, workplace child care is not available and returning home during the workday to breastfeed is not possible. We encourage working women to continue breastfeeding at whatever level they can manage, leaving some suitable alternative feed to be given by teaspoon or cup. We also stress the value of extra breastfeeding over weekends and holidays, and the importance of close contact and demand feeds during evenings and nights.

In addition to advising mothers, we also distribute materials throughout the country. Our literature reaches a much wider audience, and we consider it essential to our efforts. Our literature reaches all sorts of people - nurses and mothers of course, but also school girls, church groups - anyone who asks may have it. In the future we plan to do more training of health workers. Our study with the Ministry of Health indicated many areas where nurses do not know enough about breastfeeding management. For example, if a one or two months old child shows insufficient weight gain, more than 3/4 of our wealth workers would at present recommend use of formula, rather than first trying to increase the child's intake of breast milk. In cooperation with the Ministry of Health, we are starting to provide speakers for in-service training workshops, and occasionally organizing our own.

Of course public policies also affect breastfeeding. We are working with health professional organizations and women's organizations to try to establish in Kenya a national Code of Marketing based upon the WHO/UNICEF international model. This effort takes a tremendous commitment of time, but in the long run will be a powerful protection for ** mothers, and babies. Our International Cooperation Committee is coordinating similar breastfeeding support efforts in other African countries, through the IBFAN (International Baby Food Action Network) - Africa Network.

How do we get it all done? We often wonder. We have been fortunate in having many excellent officers, elected annually. Several are nurses, midwives, doctors and nutritionists. We take care to avoid a situation where the Breastfeeding Information Group might come to be seen as a personal power base for individuals, and we emphasize cooperative effort. Through our numerous committees (including publications, counseling, research, newsletter, fund raising) we give a responsible job to any member who wishes one. Each of us get a great deal out of working together, on this matter so close to our hearts which also builds the nation. Throughout all our work runs a common aim: to give parents the information and encouragement they so urgently ask for.

For copies of Breastfeeding Information Group (B.I.G.) publications including an article on starting a group, write the Clearing house on Infant Feeding and Maternal Nutrition, 1015 15th Street N.W., Washington, D.C. 20005, U.S.A. The Clearinghouse would also be interested in information about other groups involved in similar kinds of breastfeeding support activities.

The Breastfeeding Information Group cannot engage in extensive overseas correspondence, but welcomes letters from people in Africa who would like to be on the IBFAN - Africa mailing list. Breastfeeding Information Group materials are not copyrighted and may be reprinted or adapted to conditions elsewhere. If the text is modifies however, please contact the Breastfeeding Information Group , P.O. Box 59436, Nairobi, Kenya.

Note to readers:

In November 1982, an international meeting of community-based breastfeeding support groups was held in Jamaica. Representatives from organizations in more than 20 countries attended (including the Breastfeeding Information Group ). For more information about the conference recommendations, write: Ron Israel, INCS, Education Development Center, 55 Chapel Street, Newton, Massachusetts 02160, U.S.A.

Kenyan mother and baby

Weaning food demonstration

B.I.G. poster

Mother and baby, Kawangware, Kenya


Case Study-: Breastfeeding Information For Kenyans

1. What is the goal of the Breastfeeding Information Group?

2. What activities does the group carry out to reach that goal?

3. Who started the Breastfeeding Information Group? Who carries out the work of the group now?

4. How does the group raise funds for its activities?

5. What aspects of the Breastfeeding Information Groups' program would be beneficial and feasible in your area?

How to have plenty of milk

Breastfeed often:

- Start breastfeeding as soon as possible after birth. Most babies can suck well right after being born. The baby needs your colostrum in order to be healthy.

- Breastfeed the baby whenever he is hungry. This may be ten or more times each day. The more the baby sucks, the more milk supply you will produce,

- Night feedings help to develop a good milk supply. Keep the baby close to you at night.

- Give both breasts at each feeding. Let the baby suck as long as he wants.

- Do not give glucose water or other milk from a bottle between breast feeds. 11 you think that you do not have enough milk. give extra breast feeds to increase your milk production. Do not give other foods instead of the breast.

- Do not stop breastfeeding. Breastfeeding is still good even when your child is two years old, or older. Most babies will give up breastfeeding (wean) slowly, some time between the ages of one and three years. This is natural weaning. You do not need to hurry it.

- When the child is four to six months old, breast milk alone is no longer enough. Start giving other foods in addition to (not instead of) breast milk.

Stand-on breastfeeding

Lying down breastfeeding

Take care of yourself

- Be sure you drink plenty of liquids every day.

- Eat energy, protective, and body-building (protein) foods. All help you make milk.

energy foods: porridge, ugali, sweet potatoes, arrowroot, bread, rice

protein foods: beans, peas, cow or goal milk, eggs, meal, fish

protective foods: fruits and vegetables such as papaya, mango, carrots, spinach

- Rest whenever you can. Sometimes breastfeed lying down.

- Use family planning to space your children. If possible, use any method except pills. The pills can reduce your milk supply.

Fruits and vegetables for mother alimentation

Do not worry

- Do not worry about days when the baby cries more than usual. Comfort him by letting him suck.

- Do not worry about small or soft breast,. After the first days or weeks. your breasts will probably not leak milk. They may not be hard or large. But you still have plenty of milk. It does not simply go away. It will flow when your baby sucks.

If you have any more questions about breastfeeding, please write to:

Breast feeding Information Group PO BOX 59436, NAIROBI



- Breast milk Is the best food for your baby. He does not need any other food for the first four months of his life.

- Breast milk is always clean, always ready, and always warm enough. Night feedings are easy.

- A baby digests breast milk easily. This means he has fewer stomach problems.

- Babies who get only breast milk do not get constipation.

- Breastfed babies get more protection against diarrhoea, colds, flu and skin problems. For two to three days after you give birth, a special milk (colostrum) comes from your breasts. This colostrum gives your baby special protection.

- Sucking at the breast helps your baby's tooth and jaw development

- Breastfeeding saves you money because you do not need to buy costly artificial milk foods.

- Breastfeeding develops close and loving feelings between baby and mother.

Photocredit UNICEF

Breast feeding Information Group PO Box 59436, NAIROBI

Please help your wife to breastfeed

Mother, father and the baby

DO YOU KNOW THAT YOUR WIFE NEEDS MORE TO EAT during pregnancy and during breastfeeding (for at least two years)?

- Be sure you bring home protein foods e.g. beans, ndengu, groundnuts, meat, fish, eggs, milk. Be sure your wife eats plenty of these.

- Also she needs some extra protective foods (fresh fruits and vegetables) and energy foods. Encourage her to have bread. bananas. cassava. potatoes or groundnuts with her morning tea.


- Make sure she has something to drink each time the baby suckles: tea, uji, water, squash, or any other drink.

Enough food for the mother means enough breast milk for the baby. And buying some extra food for the mother is cheaper than buying tinned milk for baby!

Food for mothers

Do YOU KNOW THAT YOUR WIFE NEEDS YOUR APPROVAL FOR BREASTFEEDING? If she thinks that you don't care, she may give up.

Tell her, and tell your relatives and friends, that you are proud your baby is being breast fed. Remind them why breast milk is the best baby milk:

- It is free from germs and it protects baby against illnesses. Baby will be healthiest on breast milk. (Not so much diarrhoea or colds).

- It has the comet temperature and is always ready.

- It is easily digested by the baby. (Not so many stomach problems and allergies)

- It is inexpensive. ( No extra expenses for bottles, tinned milk, fuel, etc.)

- Baby is happier close to mother, nights are quieter, and parents sleep better

DO YOU KNOW THAT YOUR WIFE NEEDS REST? An exhausted woman has trouble producing enough milk.

- See what you can do to lessen your wife's burdens so that she may sometimes rest.

DO YOU KNOW THAT GOOD ADVICE CAN SOLVE BREASTFEEDING PROBLEMS? For. example. the milk supply can be increased at any time if you only know what to do. If your wife's milk 'is "going away," encourage her to put the baby to the breast as often as the baby demands. More sucking makes more milk. For the safety of your baby, don't allow the use of feeding bottles unless the clinic or doctor has prescribed them for a special reason.

Feeding bottles


- Keep your wife as happy as you can. Avoid quarrels.

- Listen it she talks about her worries and try to help her solve any problems.

- Be sure you are at home enough to give her real help with the other children.

Help with the other children


- Encourage your wife to continue breastfeeding until the baby is two years old. (It she goes out to a job, she can still breastfeed when she is at home.)

- Other foods should be added to the baby's diet starting when he is about four months old.

- Agree with your wife on a family planning method so that another pregnancy will not come sooner than you want Baby should be eating many other foods and drinking from a cup before the next pregnancy is begun

With your help and encouragement your wife can breastfeed happily.

For more information or advice, please write to us. Breastfeeding Information Group, P. O. Box 59436. Nairobi


"Breastfeeding Information for Kenyans." Mothers and Children, Vol. 3, No. 1, January 1983.

Cameron M. and Hofvander, Y. Manual on Feeding Infants and Young Children. Oxford University Press, 1983.

Ebrahim, G.J. Breastfeeding the Biological Option. MacMillan Press Ltd., Hong Kong, 1978.

Helsing, E. and Savage King F. Breast-feeding in Practice - A Manual for Health Workers. Oxford University Press, New York, 1982.

World Health Organization. Women and Breastfeeding 1982.

World Health Organization. Report of a Joint WHO/UNICEF Consultation Concerning "Infants WHO Have to be Fed on Breast-milk Substitutes." 1986.

World Health Organization. Factors Influencing Breastfeeding in Relation to Infant and Maternal Health. 1986.


Unit 4: Introducing weaning practices in the community

SESSION 1: Changing Weaning Practices

SESSION 2: Making Improved Weaning Foods in the Home

SESSION 3: Weaning Food Practice

SESSION 4: Case Study: Village Weaning Food Projects in Thailand

SESSION 5: Weaning Foods - Village Production Techniques

Session 1: Changing weaning practices

Weaning practices are often the most important causes of malnutrition in children from six months to three years of age. Habits of child feeding are based on the quantity and quality of food available; on beliefs about what is and isn't good for young children; on time available for food preparation; and on custom. Recommendations for changes in weaning practices must be practical and they must be acceptable to the community.


In this session, participants analyze common weaning practices in their regions and develop strategies for changing the current practices that result in malnutrition of weaning-age children.

Time: 1 1/2 - 2 hours


- Flipchart and marking pens

- Handout - "Guidelines for Weaning"

- Handout - "Changing Weaning Practices"

To the Trainer:

Before this session, write a short description of the common weaning practices that are detrimental to the nutrition of weaning-age children. The problem statement can be written directly on the Handout - "Changing Weaning Practices,. or it can be copied and distributed separately. An example is provided on the handout.


1. Distribute the Handout - "Guidelines for Weaning" and review with the trainees.

2. Ask trainees to think of the common weaning practices in their areas by answering the following questions:

- At what age are the first foods other than breast milk given to children

- What foods are routinely given to children six months to two years old (daily)

- What foods are never given

- How many times a day are young children fed

- At what age do most women stop breastfeeding their children

3. Conduct a discussion of common weaning problems by asking trainees to compare the practices in their areas to the "Guidelines for Weaning. "

4. Ask trainees to explain why they think families follow the current weaning practices. Summarize their responses giving emphasis to the following points:

- Foods are sometimes not available

- Mothers (and fathers) do not have enough time to prepare food and feed young children

- Beliefs about foods for young children restrict the foods they are given to eat

- Customs or habits of feeding

- Lack of knowledge about food and nutrition

5. Divide trainees into small work groups (5 - 7 persons from the same region if possible). Distribute the Handout - "Changing Weaning Practice" to each trainee. In this activity, work groups will develop plans for improving weaning practices in a village. A problem statement describing the specific weaning behaviors that they have been asked to improve should be given to each group.

6. Tell work groups that their plans should describe what they will do and how they will do it. Plans should be:

- Practical or "doable" with the resources of most families

- Acceptable to the families

7. When work groups finish, ask each group to describe the changes in feeding practices they would recommend and their plan for helping families in the project area change these practices.

8. Point out similarities and differences in the plans. Make a list on the flipchart of the types of activities proposed by the work groups. Add other activities that might be appropriate.

9. Congratulate trainees on their efforts and remind them that every plan for change will be slightly different based on the experience, training and perceptions of the group members as well as the information they have about attitudes and practices in the community. As community project managers, we should be ready to change our plans as our information and experiences increase and as conditions change in the community.


Guidelines FOR WEANING

Weaning is the period when new foods are introduced to a child's diet while breastfeeding continues. The weaning period begins between four and six months and may continue until about three years of age.

1. Breastfeeding alone is normally sufficient until an infant is 4-6 months of age.

2. From 4-6 months, soft foods should be added gradually to the diet.

3. When foods are first introduced they should be mashed smoothly; by about nine months, foods can be finely chopped; by two years, most children can manage adult foods.

4. From six months to two years, a child should be fed four to six small meals each day in addition to breastfeeding.

5. After six months, an infant should be eating body-building, energy and protective foods plus breast milk every day.

6. Food for young children, once prepared, should never be stored without refrigeration for more than two hours.

7. The hands of both mother and child should be washed before handling food.

8. Use a clean cup and spoon for feeding young children never use feeding bottles!



1. Problem Statement

Example: 40 % of the children ages 1-3 years in our project area are suffering from malnutrition. Mothers breastfeed until their children are 2-3 years, but in most villages, other foods are not given regularly until children are 9-12 months old. Young children are fed a constant diet of maize porridge, banana, cassava and other starchy foods. Even though body-building foods like beans and eggs are produced by most families, they are rarely given to young children. Since it is customary to eat two meals a day, young children are fed in the morning and again in the evening when their parents finish work in the fields.

2. What changes in feeding practices would improve the nutrition of weaning-age children in this project area?

3. What actions could be taken to help families change their current weaning practices?

Session 2: Making improved meaning foods in the home

High quality weaning foods can be made from the foods found in most homes. Individual and group education activities in the community should include practical recipes and demonstrations of improved weaning foods made from locally available ingredients.


Using the Weaning Food Square, trainees will develop improved weaning mixes from foods available in their regions. They will discuss alternative methods for home preparation of weaning foods and answer a simple set of questions to predict acceptance of new weaning food recipes.

Time: 1 hour


- Flipchart and marking pens

- Handout - "Making Improved Weaning Foods Using the Weaning Food Square"

- Handout - "Why Add Energy Supplements to Weaning Foods? "

- Large drawing of the Weaning Food Square - Samples or pictures of local foods


1. Introduce the session topic. Emphasize the need to give families practical advice about improved weaning mixtures that can be made from foods found in the home, with little or no extra work.

2. Post a large drawing of the Weaning Food Square at the front of the room, and explain that it can be a useful tool for planning improved weaning recipes from foods in their regions.

3. Describe each section of the Weaning Food Square and the types of foods belonging in each one. Ask trainees to name the foods grown or sold in their regions that belong in each section of the square. Write the names of the foods mentioned, or attach pictures of the foods, to the correct section of the large Weaning Food Square.

4. Distribute the Handout - "Why Add Energy Supplements to Weaning Foods?" and discuss with trainees.

5. Distribute the Handout - "Making Improved Weaning Foods Using the Weaning Food Square." Divide trainees into work groups of 3-4 persons each. Each work group will develop at least three improved weaning foods by completing the steps on the handout.

6. Review the steps on the handout one at a time, allowing work groups 5-10 minutes to complete each step before proceeding to the next.

7. When you reach Step 3 - Preparing Ingredients, make the following points, There are three principal ways of preparing improved weaning foods:

- Using foods from the family's meal

- Adding one or more new ingredients to the traditional porridge or gruel fed to infants

- Combining ingredients that are not typically used for child feeding in a new recipe

Simple methods of preparation that are the same as those used in every day food preparation are most likely to be accepted.

Methods of preparation that reduce extra cooking time will also guarantee that a weaning food recipe is prepared often.

8. Concerning Step 4 - Calculating Amounts of Ingredients: Nutritionists familiar with the nutrient values of local foods should calculate average portion sizes for each commonly available ingredient. Trainees should be given portion sizes for raw and cooked foods in terms of volume (ml) and common household measures (i.e., tea cup, eating spoon), as in the upcoming Example. The basic goals for a weaning food serving for one child, for one meal are:

- 300-350 kilo calories;

- 5-6 grams of reference protein;

- 200-300 ml volume.

A table showing the approximate raw weights and proportions of staple and protein supplements to achieve these goals is provided as a trainer's reference on page I-4,9.

9. When work groups finish Steps 4 and 5, ask them to write their completed recipes on newsprint and to present them to the group.

10. Use page 6 of the handout, to give each of the recipes a score for predicted community acceptance. Discuss the advantages and disadvantages of specific recipes with the group.

Look for recipes that build on traditional methods of food preparation and those that require little extra time for preparation!

11. Ask work groups to select 1-2 of their recipes for demonstration. (In some cases, the trainer may want to choose recipes to assure that a variety of weaning mixes are made.) Work groups should plan their demonstrations, listing and, in some cases, collecting needed supplies and cooking utensils.

Go on to Session 3!




Raw Volume

Cooked Volume




100 ml (1/2 tea cup)

200 ml (1 tea cup)


100 ml (1/2 tea cup)

300 ml (1 1/2 tea cup)

Protein Supplement



30 ml (2 tablespoons)

60 ml (5-6 table spoons, 1/4 cup)


180-200 ml (1 tea cup)


(whole, liquid)


Vegetable Supplement


Leafy green


20 ml (1-2 table green spoons)




Energy Supplement


Oil, Fat

5-10 ml



(1-2 teaspoons)



10-20 ml


(1 tablespoon)



A table of this type should be developed locally to be included on page 3 of the Handout - "Making Improved Weaning Foods Using the Weaning Food Square. "


Table 22. Calculated amounts of ingredients for Basic Mixes - using edible portions of raw foods

Staples (g)

Supplement (g)




Sorghum, millet



Sweet Potato


Taro, Cocoyam



Flour, gari














Legume (g)


























Soybeans (g)


























Dried skimmed milk (g)


























Dried whole milk (g)


























Chick or lean meat (g)


























Fresh fish (g)


























Egg (g)













1. The basic mixes have been calculated to give the best possible protein value (i.e. amino-acid score). The least amount of protein food is used to supplement the staple to provide the basis of a meal for a child of about two years of age.

2 To each of these basic mixes 10 g of oil OR 5 g of oil and 10 g of sugar OR 20 g of sugar should be added.

3. Each mix then provides about 350 kcal (approximately one-third of the daily needs of a two-year-old child).

4. Each mix has the same protein value and provides the approximate equivalent of 5-6 g of reference protein.

5. The weights given for the staple and the supplement are for raw foods. See Chapter 15 for variations for the supplements.

6. The volumes of most of the basic mixes are between 200-300 ml when the water absorbed by the food is taken into account.

Cameron, M; and Hofvander, Y. Manual on Feeding Infants and Young Children, Oxford Press, 1983, p. 119.



Breast milk



Energy Foods

Body-Building Foods

Cereal grains



Animal foods





Protective Foods


(Vitamins and Minerals)









Breast milk is in the middle of the Food Square because it is a complete food until a child reaches 4-6 months of age.

By the time a growing child is six months old, he needs breast milk plus foods from each of the other parts of the Food Square every day.

Recipes for improved weaning foods can be made by combining at least one food from each part of the Food Square. Recipes should include:

An Energy Food: This is usually a cereal grain like rice, corn, wheat, sorghum, millet or oats. It can also be potato, cassava, yam, banana or plantains, and other starchy roots.

A Body-Building Food: All legumes and animal products such as meat, milk, fish, eggs, chicken, etc., are included in this box. Choose a low-cost food that can be found in most homes. This will usually include legumes, eggs and fish.

A Protective Food: These include all leafy green vegetables and fruits.

A High-Energy Supplement: All oil, fats, natural and processed sugars including honey.

Breast milk



Energy Foods

Body-Building Foods



Protective Foods


(Vitamins and Minerals)


To make your own recipes for improved weaning foods, follow these steps:

Step 1. Classifying Local Foods: In each of the parts of the Weaning Food Square above, write the appropriate foods available in the homes of most families you work with. Use the description on the first page of this worksheet to decide in which part (A, B. C, D) the foods belong.

Step 2. Choosing Ingredients: Choose at least one food from each of the parts of the square. Practice making different combinations from the available foods by completing the exercise below:

Recipe 1

Recipe 2









Note: Unless animal foods are produced by the families or available at very low cost, they should be not included in your recipes. Always choose foods that most families grow or produce or those that you will help them produce as part of your project.

Step 3. Preparing Ingredients: On the worksheet that follows, describe how you will prepare the foods for each recipe. First, write the ingredients for your recipes in the spaces provided, then describe how they will be prepared and how much time it will take. (Page 5)

Preparation should be simple, involving as few steps as possible. It should not take too much time. Preparation of foods for children from six months to one year requires mashing and straining. For children 1-3 years, it may include chopping or mashing. Foods may be cooked together or cooked separately and then combined in the meal. The simplest and most successful recipes are usually those that use foods from the family meal, which are separated once cooked, and are prepared according to the ages of the children.

Step 4. Calculating Amounts of Ingredients: The amount of each food in a recipe depends on the number of children to be served, the ages of the children and whether you are using foods that are raw or cooked.

Use the following chart when figuring how much of each food to use in your recipe. These amounts are based on the needs of one child age 1-2 years, for one meal. For younger children use less of each ingredient, but make sure they are in the same proportions. For older children, add a little more of each.

Standard Portion Sizes for Weaning Food Ingredients*

* To be developed by local nutritionist prior to training.


Raw Volume

Cooked Volume



Protein Supplements


Vitamin/Mineral Supplements


Energy Supplements


Step 5. Meals for More Than One Child: Calculate how much of each ingredient will be required to prepare the recipe for several Children. Do this by writing the amount of cooked or raw ingredient you will use for one child, on the worksheet. Write this amount in local measurements, i.e., 1 handful, 1 1/2 tea cups, 1 eating spoon, etc. Multiply by the number of children the recipe will serve to find the total amount of each ingredient needed.

You have now developed several recipes for improved weaning foods using the foods available in most of the homes in your area. Once you learn the approximate amounts and types of foods to use, you will be able to develop improved weaning foods without the help of this guide.


Improved weaning foods include at least one food from each of the sections of the Weaning Food Square.

Successful recipes for improved weaning foods are simple and require little extra time.

Ingredients for improved weaning foods must be those available in every home.


Recipe 1


Amount for
One Child


Number of Children


Amount Needed


























Describe the preparation and cooking time and other ingredients.



Recipe 2


Amount for
One Child


Number of Children


Amount Needed

























Describe the preparation and cooking time and other ingredients.





First, calculate the cost for four or five servings of the new weaning food $ __________.

Then answer the following questions for each new recipe:




- Is the cost of the weaning food reasonable when compared to the resources of poor families?


- Are all of the ingredients required available in most homes?


- Are the ingredients that are not available in most homes available at low cost in the community market?


- Is total preparation time 10 minutes or less? (If the weaning food is cooked with the family's food, mark yes.)


- Is the weaning food prepared the way that most foods are prepared or together with the family's food?


- Are all of the ingredients believed to be good for children?


- Does the weaning food taste and look like the food eaten in the community?


Give each recipe a score:

Each "No" receives 0 points. Each "Yes" receives 1 point. Now, add the total score.

TOTAL: __________.

A perfect score of 7 means that we can predict good acceptance of the new weaning food. Lower scores may mean that a recipe will need extra promotion to gain acceptance in the community.

A score of 5 or less, may mean that a recipe is not likely to gain the acceptance of the community.

If the cost of the new weaning food is too high, it will not be accepted by the community.



A small child can only eat a small amount at one time: about one and a half cups of food by one year of age. In order to get maximal energy, a child must eat several small meals during the day, and those meals must include as much energy as possible.

Oils, fats and sugars contain large amounts of energy. For example, 1 tablespoon of oil contains the same amount of energy as 3 1/2 tablespoons of uncooked maize flour, or more than 7 tablespoons of cooked maize flour.

By adding a little oil, fat or sugar to a child's food we can increase the amount of energy without increasing the amount of food.

Adding oil also reduces the amount of food to be eaten because less water can be added to porridges and gruels when they are cooked. A little oil keeps porridge smooth, with less water.

The following examples show how energy supplements improve the nutrition quality of weaning foods.


1/2 cup maize flour (uncooked) + water = 235 energy units

1/2 cup maize flour (uncooked) + 1 teaspoon oil + water = 315 energy units


To get as much energy as he needs from one meal during the day, a child of one year must eat:

- more than 2 cups of porridge if it is made with only maize flour and water

More than 2 cups

- 1 1/2 cups of porridge if it is made with maize flour and a high-energy supplement

1 ½ cups

QUESTION: What will happen to a child who is fed porridge without a high-energy supplement?

ANSWER: Because the child can only eat about 1 - 1 ½ cups of porridge at one meal, if he is fed porridge without a high-energy supplement he will not get the energy he needs from three meals a day. He will become malnourished.


- Encourage the addition of high-energy supplements to all weaning foods.

- Encourage four to five small meals for children during the weaning period. Feed small children frequently with high energy weaning foods.

Note: A little bit of oil or sugar is enough! Be careful not to add too much. Mothers will tell you that too much oil can cause diarrhea in young children.

Session 3: Weaning food practice


Trainees prepare and demonstrate the preparation of improved weaning foods appropriate for introduction to the community .

Time: 2-3 hours


- Handout - "Conducting a Community Weaning Food Demonstration"

- One set of cooking utensils and equipment for each work group including cups, bowls, spoons of various sizes, cooking stoves, grinders, sieve, etc. All utensils and equipment should be similar to those used in most homes in the community

- Foods to be used in the preparation of weaning mixtures

- Space for work groups to cook and demonstrate their recipes

- Water

- Flipchart and marking pens


1. Arrange the training area and equipment so that each work group has a space for cooking.

2. Review the characteristics and steps of an effective cooking demonstration. Include the points on Handout - "Conducting a Community Weaning Food Demonstration. "

3. Allow work groups to prepare their ingredients.

4. Each group should demonstrate preparation of at least one weaning food recipe. If time is limited, work groups can be paired. In this case, one group presents its demonstration for the other's comments and vice versa.

5. Encourage trainees to learn from the reactions of families in their communities to the new weaning recipes. Women often make modifications in new recipes to reduce preparation and cooking time. They may also vary ingredients to improve taste and color according to local preference. Incorporating the changes made by women in the community will often make the new weaning recipes more appropriate and acceptable .



1. Choose a recipe that calls for no more than 3 or 4 foods that can be found in most homes at the time of the demonstration.

2. Use utensils and cooking stoves that are like those in most homes.

3. Begin the demonstration by explaining why it is important to prepare improved foods for weaning-age children. Review the types of foods young children need, when soft foods should be added to the diet and the importance of frequent feeding for young children.

4. Show the ingredients you will use. You may also make a poster or handouts with the ingredients and instructions printed on them.

5. Wash your hands and the cooking utensils to demonstrate good hygiene.

6. Prepare only enough food for two or three children so that the amounts and proportions of ingredients are clearly understood. (If you wish to have many people try the new food, prepare a larger quantity before the demonstration.)

7. Show each step in the preparation; speak loudly and talk about what you are doing - always face your audience!

8. Get the audience involved - they can help prepare ingredients and, of course, they will want to sample the finished food!

9. Ask the group what they liked or disliked about the new food. Will they try it? Why? Why not?

10. Ask those who say they will try the new food to let you know if their children like it. How can they change it to make it better?

Session 4: Case study: Village weaning food projects in Thailand


Trainees will review a description of Thailand's village weaning food and nutrition education projects. They will also discuss whether this type of community self-help activity would be appropriate in their regions.

Time: 1 1/2 hours


- Flipchart and marking pens

- Handout - "Case Study: Village Weaning Food Projects in Thailand"


1. Introduce the session by explaining that villagers can improve weaning practices and child nutrition if they work together. During this session, participants will read a case study about community weaning food projects in Thailand.

2. Distribute the case study, and ask participants to read it silently.

3. Write the discussion questions on the flipchart, and work with participants to answer each of the questions.


Divide into small groups, asking the groups to write and present their answers to the discussion questions.

4. Summarize the session by pointing out that projects of this type require:

- commitment by the village;

- training for villagers in techniques of food production; nutrition education and financial management;

- careful selection of grinders and other utensils;

- quality control and adequate hygiene to make sure that weaning foods are not contaminated;

- on-going technical advice and assistance.




Preparation of special foods for children during the weaning period (six months - two years) takes extra time and effort. In many countries, women are responsible for working in the fields, fetching water, collecting firewood, preparing food for the family and caring for small children. They often do not have time to make special meals for their young children.

In this case study, we will learn about several different programs in Thailand that are addressing the problem of malnutrition in weaning-age children. There are over 100 villages in different parts of Thailand with the type of self-help project described below.

Case Study

Thailand is a rural country of over 47 million people. Agriculture is the main source of income in rural villages, and rice is the main crop and the staple of the Thai diet. It is estimated that over two-thirds of Thailand's infants and pre-school children are affected by malnutrition.

Several years ago, a number of organizations in Thailand began working with rural villages to improve the nutrition and health of their children. Most of the villages involved were first visited by motivation teams responsible for promoting cooperative village action. These teams emphasized self-reliance and used games and discussions to learn more about village problems and "felt needs. " They also presented information to the villages about appropriate health and nutrition technologies and low cost food production.

As a result of the work of the motivators, many of the villages formed cooperatives or committees responsible for village health and nutrition activities. In most cases, cooperatives collect a small contribution from each cooperative member to start a revolving community health fund for village projects.

Cooperatives select nutrition and health volunteers who receive training from a district health team. Village volunteers then become responsible for monthly weighing of all children under three years old in the village and for nutrition education with mothers and school children. Growth cards are given to all mothers for children under three years old in most of these villages.

Village nutrition cooperatives are also introducing improved weaning foods as well as foods for the treatment of malnourished children. Different mixtures of rice, legumes and seeds or nuts are produced, packaged and distributed by the village cooperatives using local ingredients and appropriate village technology.

Members of the nutrition cooperatives generally take turns preparing the improved weaning foods. The ingredients are first cleaned; then legumes, seeds and nuts are roasted until they are fully cooked. Rice is heated for only a few minutes to kill harmful bacteria. After roasting, the weaning mixtures for young children are ground to a fine flour. For older children, mixtures are ground to a coarse flour, or they are left in their original form. Because the ingredients are roasted, the amount of time required for cooking the weaning mixtures is reduced.

Village nutrition cooperatives use utensils commonly found in the village as well as appropriate, low-cost grinders and roasters to make the improved weaning foods. Several different types of grinder are being used depending on the resources of the program and the availability of electricity. These include the common village grinding stone, the hand grinder and a low-cost electric grinder.

Families with malnourished children are assisted by the village nutrition cooperatives and their weaning food projects. If a child is suffering from severe malnutrition, weaning mixtures are given to the family at no cost. In cases of mild and moderate malnutrition, a reduced price may be charged, or raw foods may be traded for the packaged weaning foods.

The sale of weaning foods to families in their own and other nearby villages is another goal. The prices charged to the families of healthy children vary from village to village. Unfortunately, few villages keep detailed records of their expenses and sales, so it is difficult to know if cooperatives are making a profit from this activity. Income from the sale of weaning foods is reinvested in producing more of the same. Excess profit can be used by the cooperatives for projects they decide to carry out to improve the health of their villages.

Because these village projects are relatively new, it is too early to evaluate their impact. We know that villages have responded enthusiastically to the program and, in several of the first villages to establish health/nutrition cooperatives, there are reports that severe malnutrition has been eliminated.

Questions for Discussion

1. What is the problem the rural villages in Thailand are working together to solve?

2. What have the villagers done to solve this problem? List their activities.

3. What resources did the villagers need to carry out their activities? (Remember resources are people, materials, equipment, interest, money, etc.)

4. Would this type of project be feasible in the communities you work with now? Why or why not?

Session 5: Weaning foods - Village production techniques

When weaning foods like those described in the Thailand case study are available, women need much less time to prepare frequent, high-quality meals for their weaning-age children. Packaged weaning foods can be distributed or sold at a reduced price for the rehabilitation of malnourished children. They can also be sold by community groups and individuals as an income generating activity.


Trainees are introduced to the technologies and locally developed recipes for village production of weaning foods. They practice making several weaning mixtures, then analyze the production process in terms of village resources and feasibility.

Time: 2 hours


- Village-appropriate grinders. Two types of grinders are often required: a corn grinder for coarse grind and a coffee grinder for fine flour grinds.

- Village cooking utensils, including roasting pans, spoons for stirring and measuring, cups, sieve, winnow, charcoal cooker, etc.

- Handout - "How to Make Flour from Cereals, Tubers and Legumes"

- Handout - "Recipes for Village-Processed Weaning Foods"

- Handout - "Planning a Village Weaning Food Project"

- Small plastic bags and a candle for sealing

Prior to the Session:

Investigate the techniques and ingredients that have been or could be used to make mixed cereal and legume flours in your country. A description of the process and recipes developed in Indonesia are included for your information.


1. Introduction - Tell trainees that they will practice using equipment and recipes for making packaged weaning foods. The techniques they will use in this session might be used in a village for production of weaning foods for sale or distribution.

2. Describe the Production Process

a. List the possible ingredients for cereal and legume mixtures that are grown in the trainees' regions.

b. Distribute and review the Handout - "How to Make Flour from Cereals, Tubers and Legumes."

c. Demonstrate the use of roasters and grinders.

3. Practice

a. Divide trainees into work groups. Assign each work group the preparation of one of the ingredients. Prepare sufficient quantities of each flour so that they can be used in several different combinations. Also prepare different consistencies of each ingredient: coarse grind for older children, fine flours for infants, etc.

b. Distribute the Handout - "Recipes for Village Processed Weaning Foods."

Assign each work group the preparation of one of the recipes. Groups should prepare one portion for sampling and one portion for packaging.

4. Discussion: Discuss the time and labor required to produce the weaning mixtures. Compare the tastes, consistencies, etc. Ask trainees what changes could be made in the process, ingredients, etc. to improve the production and the results. Ask them if, after trying the production of mixed weaning foods themselves, they would recommend this type of village weaning food in their areas.

5. Distribute the Handout - "Planning a Village Weaning Food Project. Review the questions on the handout with participants. Ask them individually or in their work groups to answer each of the questions. Review the results of this exercise in a group discussion.

6. Summary

The process used for weaning food production in this session can be modified to fit local needs and resources.

Projects started in several countries are experimenting with alternative ways of obtaining and processing the necessary raw ingredients for weaning mixtures.

For example:

- Raw ingredients are contributed by families (Indonesia)

- Families bring one or more of the roasted ingredients for grinding. (Nepal)

- Ingredients may be roasted and packaged for grinding later at home by the family. (Thailand)

In these cases, the community project is providing partial production and ingredients; the families are providing the remaining labor and raw ingredients for the weaning mixtures.

The type of project discussed in Sessions 4 and 5 makes a high-quality weaning mixture available to the community. The weaning mixture can be used for treating malnourished children, for making quick meals for weaning age children, and as an ingredient in snacks and meals for older children and adults.

If properly managed, this type of project can be self-sustaining. It may also provide added income for community self-help activities.

Before undertaking a village weaning food project, interested managers and groups should seek advice from local experts.



Green Gram
(Mung Beans)



Dry Roast slowly until cooked

Grind while hot
(coffee grinder)


Fine flour

(Red, White)



Dry Roast slowly
until cooked

Grind coarse
(corn grinder)


Grind fine
(coffee grinder)


Fine flour

(dried, whole kernel)


Grind coarse
(corn grinder)


Grind fine




Fine and
coarse flour





Grind fine


Fine flour




Soak in lime water for about 5 minutes (2 grs. Lime to 1 liter water)

Dry with a clean cloth

Grate with metal grater

Dry about 5 hours in the sun or on a solar dryer



Fine flour



Production of weaning foods for distribution and sale requires special equipment and knowledge of production techniques. The people who will make the weaning mixtures must be trained and supervised. Distribution and sale of the mixtures require careful recordkeeping and financial skills.

Individuals and village groups who are interested in starting weaning food production should consider the following before they begin:


- What are our goals for this activity?


- What ingredients will we use?
- What equipment will we use? Types of grinders, roasters, etc.?
- Where will we produce the weaning foods?
- Who will produce them?
- How will the weaning foods be packaged?


- How will we obtain the raw ingredients?
- How will we obtain the equipment and the space we need?
- Who will train group members, workers, etc., to make and control the distribution of the weaning foods?


- Will the weaning foods be sold?
- Will the weaning foods be given free? Under what circumstances?
- What records and reports will we need to control inventory and sales?


- How will we introduce the weaning foods to community members?
- How much would most community members be able or willing to pay for the weaning foods?





Raw Weight

Local Measure



Maize flour (fine)

50 grs.

1/2 plastic cup (100 ml.)

Green gram flour (fine)

25 grs.

2 1/2 tablespoons


15 grs.

1 tablespoon (15 ml.)


1 pinch


Coconut oil or
Groundnut paste

5 grs.
15 grs.

1 teaspoon
1 tablespoon


400 ml.

2 plastic cups (400 ml.)

Cook for about 10 minutes. Makes 1-2 servings. Add 50 grs. (2 handfuls) of finely chopped green leafy vegetables about 5 minutes before porridge is ready.



Raw Weight

Local Measure



Maize flour (fine)

50 grs.

1/2 plastic cup (100 ml.)

Green gram flour (fine)

25 grs.

2 1/2 tablespoons


10 grs.

1 tablespoon (15 ml.)


1 pinch


Coconut oil

5 grs.

1 teaspoon


400 ml.

2 plastic cups (400 ml.)

Cook 10 minutes. Makes 1-2 servings. Add 50 grs. finely chopped green leafy vegetables.


"Sarbottam Pitho" (Super-flour)

Cereal grain

2 kilos

(1 kilo of 2 of the following: maize, rice, sorghum, millet)


1 kilo

(soybeans, green gram, beans)

Roast legume and cereal grains together. Grind to fine flour. Makes 3 kilos or 40-50 servings. Cook in boiling water. Add salt, sugar, oil to taste.


"Kow Tip"


3 kilos

Mung Bean

1 kilo


1 kilo



Roast mung beans and groundnuts for 5-10 minutes. Roast rice for 3-5 minutes. Combine and grind. Makes 50 packages of 100 grams each. Can be cooked as porridge or in cakes for snacks.


Cameron, M. and Hofvander, Y. Manual on Feeding Infants and Young Children. Oxford University Press, 1983.

Gibbons, G. and Griffiths, M. Program Activities for Improving Weaning Practices. World Federation of Public Health Associations, Geneva, 1984.

Nabarro, D., Gordon, G., Verney, J. and Wijga, A. "Finding Out How Children Are Weaned. " Save the Children Fund (U.K.), 1984.

Valyasevi A. "Home and Village Prepared Weaning Foods Project." Paper prepared for the Workshop of Weaning Foods Projects. MIT, Cambridge, Massachusetts, 1982.


Unit 5: Preventing diarrhea

SESSION 1: Preventing Diarrhea

SESSION 2: Diarrhea Home Management

SESSION 3: Community Activities to Prevent Diarrhea

Session 1: Preventing diarrhea*

* Much of the format and materials used in compiling this session was adapted from the WHO Programme for Control of Diarrhoeal Diseases Supervisory Skills Course: Module on Prevention of Diarrhoea, revised ed.

Diarrhea is the disease that kills more children in the world today than any other. While diarrhea! disease control programs often emphasize proper treatment, including Oral Rehydration Therapy (ORT), for the most reduction of deaths from diarrhea among young children individuals, families and communities can take action to prevent diarrhea and to prevent death from diarrhea through a variety of other effective and affordable preventive interventions.


Trainees review the relationship between diarrhea, nutrition and child survival. Rules for the prevention of diarrhea are developed.

Time: 2 1/2 hours


- Handout - "How to Prevent Diarrhea"

- Flipchart and marking pens


1. Diarrhea and malnutrition:

Begin by reviewing the relationship between diarrhea and malnutrition. (See Unit 1, Nutrition of Women and Children).

Emphasize the following points:

- Malnourished children have more severe and more prolonged diarrhea than well nourished children, which results in a cycle of more malnutrition, more days of diarrhea, greater risk of death due to diarrhea, etc.

- Diarrhea causes malnutrition because food is not absorbed in the intestine; nausea and vomiting may decrease the amount of food eaten. Diarrhea is often related to lack of appetite among young children resulting in decreased food intake. In some cultures, food may also be withheld from a child with diarrhea.

- To prevent malnutrition we must prevent diarrhea and treat it properly when it occurs.

2. Preventing Diarrhea:

- Review the fecal-oral transmission of diarrhea through contaminated food, water and hands.

- Use the handout "How to Prevent Diarrhea" as a guide, review the seven interventions recommended by WHO which have been shown by recent research to be particularly effective and affordable in preventing diarrhea. These are:


Improved weaning practices

Use of plenty of clean water


Use of latrines

Proper disposal of babies' stools

Measles immunization

- Emphasize the importance of breastfeeding as a means of preventing diarrhea in infants (discuss studies showing large differences in rates of diarrhea among exclusively breastfed infants compared with those not breastfed or receiving both bottle and breast).

3. Ask the group to brainstorm the socioeconomic and environmental causes of diarrhea in young children. These should include:

- Use of feeding bottles

- Lack of water for washing

- Unclean water

- Lack of latrines

- Spoiled or contaminated foods

4. Divide into work groups with 5-6 trainees in each. Ask work groups to develop a list of community action for prevention of diarrhea. When they finish, each work group should read its rules to the others.

5. Distribute the handout - "How to Prevent Diarrhea." Review and discuss any rules on the handout that were not mentioned by work groups.

6. Discuss the types of community programs that could help families understand and follow rules for prevention of diarrhea. Some examples are:

- Latrine construction

- Family education

- Water supply improvement

- Breastfeeding promotion

- Immunization programs

7. Summary

Point out that all efforts to prevent diarrhea must include strong educational activities because many of the causes of diarrhea are related to behaviors, i.e., personal habits of hygiene, food preparation, etc. In many instances, the role of the health worker is to help community members to adopt and maintain the recommended practices. In other cases, outside resources and assistance may also be necessary before people are able to practice good personal and environmental hygiene, i.e., materials for latrine construction or water projects.


*Adapted form WHO Supervisory Skills Module "Prevention of Diarrhea, revised edition 1987.


Breastfeeding is declining in most developing countries, especially among the more educated and more urbanized groups. Reasons for this decline may include a belief that bottle feeding is more modern, advertisement of infant formula, difficulty in breastfeeding while at work, fear of becoming less sexually attractive, and belief that one cannot breastfeed adequately.

During the first 4-6 months of life, infants should be exclusively breastfed. This means the baby should receive breastmilk and no other fluids such as water, juice or formula.

Exclusively breastfed babies are much less likely to get diarrhea than babies who are not breastfed or are partially breastfed. If an exclusively breastfed baby does get diarrhea, the baby is much less likely to die. During the first 6 months of life, the risk of having severe or fatal diarrhea is 30 times greater for infants who are not breastfed than for infants who are exclusively breastfed.

During age six months to two years, infants should be partially breastfed. This means that breastfeeding should continue after weaning foods are introduced. Babies who continue to get breastmilk will get less diarrhea than those who do not. This partial breastfeeding will greatly reduce the risk of severe diarrhea and diarrhea death.

Breastfeeding protects because it avoids use of contaminated bottles, teats and formula. The content of breastmilk also helps the baby's body build resistance to diseases. Therefore, even if bottles are clean and formula is properly prepared, a bottle-fed child is at increased risk of disease.

What Mothers Should Do

Breastfeed their babies exclusively for the first 4-6 months, and partially up to age two or more.

To breastfeed comfortably and safely,

- to decrease risk of infection, give no extra fluids such as water, sugar water, or milk formula, especially during the first days of life

- start breastfeeding as soon as possible after delivery

- breastfeed on demand (increased sucking increases milk supply)

- if it is not possible to take the baby to work, breastfeed before leaving home, on returning, at night, and at any other time when with the baby

- express milk manually to avoid engorgement during periods of separation from the baby

Breastfeed during and after illness of their babies, especially diarrhea.


Weaning is the process by which the infant gradually becomes accustomed to the adult diet. The child's diet changes from milk alone to one based on the regular family meals. Milk, preferably breastmilk, continues to be an important part of the diet.

Weaning is a hazardous period for infants. Poor weaning practices are associated with increased risk of diarrhea and diarrhea death. Good weaning practice involves attention to the when, the what and the how.

What Families Should Do

When to begin to Wean?

When the child is about 4-6 months old, continue to breastfeed regularly and introduce a few soft, mashed foods, twice per day. When the child is about six months old, continue to breastfeed but expand the variety of foods and give them 4 times per day. From one year of age, continue to breastfeed as desired and give all foods, suitably prepared, 4 to 6 times per day.


- Wash hands before preparing weaning food and before feeding the baby.

- Prepare food in a clean place.

- Wash uncooked food well when preparing it.

- Cook or boil food when preparing it.

- If possible prepare weaning foods immediately before they will be eaten.

- Cover foods which are being kept. Keep foods in a cool place. Refrigerate if possible.

- If cooked food is prepared more than 2 hours in advance, heat it to a boil before feeding it to the baby.

- Feed the baby with a clean spoon. (Do not use a bottle).


In preventing measles, measles immunization also prevents the diarrhea that often accompanies or follows it. Diarrhea which is associated with measles is particularly severe, is often dysentery, and is more likely to lead to death than most diarrhea in children. Up to 10% of children with measles and diarrhea die.

What Families Should Do

Immunize children against measles as soon as possible following the approved national vaccination schedule.


Using plenty of clean water helps protect families from diarrhea. Families that have good access to a reliable supply of clean water have less diarrhea than less fortunate families. In general, families cannot make major changes in the availability of a good water supply. Improvements in water supply usually come about through government-assisted projects, in which families and communities may play an important role. Families may also be able to improve their facilities for collecting and storing rainwater. Families can reduce their risk of diarrhea by using the cleanest available water and protecting it from contamination, at the source and in the home.

What Families Should Do

Collect water from the cleanest available water source.

Protect water sources by keeping animals away, by locating latrines more than 10 meters away and downhill, and by digging drainage ditches uphill from the source to channel storm water away from it.

Collect and store water in clean containers. Empty and rinse out containers daily. Keep the storage container covered and do not allow children or animals to drink from it. Allow no one, especially a child, to put his hands into the storage container. Obtain water with a long-handled dipper which is kept specially for that purpose.

Boil water used from making food or drinks for young children. Boil other drinking water if sufficient fuel is available. Water needs only to be brought just to a boil. (Vigorous boiling wastes fuel and is unnecessary.)


Parents can help protect young children against diarrhea by adopting certain hygiene practices. These practices may differ from one culture to another. One very important practice is handwashing.

Good handwashing means use of soap (or a local substitute), use of plenty of water, and careful cleaning of all parts of the hands. If water is scarce, it may be used more than once to wash hands and utensils. It can then be used to wash the food or to irrigate the vegetable garden.

What Families Should Do

All family members should wash their hands well

- after cleaning a child who has defecated, and after disposing of a child's stool

- after defecation

- before preparing food

- before eating

- before feeding a child

An adult or older sibling should wash the hands of young children.


Diarrheal diseases are spread by the stools of infected persons. Disposing of stools more safely reduces the diarrhea transmission. In some countries, latrine use reduces the risk of diarrhea even more than improving water supplies.

All families should have and use a clean and functioning latrine. Families who do not have a latrine should build one, following a design recommended by the relevant government agency. (Two practical designs are in Annexes A and B). When there is no latrine, families should defecate as hygienically as possible. Consideration should be shown by not defecating uphill or upstream from other people or villages.

What Families Should Do

Have a clean functioning latrine that is used by all members of the family old enough to do so. Keep the latrine clean by regularly washing down dirty surfaces.

If there is no latrine

- defecate away from the house, paths, or anywhere that children play, and at least 10 meters from the water supply

- avoid going barefoot to defecate

- do not allow a child to visit the defecation ground alone


Hygienic disposal of the stools of young children is important everywhere. In some communities, the stools of infants and young children are considered harmless. However, these stools are dangerous because they transmit diseases to the children and parents. They should be disposed of quickly and hygienically.

What Families Should Do

Quickly collect the stool of a young child or baby, wrapping it in a leaf or newspaper and putting it into a latrine.

Help young children to defecate into an easily cleaned container, such as a potty. Immediately put the stool in a latrine and wash out the container. Alternatively, have the child defecate onto a disposable surface, such as a newspaper or a large leaf. Wrap up the stool and put it into a latrine. If there is no latrine, select a place to dispose of children's stools, such as in a hole or in one corner of the yard.

Promptly clean a child who has defecated. Then wash your hands and the child's hands.

Session 2: Diarrhea home management


Trainees discuss the treatment of diarrhea following the WHO rules for treating diarrhea at home. They practice making two common types of oral rehydration fluids, a prepackaged mixture and a salt-sugar solution, the latrine using local measurements and common household utensils. Trainees are taught to recognize the signs and symptoms of dehydration and encouraged to refer dehydrated children to trained health workers for treatment.

Time: 2 hours


- Handouts - "Three Rules for Treating Diarrhea at Home"

- "How to Make ORS and SSS Oral Rehydration Fluids"

- "How to Recognize Dehydration" Prepackaged ORS (available from UNICEF)

- ORT measuring spoons (available from TALC, P.O. Box 49, St. Albany, AL14AX, London, England)

- Slides or pictures showing signs of dehydration

- Sugar, salt, boiled water, cups, spoons and liter containers

- Flipcharts and marking pens


1. Read the story below to the group.

"The mother notices that her child has had watery stool, not an uncommon occurrence for children in any part of the world. A touch of diarrhea. It will go away, she thinks. Likely it is something bad passing out of his system. The day goes on and the diarrhea continues. The child becomes restless. His skin loses elasticity. His mouth becomes dry and red. The mother is afraid to feed him and give him liquids, thinking that she will only encourage the diarrhea.

Hours pass and the child's condition worsens. He is now semiconscious and has cold skin, a weak pulse and little urine flow. Terrified, the mother calls for help from the village health worker. She is told that the child is severely dehydrated and in danger of death. He must have intravenous therapy immediately, but there is no apparatus available in the village. The child will probably die."

Salubritas, Volume 3, Number 1

January 1979

2. To start the discussion, ask trainees. "What happened in this story? How could the child's life have been saved?"

3. Make the following points:

- A young child can die from severe diarrhea in as few as six hours.

- Dehydration is the cause of death from diarrhea. Dehydration is caused by the loss of water and important salts from the body in stool.

- Until a few years ago, the only way to treat dehydration was to inject rehydration fluid into the body through a vein. This requires special, sterile apparatus and a health worker trained to administer the I.V. solution.

- In the late 1950's, a health technology was developed whereby rehydration fluids could be administered orally for the prevention or treatment of dehydration due to diarrhea. This Oral Rehydration Therapy (ORT) has made it possible for families and health workers to prevent dehydration from diarrhea in the home. In a hospital or clinic, it provides the trained health worker with a low cost alternative for the treatment of dehydration.

- Most diarrheas are self limiting, i.e., if dehydration can be prevented or controlled, the diarrhea itself will disappear in a few days.

4. Definitions - Before attempting to discuss the more technical aspects of Oral Rehydration Therapy in depth, present the following definitions to the group to avoid confusion during the discussion to follow:

* Oral Rehydration Therapy (ORT)

The giving of fluids by the mouth to prevent or treat dehydration.

* Oral Rehydration Salts (ORS)

Although formerly used to abbreviate Oral Rehydration Solution, for the purpose of containing sodium chloride, potassium chloride, trisodium citrate (or in older preparations, sodium bicarbonate) and glucose. ORS is only one type of oral rehydration fluid and is the treatment of choice for dehydration due to diarrhea. It may also be used at home to prevent dehydration.

* Salt-Sugar Solution (SSS)

Again, only one type of home available oral rehydration fluid. This fluid is a simple mixture containing only sugar, salt and water.

* Home-available solutions

Refers to a variety of oral rehydration fluids, including sugar-salt and other food-based solutions that can be mixed with common household ingredients.

* Oral Therapy for Diarrhea ORT plus feeding.

5. Review the handout "Three Rules for Treating Diarrhea at Home". Point out that the purpose of this training is to learn how to manage diarrhea at home and that dehydrated children should be referred to a trained health provider for treatment. Mention that more detail on how to recognize dehydration will be given later in the session.

6. Selecting an Oral Rehydration Fluid.

There are a variety of oral rehydration fluids suitable for home management of diarrhea, including food-based fluids, salt-sugar solutions (SSS) and oral rehydration salts (ORS) solution. It is now understood that early administration of fluids such as rice, water, or cereal gruel at the first sign of loose stools can help prevent dehydration. This can be particularly important when prepackaged ORS solutions are not available. However while some fluids found in the home are helpful, some are potentially dangerous, such as soft drinks, highly sugared teas and very salty soup. Therefore, diarrhea! disease control programs should try to identify the particular fluid likely to be available in the home and to advocate it specifically. Generally, recommended fluids should contain some salt and sugar or starch and should meet the following criteria. (Write on flip chart)

- safe and effective in preventing dehydration

- locally available and affordable

- culturally acceptable

- easily prepared

- one that mothers are likely to use when needed

Many diarrheal disease control programs currently advocate the use of a salt-sugar (SSS) in the home. However, research has shown that serious errors in measuring both salt and sugar occur all too frequently. It is therefore extremely important to stress the necessity for accuracy in measurement when teaching this technique. Further, it is important that programs to train people in the use of this technique incorporate a follow up component to monitor the continued accuracy of fluid preparation.

In many areas, policy decisions have been made as to which fluid mixture or mixtures should be used. Trainees should be encouraged to find out what, if any, decisions have been made in their own areas, and encouraged to follow the approved policy, including instructions for measuring and mixing ingredients.

7. Distribute the Handout - "How to Make ORS and SSS Oral Rehydration Fluid." The Handout shows two different techniques for making oral rehydration fluid using: 1) a pre-packaged mix, and 2) a mix made with sugar, salt and water. Recipes for the simple sugar, salt and water mix are shown as they might be adapted using local measurements and common household utensils. Review the Handout, then demonstrate preparation of each recipe. Or distribute containers and utensils and ask work groups (5-6 persons) to practice making each of the recipes.

8. Ask trainees to list the advantages and disadvantages of prepackaged and home available fluid mixtures when they are used in the home to prevent dehydration due to diarrhea. They may include:

a) Pre-packaged mix

Advantages - Ease of preparation; standardized amounts of each ingredient; low potential for mixing errors; only need to measure water; may better fulfill desire of mothers to use medicine when their child is ill; the education message is simpler and easier to get across.

Disadvantages - Usually imported or made nationally; expensive to distribute; difficult to distribute; taste of solution may not appeal to the non-dehydrated child; mothers may not be motivated to go out and to get packages for mild cases of diarrhea; creates dependence on product which may not always be available.

b) Home available fluids with common measure and containers:

Advantages - Ingredients are available in all homes; lower cost; good for early treatment of diarrhea.

Disadvantages - Must decide which mixture to use; more difficult to get across the educational message; more difficult mixing; measurements are not standardized so amounts of ingredients may vary from solution to solution; lack of "glamour" (not really "medicine").

Make the point that for either method, availability of clean water and variability in the sizes of containers and measuring tools present problems. Emphasize the negative effects that too much salt or too much sugar can have.

9. Describe how to give oral rehydration fluid using a cup and spoon. It is important to continue giving fluid even if vomiting occurs. In cases of vomiting, wait 10 minutes, then continue giving the solution but more slowly.

Write the following general rule on the flipchart:

Rule: Begin giving oral rehydration fluid after the first loose stool.

10. Explain that young children, who usually have many short periods of diarrhea each year, must be fed during the diarrhea, or they will become malnourished and more likely to get severe diarrhea again and again. Even though the food that a child eats when he has diarrhea will not be completely digested, some of the food is absorbed and used by the body. Mothers should be encouraged to begin feeding soft foods to their children as soon as they are able (willing) to eat. Since a mother will only know if the child is willing to eat if he accepts food, the mother should continue to offer small amounts of different kinds of food. Once the child shows a willingness to eat, it is important to offer foods that are easily digestible and to encourage the child to eat foods high in calories and energy density. Good foods, depending on the age of the child, are mixes of cereals and beans or mixes of cereals and meat or fish. It is good to add oils to these foods to increase the energy content. It is also good to encourage potassium rich foods such as fresh fruit juices and bananas. CAUTION: artificially sweetened juices contain too much sugar.

11. Rule: Breastfeeding should be continued during diarrhea.

Most children will continue to breastfeed and may even suckle during diarrhea. Continued breastfeeding may be the most important step taken to prevent malnutrition. Breastfeeding should be encouraged for the sick child.

12. Show the growth chart of a child with diarrhea.


Growth chart of a child with diarrhea.

The chart demonstrates weight loss during diarrhea. To recover the lost weight and to remain well nourished, a child should be fed extra food (ex., one extra meal) each day for 5-7 days after the diarrhea has stopped. We call this "catch-up" feeding.

Rule: Feed extra food every day for 5-7 days after the diarrhea stops.

13. Distribute the Handout "How to Recognize Dehydration". Use the Handout plus slides or pictures to discuss the signs and severity of dehydration.

- Make the following points:

* While preventions of dehydration due to diarrhea can be accomplished in the home, treatment of children that are already dehydrated should be done by a trained health provider.

* Filed research indicated that a significant proportion of diarrhea! disease episodes and deaths due to diarrhea are the result of dysentery. Although dysentery treatment should include the administration of fluids and feeding, these therapies are not sufficient.

* Referral to a trained health provider is particularly important if there is blood in the stool, if there is a high fever (38.5 C or 101 F), if the child is undernourished or shows signs of dehydration or if the diarrhea worsens or does not get better.

14. Summary

Review the Handout "Three Rules for Treating Diarrhea at Home" with the trainees. Finish by discussing the "danger signs" of diarrhea. When these signs are present, it means that a health worker should be called.



*From Treatment of Diarrhea Module, WHO Supervisory Skills Course, 1987 Field Test.

To treat a child with diarrhea who has no signs of dehydration, the mother should give the child FLUIDS and FOOD in normal and generous amounts and watch carefully to see if the child becomes worse.



- Food based fluids, such as gruel, soup or rice water.

- Breastmilk or milk feeds prepared with twice the usual amount of water.

If you do not have a recommended food-based fluid, you can give a specially prepared salt and sugar solution.


- Give freshly prepared foods. Recommended foods are mixes of cereal and beans, or cereal and meat or fish. Add a few drops of oil to the food, if possible.

- Give fresh fruit juices or bananas to provide potassium.

- Offer food every 3 or 4 hours (6 times a day) or more often for very young children.

- Encourage the child to eat as much as he wants.

- Cook or mash or grind food well so it will be easier to digest.

- After the diarrhea stops, give one extra meal each day for a week, or until the child has regained normal weight.


- passes many stools

- has unusual thirst

- has sunken eyes

(These three signs suggest your child is dehydrated.)

- has a high fever

- does not eat or drink normally

- seems not to be getting better


How to Make ORS and SSS Oral Rehydration Fluids

A variety of oral rehydration fluids suitable for home management of diarrhea, including food-based, salt-sugar solution (SSS) and oral rehydration salts (ORS) have been developed. In countries where national policy decisions have been made, it is best to follow the approved policies, including instructions for measuring and mixing ingredients.

1. Pre-Packaged ORS Mixes

Packets or oral rehydration salts are often available through clinics, health workers and pharmacies. UNICEF is the major distributor of ORS packets; however, many governments are now packaging ORS locally for distribution in their countries.

ORS packets usually contain:


20 grams

This is added

Sodium Chloride

3.5 grams

to 1 liter of

Trisodium Citrate

2.9 grams

clean water

Potassium Chloride

1.5 grams


2. Village or Home-Made Sugar, Salt and Water Solution

A simple SSS can be made using ingredients found in most homes and villages. This solution contains:


For 1 liter

For 1 glass (250 ml)


40 grams

10 grams


3.5 grams

1 gram


1 liter

250 mls

* Some older ORS preparations used sodium bicarbonate 2.5 grams/liter.

** In most places household sugar is sucrose and the proper amount is 40 grams. However, in some places household sugar is glucose and the proper amount would then be 20 grams.

This basic information must be adapted to measurements and containers common to health workers and families in your region. Several examples are shown on the next page:


For one glass of ORS:

In one glass
of water


2 level
teaspoons and

a 3-finger
pinch of
salt (1 gr.)

One glass of ORS

Or. where people traditionally measure with their fingers:

In one glass
of water


enough sugar
to fill the hollow
of the hand

a 3-finger
pinch of
salt (1 gr.)

Traditionally measure

TALC - Teachings Aids at Low Cost has developed a special measuring spoon for making ORS in a cup of water. The spoon, which gives instructions for making and giving ORS, is shown below and can be ordered from TALC.

The spoon may be used by health workers to develop a local recipe for ORS. Use the TALC spoon to find local utensils (spoons, hand measures) that give the same amounts of salt and sugar as the spoon.

Measuring spoon

How to use the spoon

- Important: Adding too much salt or sugar can be very dangerous. Be sure to measure all ingredients accurately.

- Water used in ORS solutions should be as clean as possible; however, the need for liquid in a dehydrated child is so urgent that there may not be time to boil and cool the water. Use the cleanest water available for the first fluid given, then boil some water and store it to make the next solution.

How to Give Oral Rehydration Fluid

- Begin giving oral rehydration fluid and other liquids when the diarrhea starts.

- The amount of fluid given depends on the size of the child:

- 1/4 - 1/2 large cup after each stool for children under two years.

- 1/2 - 1 large cup for older children

- Give fluid in a cup to older children, or with a cup and a spoon to infants.

- Give fluid slowly - two or three spoonfuls at a time to avoid vomiting. Continue to give fluid even if the child vomits - some of the solution will stay with him.

- Mix a new batch of oral rehydration fluid every day.

- Continue giving oral rehydration fluid and other liquids until the diarrhea stops.


Practical advice series

Reference: AHRTAG

Issue No. 2

Diarrhoea Dialogue

How to recognize dehydration

Diarrhoea kills because it causes dehydration. The stools of a healthy child contain relatively little water but a child with diarrhoea passes very watery stools which also contain vital salts (sodium, sodium chloride, potassium and bicarbonate). II the losses are great, both the water and the salts must be replaced or the child will die. To recognize the signs of dehydration it is necessary to ask. look feel and. if possible. weigh the child.

Important signs and symptoms

Signs of dehydration

Stools Ask about the number and size of the diarrhoea stools. Has there also been vomiting? These answers may also give clues to the severity of dehydration.

Thirst This may be the earliest sign of dehydration. Until a child has lost more than five per cent of his body weight, dehydration causes few signs. When severely dehydrated, a child may not be fully conscious and may be unable to drink.

Urine A healthy child usually passes urine about every three hours. The body of a dehydrated child tries to save water and only produces a small amount of dark coloured urine. Mothers usually know how much urine their children have passed, so ask them if there has been less that usual.

Condition If there is no dehydration, a child will appear alert and well. At a later stage, he will be weak, irritable and may look unwell or sleepy. A severely dehydrated child may appear very sleepy or be unconscious. He may also have fits or convulsions.

Sunken eyes A child's eyes lie in soft, wet, fatty tissue. If he becomes dehydrated, this tissue shrinks and becomes drier and his eyes sink back into his skull. His eyes also lose their shining appearance and stay half open when he is asleep.

Dry mouth A dehydrated child cannot make enough saliva and so his mouth and tongue become dry. This is an important sign.

Breathing Sometimes, a severely dehydrated child breathes fast and deeply. This kind of breathing occurs when a child has been dehydrated for some days or has been rehydrated with the wrong fluids. Do not mistake this deep, fast breathing for the shallow, rapid breathing of pneumonia.

Loss of skin elasticity The skin of a healthy child is elastic. If you pinch the skin of the abdomen and then let go, the skin quickly flattens again. De. hydration makes a child's skin dry and less elastic so when pinched it sticks up for some seconds before going net again. If it child is very thin or very fat, loss of skin elasticity is not easy to detect and therefore not a helpful sign in diagnosing dehydration.

Pulse Dehydration makes a child's pulse faster and weaker. When he becomes severely dehydrated, it may not be possible to feel the puke at the west, you may have to feel at the groin or listen to the heart. (With very severe dehydration, the pulse is sometimes slow).

Sunken fontanelle The fontanelle is the soft place between the bones at the top of a baby's skull. It is large when he is born but closes over by the time he is about 18 months old. When a baby becomes dehydrated, his brain and tissues in the skull lose water and shrink. The fontanelle sinks down between the bones of the skull.

Loss of weight This may occur quickly during a few hours or over several days. A severely dehydrated child may have lost a tenth or mom of his normal body weight. If he weighed ten kilograms before the onset of diarrhoea, he may have lost at least a kilo of water and may now weigh only nine kilograms. Loss of weight due to malnutrition occurs more slowly over several weeks or months.


Seriously dehydrated child

Dehydrated children need urgent rehydration and should be encouraged to drink even if vomiting occurs Those with severe dehydration and complications such as convulsions should be given oral rehydration fluid and taken to a centre where they can receive special care.

6 Diarrhoea Dialogue, Issue 2, August 1980. Produced quarterly by AHRTAG at 85 Marylebone High Street, London W1M 3DE

Session 3: Community activities to prevent diarrhea*


In this session trainees will learn how to assess a community's current practices with regard to diarrhea, how to use assessment information to, prioritize specific preventive practices to emphasize in their particular area using the WHO recommended step-by-step approach and discuss ways that health workers can support selected preventive practices at the community level.

Time: 3 hours


- Handout - "About Prevention of Diarrhea"

- Flipchart and marking pens


1. Write on the flipchart:

* The best ways to prevent diarrhea are:


Improved Weaning Practices

Use of Plenty of Clean Water


Use of Latrines Proper Disposal of Babies' Stools

Measles Immunization

* Much of the format and material used to compile this session were adapted from the WHO Programme for Control of Diarrhoeal Diseases Supervisory Skills Course: Module on Prevention of Diarrhoea, and Community Involvement, revised ed.

Briefly review the methods for preventing diarrhea which have already been treated in some detail in Session 1 of the module. Make the point that each one of these methods represents an area which can be addressed through community action in a comprehensive program to control diarrhea! diseases.

2. Assessing Community Practices

The first step in designing community interventions to address diarrhea! diseases is to learn about the community's current practices regarding diarrhea and the reasons for them. This information will provide guidance to further actions by helping you to select which interventions are most needed and which are most likely to be successful in a particular setting.

Trainer: Take a few minutes to solicit suggestions from the group about various ways that this type of information can be obtained and write them on newsprint. The finished list should include:


Home Visits


Key Informants

Five types of information on community practices should be obtained about each of the seven ways to prevent diarrhea listed above.

Write on newsprint:

- The extent to which the community engages in the preventive practice

- What community members do instead of or in addition to the preventive practices

- Reasons community members continue their current practices, as well as barriers and constraints to change

- Latrines: their number, type and cleanliness

- Water sources: their quality, convenience and quantity of supply

3. Selecting Preventive Emphasis

Once information has been obtained regarding the community's current practices, the next step is to select one or more preventive practices to emphasize in your particular area. The WHO recommends a step-by-step approach to selecting preventive emphasis.

Write on each newsprint:

Step 1: List the practices that need to be improved in your area

Point out that this includes:

- People who are not doing the preventive practices

- People doing other practices that are harmful

Step 2: Select the more important practices to improve

Trainer: Brainstorm with the large group a list of ways to prioritize practices as feasible. The list should include:

- Whether or not the government already considers the practice a priority

- What the expected effect of the change will be on the diarrhea rates

- How many people, particularly young children, will be affected

Make the point that overall, the most important practices are those which, if changed, would result in the greatest health improvement for the community.

Step 3: From the more important practices, identify some that will be more feasible to change

Trainer: Brainstorm with the large group a list of ways to prioritize practices as feasible. This list should include:

- Will community members understand and believe the benefits of the new practice or the harm in continuing the current practices?

- Do community members have the necessary resources, or can they be obtained?

- Will community members be willing to do the practice, and not feel that it is against tradition, too difficult, too expensive, or too time consuming?

- Can health workers correctly teach the new practice with little or no training themselves?

Point out that if the answer to all of these questions is yes, the change is more likely to be feasible. If the answer to any questions is no, it is unlikely that an effort to change the practice or introduce a new one will be successful, especially without a large commitment of resources.

Step 4: Select preventive practices to emphasize in your area

Having discussed each practice on both the aspect of importance (i.e. government plans, expected effect on disease rate and number of people affected) and feasibility (i.e. community interest, resource availability and health manpower capability), select one or two practices to emphasize in your area.

4. Undertaking Specific Activities

Health and extension workers can play important roles in bringing about improvements in community health. In the prevention and control of diarrhea! disease the following activities are recommended:

(Write each activity on newsprint)

1. Health and extension workers can use food counseling techniques.

Point out that messages should be brief and clearly relevant to the person or group being addressed. Only a few messages should be given at a time. If too many messages are given, none are likely to be remembered, but the right message at the right time will make an impression.

2. Health and extension workers can -at good examples

What a person does always sends a more powerful message than what a person says.

3. Health and extension workers can participate in community projects to improve preventive practices.

Trainer: Brainstorm with the large group to solicit ideas for community projects that could improve preventive practices and that could be accomplished with limited community resources. Some examples are:

- Buying soap cooperatively

- Improving water sources

- Designating and supporting a tradesman to build family latrines

- Having a breastfeeding support group

- Gardening for improved weaning foods

4. Health and extension workers can support breastfeeding

Opportunities to support breastfeeding can be found particularly when the health worker attends births, prescribes drugs or when mothers are having difficulties with breastfeeding and seek out the health worker for advice.

5. Health and extension workers can build and maintain latrines where they work

A clean, functioning latrine can be an example to others in the community. It should be properly maintained so that people can see how a latrine works.

6. Health and extension workers can advise community members of the cleaner water sources and ways to improve water sources

When the assessments of community practices were done, the cleaner water sources were identified so it should be possible to advise community members about the best water sources. Probably, some water sources can be improved by taking simple measures.

Trainer: Brainstorm with the large group to develop a list of simple improvements that can be made to existing water sources. Include:

- Build a fence or wall around the water source to keep animals away

- Dig drainage ditches from an open well to prevent storm water from flowing into it

- Do not allow washing in the water source

- Do not allow children to play in or around the water source

- Do not locate the latrines uphill or within 10 meters of the water source

- Do not defecate within 10 meters of the water source

- Install a simple pulley device and bucket to make it easier to raise from a well

Summary: Distribute the Handout "About Prevention of Diarrhea". Review the Handout reinforcing the main points and answering any remaining questions.



* From WHO Supervisory Skills Course: Module on Prevention of Diarrhea.

- The best ways to prevent diarrhea are:

Breast feeding

Improved Weaning Practices

Use of Plenty of Clean Water


Use of Latrines

Proper Disposal of Babies' Stools

Measles Immunization

- It is important to assess a community's current practices related to diarrhea and the reasons for them to know what preventive interventions are needed.

- Use of step-by-step approach to select the specific preventive practices to emphasize in a health area. Briefly, the steps include:

- List the practices that need to be improved in the area.

- Select the more important practices to improve.

- Identify the practices that will be more feasible to change.

- Select one or two preventive practices to emphasize.

- Health services should play an important role in bringing about improvements in a community's practices. Some activities that health workers can do to support selected preventive practices include:

- Use of good counseling techniques

- Set a good example

- Participate in community projects to improve preventive practices

- Support breastfeeding

- Build and maintain a latrine at the health facility

- Advise community members of the cleaner water sources and ways to improve water sources


Chen, LC, and Scrimshaw, NS, eds. Diarrhea and Malnutrition: Interactions, Mechanisms and Interventions. The United Nations University. New York, New York, 1983.

"Dialogue on Diarrhoea". Issues 1-31, AHRTAG. 85 Maryleborne High Street, London WIM3DE.

Esrey SA, and Bently ME. Nutrition and Diarrhea: Draft Guidelines for PRITECH II Country Work Plan. Division of Human Nutrition, Department of International Health, Johns Hopkins University. Baltimore, Maryland, 1987.

Favin M, and McMurtry. Oral Rehydration Therapy. World Health Federation of Public Health Associations. Washington, D.C., 1983.

"Salubritas". Oral Rehydration in the Village. Vol. 3, No. 1, January 1979.

Werner, D. Helping Health Workers Learn: A Book of Methods, Aids and Ideas for Instructors at the Village Level. Hisperian Foundation. Palo Alto, Ca., 1983.

Werner, D. Where There Is No Doctor: A Village Health Care Handbook. Hisperian Foundation. Palo Alto, Cal, 1977.

World Health Organization. Programme for Control of Diarrhoeal Diseases Supervisory Skills Course: Modules on Prevention and Treatment of Diarrhoea, revised ed. Geneva, Switzerland, 1987.

World Health Organization. A Decision Process for Establishing Policy on Fluids for Home Therapy of Diarrhoea. WHO/CDD/SER/87.10. Geneva, Switzerland, 1987.

There are two newsletters which contain current information on diarrhea and other related topics that are available to Third World subscribers:

"Dialogue on Diarrhoea", AHRTAG, 85 Marylebone High Street, London, WIM3DE, United Kingdom.

"Mothers and Children". American Public Health Association, Clearinghouse on Infant Feeding and Maternal Nutrition, 1015 Fifteenth Street, Washington, D.C., 20005.


Unit 6: Immunization

SESSION: Improving Immunization Coverage - The Community's Role

Session: Improving immunization coverage - The community's role

Measles, whooping cough (pertussis) and tuberculosis are diseases that can have an extremely negative effect on the nutrition status and the survival of young children. These illnesses, together with diphtheria, tetanus and polio, are preventable through immunization. Most countries have started national programs that aim to achieve immunization of all children under five years old against these diseases. Because it is difficult to obtain, transport and store the vaccines, immunization programs are usually managed by regional or district health officers. Communities can make sure that all of their young children are immunized by:

- Contacting the national immunization program or the nearest health office and requesting that vaccinators visit their communities regularly.

- Promoting immunization and organizing immunization sessions in the community.

- Identifying and referring all children with incomplete immunization coverage to the vaccination team.


Trainees discuss the national guidelines for immunization of women and young children and learn to identify children with incomplete immunization coverage. The steps a community might take to organize immunization sessions are detailed.

Time: 2 hours


- Handouts -

- Immunization Overview

- Understanding the Target Diseases

- Sample Immunization Schedules

- Immunization Problems: Missed Dates, Reactions and Sick Children

- Exercise: "Identifying Children Who Need Immunization"

- Educational material 5 available to trainees for promotion of immunization


1. Discuss the importance of immunization programs by going over the handouts "Immunization Overview" and Understanding the Six Target Diseases".

2. Using the following growth charts and the wall-sized growth chart, show the effects that measles, tuberculosis and whooping cough (pertussis) can have on the growth and survival of young children. Point out that these diseases can cause malnutrition in healthy children. In malnourished children, they often cause death.


Whooping Cough


3. Review the immunization schedule handouts so trainees become familiar with the vaccines, number of doses and recommended ages and intervals for vaccination. Note that there are 3 schedules, the WHO standard recommended schedule, and illustrative examples for the simplified schedule and the single day campaigns.

4. Discuss some of the immunization problems noted in the handout that may occur such as missed dates, reactions and sick children. Explore ways in which the community can work with families and children to overcome these problems, and also other problems they may encounter related to traditional practices and cultural beliefs.

5. Go through the exercise on "Identifying Children Who Need Immunization" in order to demonstrate what is necessary to achieve full vaccination coverage.

- Use the WHO recommended vaccination schedule handout to review what is full coverage for each disease.

- Each trainee should complete the exercise form (using the WHO standard schedule) and note which children are not fully vaccinated. It should be stressed that those children who have not received all 3 doses for both DPT and polio are not fully covered. Also, we cannot simply total the number of DPT and polio vaccines given and assume that this total equals the number of children protected since 3 doses per child are required.

6. Discuss and list on the flipchart the steps trainees would take to improve the immunization coverage in this neighborhood.

7. Draw a diagram like the one below to summarize the steps a community might take to promote and organize immunization activities.

Diagram of activities

8. Explore ways in which the trainees might be able to mobilize the community to participate in immunization programs. Trainees who have organized community immunization activities may wish to tell the group about their successes and their problems. Problems raised should be discussed by asking trainees to suggest possible causes and solutions for each problem.

9. Help trainees identify whom to contact in their region to request immunization services.

10. Show educational materials available for community immunization promotion and explain how trainees can obtain them.

11. Summarize the session

- Several serious diseases that cause malnutrition and death can be prevented by immunization. These include measles, tuberculosis, diphtheria, pertussis, tetanus and polio.

- By identifying women and children who need immunization, and by coordinating with national and regional health officials, communities can insure protection from these deadly diseases.



Six preventable childhood diseases for which vaccines are widely available are measles, pertussis (whooping cough), tetanus, polio, diphtheria and tuberculosis. Of these, measles is the most clearly related to diarrhea. Diarrhea often follows an episode of measles, and the combination of the two illnesses can be fatal. It is estimated that up to 26 percent of diarrhea-associated mortality could be prevented by measles vaccination. (1) Pneumonia, malnutrition and shigella dysentery are complications associated with measles. Preventing measles could also reduce the incidence of malnutrition and vitamin A deficiency, both of which are associated with serious attacks of diarrhea.

(1) R.G. Feachem and M.A. Koblinsky: Interventions for the control of diarrhoeal diseases among young children: measles immunization. Bulletin WHO 61, 641-652, 1983.

What is immunization?

Immunization is the giving of a vaccine or vaccines to stimulate the body to create immunity against specific diseases. Immunity is the body's ability to protect itself against the bacteria and viruses which cause disease.

Why immunize?

Every year in developing countries 110 million episodes of illness occur which could be prevented by immunization. As a result 3.5 million children die. Children with these illnesses are also more likely to develop other infections, such as diarrhea, as their resistance and ability to fight off infection is reduced. Widespread use of vaccines in the developed world is a major factor in the reduced mortality and morbidity from these six diseases and associated illnesses.. Immunization is a more effective way of using scarce resources than treating diseases after they occur.

The six major childhood immunizations


- Measles vaccine is made from live measles virus which has been weakened (or attenuated) and is given subcutaneously in one dose. The infection provides long lasting protection against measles. Those vaccinated may feel unwell with a mild fever, and/or rash five to ten days after vaccination.

Diphtheria, pertussis, tetanus

- DPT vaccine combines diphtheria, pertussis (whooping cough), and tetanus immunizations in one injection. The injection is given intramuscularly in three doses four weeks or more apart and protects for at least ten years against the three diseases. Common side effects to the injection include fever and redness and swelling at the injection site.


- The oral polio vaccine contains the weakened viruses of the three types that cause polio. It usually provides permanent protection against this crippling disease, and is given in three doses 4 weeks or more apart (usually at the same time as DPT In countries where polio remains endemic, if possible, a child should receive an additional polio vaccination at birth.


- BCG vaccine its given intradermally (within the skin layer, raising a blister) and guards against tuberculosis (TB). Studies concerning efficacy of the BCG vaccine have produced conflicting reports. Most people agree that it gives good protection against the lethal forms of childhood TB. An ulcer forms at the injection site and heals without treatment, forming a scar.

Reprinted from Dialogue on Diarrhoea, "Health Basics: Immunization", Issue 30, September 1987, Appropriate Health Resources and Technologies Action Group, Ltd., London.



(1) Measles. Measles is a highly contagious disease which 90 percent of the unprotected under-five population contract in some countries. A relatively mild disease in developed countries, measles is a major cause of childhood mortality in many developing countries, particularly in Africa and Central America. Poor nutritional status seems to be the main factor leading to the most severe consequences of measles. The common practice of withholding food during a child's illness exacerbates the condition. Death is caused by pneumonia, diarrhea, or in a small number of cases, encephalitis, in association with the disease. Maternal antibodies transferred through the placenta protect the infant during the first months of life. If measles vaccine is given to the infant before nine months of age, these antibodies may prevent the vaccine from producing immunity in the child. But if the child is vaccinated too late, the period of greatest danger to the child will be past. The seasonality of measles incidence should also be considered in deciding age guidelines.

(2) Pertussis. Pertussis (whooping cough) is second to measles as a cause of morbidity and mortality among vaccine-preventable diseases in some developing countries. The World Health Organization estimates that up to 80 percent: of unimmunized children will contract it. Pertussis, an acute bacterial infection affecting the respiratory tract, is very contagious in the first week or two of infection. The spasmodic coughing or "whooping" that characterizes the disease is readily recognized and lasts one to two months. Pertussis is most severe in children under five months of age and may lead to death through pneumonia or other conditions. In very young children, there is no characteristic whoop, so the disease may be difficult to recognize. Immunity requires three vaccinations which may begin as early as six weeks of age.

(3) Tetanus. Caused by a toxin of a bacterium which enters the body through broken skin, this major killer of infants in developing countries is often caused by infection from the cut umbilical cord. Pregnant women who receive two tetanus toxoid immunizations pass immunity which protects the newborn during the first months of life. Tetanus bacteria reside in soil so, unlike smallpox, there is no hope of eliminating the reservoir of harmful organisms. Instead, protection comes only through immunization against the disease or through improved hygiene.

(4) Poliomyelitis. Polio is a vital disease spread by contact with objects, food, or water contaminated with excrete. Although polio infection is universal, most persons experience no symptoms. In a small minority of cases, polio leads to varying degrees of paralysis and, sometimes, death. The older the child at age of infection, the more likely the infection will lead to severe consequences. The use of polio vaccines in the last 20 years in developed countries has markedly reduced the incidence of polio; however, its relative infrequency has led to laxity and occasional outbreaks among the unimmunized. In developing countries, the incidence of paralytic polio appears to have been seriously under-estimated. Good evidence for the paralytic form of polio is lameness with no loss of the sense of touch in the affected limb.

(5) Tuberculosis (TB). TB is a bacterial disease spread by coughing and the sputum of infected persons. The disease takes many forms in children, infecting the bones, lungs, or brain. Often, it may not be recognized as the same disease that affects adults. TB is particularly common where many persons share the same crowded living quarters. In some cities in developing countries, one percent of the adults nay be in the active infective stage of the disease. Improved housing, clothing, diet, early detection, and uninterrupted treatment-all difficult to achieve in many developing countries- are al] necessary to effectively control TB. Even though BCG's efficacy under certain conditions has been questioned, it remains an important means of protecting many children in developing countries.

(6) Diphtheria. A major child killer of the past in temperate countries, the mortality and morbidity of diphtheria are the least well documented of the six diseases in developing countries today. Although typically manifested as an acute infection of the throat, diphtheria can affect the heart or brain of infants and young children. Vaccination against diphtheria over the past 50 years has eliminated the disease in many developed countries. Partial immunity acquired through skin infections with C. diphtheria in cuts and abrasions may protect many children in developing countries from the severe infection.

Of the six diseases reviewed here, measles and paralytic polio are the most likely to be eliminated in humans (although not eradicated from the environment) through a continuous and comprehensive immunization program. TB and tetanus are greatly influenced by general living conditions and sanitation, and will decrease as standards of housing and hygiene improve The overall incidence of measles and pertussis is not greatly affected by living standards, but cases are much less severe and occur later when children are well nourished. Diphtheria and polio,, by contrast, may actually increase as standards of living improve and children do not gain natural active immunity.

Reprinted from Immunizations: Information for Action Issue Paper; World Federation of Public Health Associations, May 1984.




Age at First

Number of

Minimum Interval Between Doses


BCG (intra-dermal Injection)




BCG given at the earliest possible age protects against the possibility of infection from other family members
BCG scar is often used as an indicator of previous BCG immunization

DPT (Intra-muscular injection)

6 weeks


1 month

An early start with OFT reduces the chances of severe pertussis. Followed by four week intervals for effective protection reduces the time a child is exposed without protection particularly to pertussis

Polio (Oral)



1 month

The extent of protection against polio Is increased the earlier the OPV is given

Measles (Sub- cutaneous. injection)

9 months



At least 60 per cent of measles in the third world can be prevented by immunization at this age


Women of child-bearing age

At least 2 doses before or during early pregnancy, should not be given later than 2 weeks before delivery

1 months

-for pregnant women with no previous tetanus immunization - 2 doses during pregnancy
- for pregnant women with 3 previous tetanus immunizations during childhood - 2 boosters during pregnancy required
- After 5 doses, all children born are protected from maternal tetanus

*BCG: Bacillus Calmette Guerin (against TB)

*OPV: Oral Poliovirus Vaccine (dose at birth is in addition to the standard schedule of 3 doses)

*DPT: Diphtherial/ Petussis/ Tetanus Toxoid


Simplified schedule for remote population (two contacts as used in parts of West Africa)





All children
3-8 months old

IPV in two doses is protective against paralytic polio


All children
9-14 months old

In remote areas the average age of contracting measles is delayed to the second and third years of life and later vaccination is still effective


IPV: Inactive Poliovirus Vaccine

DPT-IPV may be obtained in a single preparation

EPI also recommends that OPV be added to this schedule


Semi-annual single day "pulse" campaigns (as used in Brazil)



Number of Doses



All children
0-59 months old

Up to 10 doses

After regular vaccination with OPV vaccine. the virus replaces the naturally occurring disease- causing virus in the environment


All children
9-23 months old

Up to 2 doses

Giving a second dose of measles vaccine increases effective coverage


All children
2-11 months old

2 doses

Third DPT through regular primary health care services in clinics; 2 doses of DPT are partially effective(50-60%) against pertussis


Immunization Schedule

Infants and children

All children should be immunized against the preventable childhood diseases. The immunization schedule describes the number of times that a child needs to be given vaccinations and how far apart each visit should be. Following the ideal schedule, each child should be fully immunized by the age of nine months, or soon after, because infants are at greater risk from these diseases. Many countries try to immunize all children under five years of age who may be at risk.


Neonatal tetanus is prevented for several years by immunizing women of child-bearing age with at least two doses of tetanus toxoid. After five doses of tetanus toxoid all children born subsequently are protected from neonatal tetanus. A woman who received three doses of DPT as a child will greatly increase her infants' protection by two boosters (ideally before or during early pregnancy) when she is ready to bear children. (Hygienic cord treatment can also prevent neonatal tetanus but is not as effective as complete immunization of the mother.)

(Above reprinted from Dialogue on Diarrhoea, "Health Basics: Immunization," Issue 30, September, 1987)

The following handouts present 3 immunization schedules. The WHO recommended schedule provides the optimum schedule in which a child will be fully immunized by 9 months. However, recognizing that numerous children in many developing countries have not been immunized according to this schedule, children may begin to receive vaccinations at an older age. In addition, other program approaches have been implemented in efforts to address this deficiency in providing widespread vaccination coverage to children. Two other illustrative approaches, the simplified schedule and the pulse campaign are also presented. The simplified schedule focuses on vaccinating younger children under 14 months through 2 contacts. These 2 contacts can be spaced according to the country situation. This approach has been restricted primarily to Francophone Africa to date. The pulse campaign also focuses on children up to 2 years for measles and DPT and up to 5 years for polio. The pulse campaign, also often referred to as a mass campaign, is carried out in an effort to catch up the backlog of children that May not have been previously vaccinated and may also fall outside the normal health care network responsible for vaccination programs. However, most country immunization programs continue to follow the WHO recommended schedule.


Immunization Problems: Missed Dates, Reactions and Sick Children

If it is not possible to bring a child for immunization on the right day-, the immunization must be given as soon as possible afterwards. Once begun, a series of immunizations. must be completed to be effective. Even if the time between immunizations is longer than recommended, the next dose in the polio and DPT series is given; there is no need to start from the beginning again. Only a completed series of immunizations adequately protects a child. In remote areas, and places where for other reasons it is not possible to do this, simplified schedules and mass immunization days have been used.

Vaccine schedules have to suit the circumstances in particular countries. Ideally, most developing countries should follow the WHO recommended schedule of five contacts but this requires an effective health infrastructure to which all people have access. Mass campaigns, with immunization days, can successfully increase awareness about immunization and vaccinate large numbers of children. However, only when health systems are developed to ensure regular vaccination of all newly born children every year, will full coverage be achieved.

Reaction to Immunization

After immunization some children develop mild reactions, such as fever, or a swollen area around the injection site. This is quite normal with some vaccines and may be part of the body's response to developing protection. Parents should be told that this is likely to happen so that they do not worry about it and it does not prevent them:

- from bringing the child back for further immunization doses; or

- from bringing their other children to the clinic for immunization.

Can a sick child be immunized?

Mothers sometimes do not bring a sick child for immunization and if they do, health workers frequently do not immunize them. Mothers and health workers need to know that all EPI immunizations are safe and effective even if a child is ill with fever, diarrhea, vomiting, or respiratory infection. No chance should be missed to immunize a child. This is a recommendation of the EPI.

The benefits of immunization far outweigh the risk, especially in malnourished children. Only- in very few exceptional cases is it not advisable to immunize. For example, a child who has had a severe reaction to DPT (fits, extreme crying) should not be given pertussis immunization, but should get diphtheria-tetanus vaccine.

Reprinted from Dialogue on Diarrhoea, "Health Basics: Immunization," Issue 30, September 1987.


1. You have just completed an immunization survey In your neighborhood. By interviewing mothers and reviewing immunization cards, you collected the following information:

Maria (13 months)

- no vaccines

Jane (18 months)

- BCG, measles

John (2 years)

- BCG, Polio I

Ruth (4 years)

- BCG, measles

Henry (3 years)

- BCG,

Caroline (7 months)

- no vaccines

Edward (6 months)

- no vaccines

Susan (2 1/2 years)

- BCG,

Richard (4 months)

- no vaccines

Peggy (4 1/2 years)

- Measles, DPT I & II, Polio I & II

Tom (3 years)

- no vaccines

Mary (1 year)

- no vaccines

Ellen (4 1/2 years)

- Measles, BCG,

Louisa (3 years)

- no vaccines

2. Transfer this information to the chart below. Complete one column on the chart for each child, by writing the child's name at the top and putting on X In the column next to the vaccines each child has taken.

Children 0-5 Years NAME:




1 dose




1. dose




1. dose


2. dose


3. dose




1. dose


2. dose


3. dose


3. Answer the questions below about the immunization status of children in your neighborhood.

- How many children were included in your survey?

- How many children have not had the following immunizations?



% of Total Children





DPT (3 doses)


Polio (3 doses)


What will you do to achieve your goal of completed immunizations for all children in the neighborhood?


World Federation of Public Health Associations. Immunizations: Information for Action Issue Paper. May 1984.

American Public Health Association. Immunization. 1982.

Appropriate Health Resources & Technologies Action Group Ltd. Dialogue on Diarrhoea, "Health Basics: Immunization," Issue 30, London. September 1987.

For further information:

Werner, David. Where There Is No Doctor: A Village Health Care Handbook. The Hesperian Foundation, P.O. Box 1692, Palo Alto, CA, 94302.

Werner, David and Bill Bower. Helping Health Workers Learn, 1982. The Hesperian Foundation, Palo Alto, CA


Unit 7: Family planning and nutrition

SESSION 1: Family Planning and Nutrition

SESSION 2: Providing the Facts About Family Planning

SESSION 3: Community-Based Distribution of Family Planning Methods


Short birth intervals and large families are common causes of malnutrition in most countries. Communities can kelp prevent malnutrition by making family planning information and contraceptive methods available to all couples.

When we use the tern, "family planning" in this unit, we are talking about two things:

- Lengthening the time between births - birth spacing

- Limiting the total number of births according to what a couple desires

Session 1: Family planning and nutrition

Successful programs to improve nutrition and increase family planning acceptance provide factual information to men and women. Some also prepare adolescents for their future roles as parents by providing orientation in responsible parenthood and reproductive physiology.


Trainees review the benefits of family planning and the traditional and modern methods of contraception. Facts about breastfeeding and family planning are also discussed.


Family planning workers - 2 hour review

Non-family planning workers - 2 hours


- Flipchart and marking pens

- Handout - "Facts About Family Planning methods"

- Handout - "Breastfeeding and Family Planning''


1. Read the two problem cases below to the group.


Problem 1

A community worker visits the home of a middle income family in the village. The mother greets her carrying a healthy four-month-old baby boy. Behind her is a thin little girl about two years old; her dark hair is streaked with light colored areas and she is coughing. When the worker measures her arm with the three-color tape, she finds that the little girl is severely malnourished (Red). The community worker thinks, "This is a prosperous family. How can they have such a sick child?"

Problem 2
In another home, the worker meets a mother who has just come from the field. Looking around, the worker notices that the house is in very poor condition. Chickens, buffalo and people seem to share the same living space. There are two young children in this family, one about four years old and the other eighteen months old. Both children have yellow arm circumference (moderate malnutrition). The older one is sick with fever and diarrhea. The woman tells the worker that she has given birth to nine children but only four are living; all of the others died before they were four years old. The worker asks herself, "What can be done to help this family?.

Ask the following questions about each problem to promote discussion:

- What are the possible causes of malnutrition?

- What should the community worker do to help the family?

Answers should include:

- Teach them how to feed the child.

- Talk to them about family planning

2. What Is Family Planning?

Ask trainees to define "family planning" by finishing the sentence:

Family planning is________________________________________________________________.

Write five or six responses on the flipchart, and work with the group to develop a definition that all can accept. Some of the definitions from other workshops have included:

- "Family planning is having the number of children you want when you want them. "

- "Family planning is having the number of children you can support emotionally and financially."

3. Tell trainees that the term Family Planning will be used in this unit to mean two things:

- Spacing births to insure the health of mothers and children

- Limiting the number of births to control the size of one's family

4. Benefits of Family Planning

Ask trainees to brainstorm answers to the following question:

- "How does family planning contribute to improved nutrition and health for women and children?"

Write the answers on the flipchart.

5. Review the following consequences of closely spaced, repeated pregnancies:

- Maternal depletion - Women who do not allow at least two years between pregnancies are more often malnourished than those who allow two or more years between births. Women who do not space their pregnancies have a greater chance of complications during pregnancy and birth; their infants may be small and malnourished; and they may have difficulty breastfeeding.

Family planning can help a couple to allow at least two years between births. This allows a woman to regain her strength so that she and her infant will be properly nourished and healthy.

- Early termination of breastfeeding - If a woman becomes pregnant when her youngest child is less than two years old, that child will often become malnourished. In some cultures, this is because breastfeeding is stopped as soon as the woman discovers she is pregnant, or shortly before the new baby arrives. When this ha>pens, the young child doses the nutrients from breast milk at the same time that he is exposed to more contamination from new foods. Also, the mother has less time to care for the older child even though he is at a stage (weaning) when more attention should be given to feeding and hygiene. Protein energy malnutrition is frequently the result of the early termination of breastfeeding because of a new pregnancy.

Family planning can help couples space the births of their children so that one child has passed the critical weaning stage before another one is conceived.

(For a more detailed discussion of breastfeeding see Session I-3)

- Limited family resources, especially food - The amount of food a family can produce or buy is an important determinant of nutrition status. The number of family members determines the amount of food given to women and children as well as the family's resources for health care, education, etc.

Family planning can help families limit the number of children to those they can feed and care for.

6. Traditional Methods of Family Planning

Point out that family planning is not a new practice in most areas. Ask trainees if couples in their areas have any traditional ways for avoiding births. These might include:

- Abstinence from sexual intercourse. In Africa, couples traditionally abstained from intercourse while a woman was breastfeeding (2-3 years). In polygamous areas, a husband would often stay with another of his wives during this period. These customs are changing rapidly in many areas.

- Breastfeeding - Breastfeeding (on demand) gives several months of natural protection from pregnancy to most women. However, use of feeding bottles and the introduction of breast milk supplements at earlier and earlier ages have shortened the natural birth-spacing effects of breastfeeding.

- Septic Abortion - For centuries, women have resorted to illegal abortion to avoid having additional children. These abortions are often performed by untrained persons under unsterile conditions. In Latin America, complications from septic abortion are estimated to cause 30-50% of maternal deaths; in Bangladesh, 26% of pregnancy-related deaths have been attributed to illegal abortions. Although underreported, septic abortion is believed to be a significant cause of maternal death throughout the developing world. (Favin, et al. "Improving Maternal Health in Developing Countries," p. 3-6)

7. Modern Methods of Family Planning - Distribute the Handout - "Facts About Family Planning Methods." Use pictures/slides and samples of contraceptives available in the areas where trainees work, to describe:

- what each method looks like;

- how it is used;

- how it functions to stop pregnancy;

- common side effects and danger signs.

Point out that, in order to be effective, some family planning methods require significantly more knowledge and more motivation on the part of the users than do other methods.

(You may need to review the physiology of reproduction with some groups.)

8. Breastfeeding and Family Planning - Distribute the Handout - "Facts About Breastfeeding and Family Planning." Review the relationship between breastfeeding and the nutrition status of an infant. List the contraceptives that are appropriate for use by a breastfeeding woman. Discuss when a couple should begin using a family planning method to delay a new pregnancy. This varies from community to community. (See WHO, Breastfeeding and Fertility Regulation, p. 377.)

9. Summary - Ask participants to list information presented during this session that was new to them.

Leave time for questions and answers. Even groups with previous family planning experience and training will have questions and doubts that need to be answered.







Permanent Methods

Vasectomy - Men

A small section of the vas deferens (the tube through which sperm travels from the testes to the penis) is removed. This blocks the sperm from leaving a man's body in the semen, but has no effect on potency or ability to have intercourse. Effectiveness: 99%

A vasectomy is a surgical procedure. A local anesthetic is given and a small incision is made in the scrotum on the right or the left side. The vas is found, a small section is removed and the incision is closed. This is repeated on the other side.

Swelling and discomfort following the surgery. Infections occur in rare cases. Because a man is not immediately sterile after a vasectomy (some sperm remain in the tubes), precautions should be taken by using a temporary contraceptive for at least the first month. In rare cases, the vas may grow together again. This can result in an unwanted pregnancy.

Excessive pain or swelling Fever

Tubal Ligation - Women

A small section of each fallopian tube is removed or clamped. This blocks the eggs from traveling from the ovaries to the uterus, and it blocks sperm from reaching the egg for fertilization, but has no effect on the ability to have intercourse. Effectiveness: 99%

Mini laparoscopy is the next common and the simplest method of tubal ligation. A local anesthetic is given and a small incision (2-3 cm) is made below the umbilicus. The fallopian tubes are found, using the laparoscope, and a small section of each is either re- moved, cauterized or clamped. The incision is closed with absorbable sutures.

Pain and discomfort following surgery. In a few cases, the tubes grow back together and pregnancy occurs. If a woman misses a period, she should visit a health worker immediately to find out if she is pregnant.

Fever greater than 100 F Fainting spells Abdominal pain that in creases over 12 hours Bleeding from the incision

Temporary Methods

Oral Contraceptives

Oral contraceptives contain hormones similar to those produced in a woman's body. These hormones keep the ovaries from releasing eggs. Menstruation continues but may be lighter than before. Effectiveness: 98%

Take oral contraceptives as directed (usually 1 pill each day for 28 days or 21 days with 7 days rest). If pregnancy is desired, stop taking the pills and wait for menstrual periods to resume normally.

Women with high blood pressure, diabetes and excessive weight should not take pills. Women 35 years or older should also be given another method. Breastfeeding women should not take combined oral contraceptives during the first months post-partum because they may decrease milk production.

Swelling or pain in legs Yellowing of skin or eyes Pain in abdomen, chest. arms Shortness of breath Severe headaches Severe depression Blurred or double vision

Intrauterine Device (IUD)

The IUD is a small device made of plastic. The Copper-T and Copper-7 IUD's also contain small amounts of copper. When placed in the uterus, the IUD prevents pregnancy by changing the lining of the uterus. Effectiveness: 96%

An IUD is inserted through the cervix into the uterus by a clinically trained person. The IUD remains in place until it is clinically removed. Some IUD's can remain indefinitely; others using copper must be replaced every 3-4 years.

Many women experience cramping and heavier than normal bleeding during menstruation. The device can also fall out of the uterus, in which case pregnancy may occur. Women should be taught to check the string of the IUD in the vagina to make sure it is in place. If pregnancy occurs, the IUD should be removed immediately to avoid infection.

Severe pain in the lower abdomen Pain during intercourse Unexplained fever and/or chills Increased bad-smelling discharge Inability to find the string

Injection (Medroxy-progesterone acetate (Depo Provera)

A hormone similar to that produced by a woman's body acts to prevent the release of eggs by the ovaries. Effectiveness: 98%

An intramuscular injection is given once every three months to non-pregnant women. The injection should be taken again after three months to insure lasting protection from pregnancy.

Irregular menstrual bleeding; delayed return of fertility after suspending injections; weight gain. Should not be taken by women with irregular genital bleeding, diabetes, cancer.

Prolonged, excessive bleeding Chest pains


The condom is a sheath of thin rubber or animal tissue worn by the man to keep sperm from entering a woman's vagina Condoms also prevent spread of venereal disease. Effectiveness: 90%(If the woman uses a vaginal spermicide at the same time, effectiveness is increased.)

The condom is put on the man’s erect penis before insertion into the vagina during intercourse. About one-half inch at the top of the penis is left slack to catch the semen. After climax, the condom should be held against the penis as the man withdraws so that the semen does not spill into the vagina. A new condom must be used for each act of intercourse.

Rough handling may tear the condom. Exposure to excessive heat can also weaken rubber and make it more susceptible to tearing.


Vaginal Spermicides

Foams, foaming tablets, jellies and creams contain chemicals (spermicides) that stop the sperm from entering the uterus but do not harm the vagina. Effectiveness: 85%(If a man uses a condom at the same time, effectiveness is increased.)

One of these methods is inserted in the vagina before intercourse. It spreads over the entrance to the uterus and the chemical halts sperm movement. Some should be inserted not more than one hour before intercourse; others not more than 10 minutes. More spermicide must be inserted for each act of intercourse.

No known side effects except occasional itching.



Breastfeeding stimulates certain hormones in the woman's body that keep he ovaries from releasing eggs. Menstruation may be suspended for many months when breast- feeding is frequent (on-demand). Effectiveness: 91-97% Before return of Menstruation.

To be an effective, family planning method, breastfeeding must be on-demand and supplements to breast milk must not be given until 4-6 months. Breastfeeding is an effective contraceptive method for most women until 1-2 months before the return of menstruation. Since it is not possible to know exactly when this will occur, another temporary method of contraception is usually recommended after the(sixth) month.

Breastfeeding-women should not be given combined oral contraceptives during the first months post-partum, as they may reduce milk production. Early return of menstruation. Pregnancy.


Natural Family Planning

A woman's body changes each month as it completes the cycle of ovulation and menstruation. Specific signs of ovulation (release of eggs by the ovaries) can tell a woman when she is most likely to become pregnant. By avoiding intercourse several days before, during and after ovulation, a couple can avoid pregnancy. Effectiveness: 81%

A woman's body temperature rises a little when an egg is released and stays up until she begins menstruating. The vaginal mucus increases just before an egg is released, and is clear and slippery. After ovulation it becomes cloudy and sticky. In natural family planning, the temperature is taken and/or the vaginal mucus is checked daily. A woman can learn to recognize the signs of ovulation and take steps to avoid intercourse during this period.

Care must be taken when keeping records and interpreting signs. Illness can produce a rise in temperature. Vaginal infections or use of medications can make it impossible to detect changes in natural vaginal mucus. Mistakes in calculating when ovulation will occur will result in pregnancy.





1. In most parts of the developing world, more births are avoided by breastfeeding than by any other method of family planning.

2. The suckling of an infant at the breast inhibits ovulation, or the release of eggs by the ovaries. This in turn stops menstruation until some months after birth. While a woman is not ovulating, she cannot become pregnant.

3. Frequent breastfeeding (on-demand), including night feeds, increases the number of months of natural protection from pregnancy.

4. There is no sure way to predict when ovulation will return: In some women it will return at six months; in others between twelve and twenty-four. Still others may have more than two years of protection.

5. Because it is impossible to say exactly when a woman will again be fertile, most programs decide on a specific number of months post-partum (i.e., six months) when they begin advising women to use another family planning method to avoid pregnancy.

6. Studies indicate that combined oral contraceptives (estrogen and progesterone) may reduce breast milk production.

7. During the first 4-6 months post-partum, breastfeeding-women should be advised to use a family planning method that does not affect breastfeeding. These include:

- Intrauterine Device

- Vaginal Spermicides

- Condoms

- Vasectomy

- Tubal Ligation

- Injectables (Depo Provera)

- Progestogen-only Oral Contraceptives

8. Breastfeeding should be encouraged for its nutritional and natural child-spacing effects. The trend away from breastfeeding is very serious. It will result in more malnutrition and higher birth rates in many parts of the world, if it is not reversed.

Session 2: Providing the facts about family planning


Trainers list rumors and attitudes that have a negative effect on Family planning acceptance in their areas. They then identify facts that counter these attitudes and rumors and discuss ways for making factual information about family planning available.

Time: 1 hour


- Flipchart and marking pens


1. Introduction: Couples may reject the use of family planning for different reasons:

- They want to have another child in the near future

- They have heard rumors about family planning methods

- They have cultural or religious reasons for not accepting family planning

- In-laws are opposed

- Etc.

In many cases, couples do not have the factual information they need to make an informed decision about contraception. In this session, we will discuss some of the specific facts about child-spacing and family planning methods that couples need in order to make an informed choice. We will also identify different methods for providing information to couples in their communities.

2. Ask trainees to begin by listing all of the rumors and negative beliefs that they have heard about family planning. When they finish, make a group list of rumors and beliefs on the chalkboard. Do this by asking each trainee for a rumor or belief from their list.

Ask trainees to list facts that would disprove each incorrect rumor. For each belief or attitude against family planning ask them to think of a logical response that might help change the negative attitude. Write these on the right side of the chalkboard across from the rumors and attitudes they refer to.

3. Role Play: Conduct several role plays based on the rumors and negative beliefs listed above. In the role plays, a "Family planning promoter" should try to convince a woman, man or couple that a rumor they have heard about family Planning is untrue. Encourage the rode players to provide facts, use examples and develop persuasive arguments to dispel these rumors. Make sure that "family planning promoters" are courteous and respectful of other people's beliefs and attitudes. They won't change attitudes by offending their clients.

4. Community Education: Ask trainees to list different types of community activities and events in which information about family planning could be presented and discussed.


- discussions with organized groups (women's groups, cooperatives, teachers, etc.)

- education sessions in the clinic

- home visits

- community meetings

Encourage trainees to tell the group about successful activities they have conducted or participated in that increase people's knowledge about family planning.

5. Ask: "Who should provide family planning information to the community?"


- doctors, nurses

- chief or village leaders

- satisfied family planning users (men and women)

- volunteer health workers

- extensionists

Discuss the advantages and disadvantages of involving each type of- individual listed. What kind of training would each need?

6. Summarize:

Community programs to improve nutrition must provide correct information about:

- the benefits of child spacing and small families;

- modern methods of family planning;

- family planning for the breastfeeding mother.

Negative attitudes and rumors about family planning can be changed by providing factual information about family planning methods, and by stressing the benefits of small families and birth spacing to the family and the community.

Activities to spread family planning information could include presentations and discussions with groups as well as counseling of individuals and couples. Promotion of family planning by community leaders, medical professionals, satisfied family planning acceptors and other respected individuals can be important in changing community attitudes towards family planning.

Session 3: Community-based distribution of family planning methods

Once couples know about and want to use family planning, they must be able to obtain an effective contraceptive method without excessive expenditures of time and money. Community-based programs can help couples obtain contraceptives and/or learn about natural family planning in several ways:

- Provide contraceptives in the community through a clinic or community workers

- Provide referral for contraceptive services and transportation to a nearby clinic

- Provide follow-up of contraceptive users to encourage continuation and solve problems with side effects

- Keep records of the eligible couples and family planning acceptors in the community


Trainees discuss the availability of family planning services in their areas and the socioeconomic barriers to the use of these services. The advantages of community-based distribution (CBD) of contraceptives are listed and the components of a CBD program discussed.

Time: 2 hours


- Handout - Case Study: Community-Based Family Planning Service Delivery

- Flipchart and marking pens

Time: 2 hours


1. Ask trainees to complete the following chart:

Where do people in your area currently go to obtain family planning services:


How far is this from village(s)?

Cost Round Trip

Time Round Trip

What methods are provided?


2. Discuss the effects that distance, cost and time for travel have on family planning acceptance and continuing use. Brainstorm other reasons why women who want to avoid pregnancy may not visit family planning clinics. These may include:

- Cultural restrictions on women's movement

- Negative attitudes toward family planning

- Poor treatment by health workers

- Lack of privacy

3. Role Play: Divide into work groups (5-6 people). Assign each work group the task of developing and presenting a role play based on the following situation:

Elizabeth has had four children. She and her husband have decided that they should wait for a few years before having another child. A family planning worker visited her several months ago and referred her to the clinic in Kisumu. Two months ago she traveled to Kisumu. Kisumu is 15 km away from Elizabeth's village. On most days the bus ride is about two hours. However, on the day she traveled to Kisumu, it was raining so hard that the bus became stuck and they arrived late. At the clinic, she was made to wait for a long time until she finally saw the nurse. It was so late when she finished that she had to wait until the next day to return to her village. Her husband was angry and accused her of lying about the wait at the clinic and the money she had spent on the bus and the contraceptives. The nurse gave Elizabeth three packages of oral contraceptive pills and told her that she must come back at the end of three months to get more.

In this role play, the family planning motivator is again visiting Elizabeth. Elizabeth explains to her why she has decided not to return to the clinic in Kisumu to fetch more contraceptives.

Trainer: Write your own role play situations based on local problems of transportation, culture! restrictions, health worker/client interactions, etc.

4. Case Study: Distribute the Handout - Case Study: "Community-Based Family Planning Service Delivery. " Ask trainees to read the case study individually and then to work with their groups to answer the questions et the end of the case study.

5. Go over the group's answers to the case study questions. Point out that community-based distribution:

- makes family planning methods easily available in the community;

- helps overcome geographic and financial barriers to contraceptive use;

- helps overcome restrictions on women's mobility and contact between female clients and workers;

- allows for rapid follow-up of "family planning acceptors to insure continuation of use.

6. Management Decisions: Review the important decisions managers must make when planning a CBD program:

- What contraceptives should be provided in the community

- Who should provide contraceptives in the community? (Selection, qualifications)

- What kind of training will community workers need? - How to supply and monitor contraceptive supplies?

- Where to refer? For what reasons? For v/hat services?

- How to supervise CBD workers?

7. Stress the importance of an effective referral system for any CBD project. The referral system must support the work of the community worker and provide clinical assessment and services as needed.

8. Summarize the unit:

Spacing births and limiting the size of a family means better health and nutrition for women and young children.

Modern and traditional methods of family planning make it possible for couples to have the number of children they can support.

Two important reasons why couples do not practice family planning are lack of information (or misinformation) and lack of access to contraceptives and contraceptive services.

Communities can play an important role in making information about family planning and contraceptive methods available to of their members.

Community-based family planning distribution programs can be organized with the active participation of community members to make contraceptive services available to all interested couples.



Concerned Women for Family Planning was started in 1976 to provide family planning services to poor women living in the crowded slums of Dhaka, Bangladesh. The founders of the organization had come to realize that low-income women throughout the city were eager to obtain the baby preventing medicine" they had heard about but could not visit family planning clinics for a variety of reasons. In Bangladesh, the majority of women live in "prudish," or behind the veil. Their contacts are limited to the members of their families, and they seldom leave their own homes or compounds. Traveling to a family planning clinic, staffed by male and female workers, poses serious cultural as well as economic problems for most women.

To overcome these barriers, Concerned Women for Family Planning started a pilot program for the household distribution of family planning information and contraceptives. A team of four field assistants and one supervisor began working in a neighborhood of approximately 74,000 people. The neighborhood was divided into four sections, with each field assistant responsible for the families in one of the sections.

Field assistants began by visiting and getting to know the women in each of their sections. At the same time, they carried and distributed oral contraceptives and condoms and provided information on other clinical methods of family planning. Each field assistant eventually reached all of the homes in her section; however, more emphasis was placed on acceptor satisfaction and continuation than on the total number of new acceptors she recruited. Other programs had shown that many couples who decided to try family planning methods would discontinue use because of minor side effects or general dissatisfaction with the contraceptive method they had chosen. Concerned Women found that follow-up visits, during the first few months after a couple began using a contraceptive, would help them adjust to the method or change to a more satisfactory method without discontinuing family planning use.

Besides household distribution of contraceptives and active follow-up of acceptors, the Concerned Women's program provided referral and transportation to women who were interested in clinical family planning methods, sterilization, IUD insertion and Depo Provera injections. These clinical services were provided to clients referred by Concerned Women at two clinics in Dhaka.

During the first month of the Concerned Women project, 268 couples accepted family planning methods. Of these, 70 percent were still using family planning methods a year later. These high levels of acceptance and continuation proved that the Concerned Women's strategy worked!

Because of its success, the Concerned Women's program has continued to expand. By 1977, 88 field assistants and supervisors had been trained, and were providing information and delivering contraceptives house-to-house in 17 neighborhoods. In 1978, Concerned Women opened its women's clinic in the heart of the most crowded area of the old city, and the program is still growing. Today, the Concerned Women's program includes counseling, maternal/child health care, nutrition education as well as family planning services.


This case study describes an urban, community-based distribution program designed to overcome cultural restrictions on women's movement outside the home.

It is best to develop a case study for a program that increases access to family planning methods by overcoming the most important barriers in your region. For example, in rural areas, distance and cost of transportation may be major barriers to the acceptance of family planning.



1. What barriers to family planning acceptance did the program in the case study overcome?

2. What family planning methods were provided in the community?

3. Where did the community workers (field assistants) refer clients for clinical services? What family planning methods and services were provided at these referral points?

4. Why do you think this program has been so successful?

(List as many possible reasons as you can think of.)


Baer, Edward C. and Winikoff, Beverly. Breastfeeding, Program. Policy and Research Issues, Studies in Family Planning, Vol. 12, No. 4, April 1981.

Center for Population and Family Health. Family Planning: Impact on the Health of Women and Children. Columbia University, 1981.

Favin, M., Bradford, B., and Abula, D. Improving Maternal Health in Developing Countries. World Federation of Public Health Associations. August, 1984.

Hatcher, Robert et. al. Contraceptive Technology 1984-1985. Irving Publishers, Inc., New York, 1985.