| Community Nutrition Action for Child Survival |
|Table of contents|
|How to use community nutrition action for child survival|
|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 2: Focus on women and children|
|Session 3: Important causes of malnutrition in women and children|
|Session 4: Community nutrition action for child survival|
|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 6: Counseling, referral and follow-up of malnourished children|
|Unit 3: PROMOTING BREASTFEEDING|
|Session 1: The importance of breastfeeding|
|Session 2: Helping mothers breastfeed|
|Session 3: Breastfeeding information for Kenyans|
|Unit 4: Introducing weaning practices in the community|
|Session 1: Changing weaning practices|
|Session 2: Making improved meaning 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|
|Unit 5: Preventing diarrhea|
|Session 1: Preventing diarrhea*|
|Session 2: Diarrhea home management|
|Session 3: Community activities to prevent diarrhea*|
|Unit 6: Immunization|
|Session: Improving immunization coverage - The community's role|
|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|
|Part II - Planning nutrition action projects|
|Unit 1: Working with the community to improve nutrition|
|Session: Simulation exercise|
|Unit 2: Finding the causes of malnutrition|
|Session 1: Conducting a community nutrition mini-survey|
|Session 2: Analyzing community nutrition information|
|Unit 3: Deciding what to do|
|Session 1: Visits to on-going nutrition projects|
|Session 2: Case studies/panel discussion|
|Unit 4: Planning nutrition action projects|
|Session 1: Describing the problem|
|Session 2: Writing project goals and objectives|
|Session 3: Choosing project activities|
|Session 4: Developing a project work plan|
|Session 5: Planning how to evaluate|
|Session 6: Preparing a budget|
|Unit 5 - Session: Writing a project proposal/Mini-Workshop|
|Session: Writing a project proposal Mini-Workshop|
|Part III - Project management systems|
|Unit 1: Training community nutrition workers|
|Session 1: Introduction|
|Session 2: Assessing training needs/writing objectives|
|Session 3: Choosing training methods|
|Session 4: Scheduling training content|
|Unit 2: Evaluating progress|
|Session 1: What do he need to know? How can we find out?|
|Session 2: Records and reports|
|Session 3: A prototype record keeping system|
|Session 4: Evaluating activities with the community|
|Unit 3 - Supervising community nutrition activities|
|Session 1: The role of the supervisor|
|Session 2: Identifying and solving problems|
|Session 3: Problem-solving/role play|
|Session 4: Planning and conducting supervision visits|
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.
- "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.
"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."
A STORY ABOUT MALNUTRITION
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.
List as many possible causes of malnutrition in this story as you can.
CAUSES OF MALNUTRITION IN MY REGION
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!
SOCIO-CULTURAL CAUSES OF MALNUTRITION
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.