|Nutrition education for the public. Discussion papers of the FAO Expert Consultation (Rome, Italy, 18-22 September 1995) - FAO Food and Nutrition Paper 62 - (1997)|
|Past experiences and needs for nutrition education: Summary and conclusions of nine case studies|
|Summary of case studies|
8 K. Vijayaraghavan.
Many strategies are employed in India to alleviate poverty and malnutrition. Although the primary determinant of undernutrition is an inadequate dietary intake, lack of knowledge is a contributory factor. Nutrition education therefore has the potential to improve nutritional well-being. The Tamil Nadu Integrated Nutrition Programme (TINP) is a large-scale programme, implemented in the South Indian State of Tamil Nadu since the 1980s. TINP is funded by the World Bank and integrates health and nutrition interventions with a major communication component. TINP - 1, which is discussed in this paper, operated in six less developed districts, covering an estimated 1.1 million children and 0.28 million expectant and nursing mothers.
· To reduce malnutrition and the consequent high mortality in children under three years of age.
· To improve the health and nutritional status of children under three years and that of expectant and nursing mothers.
Children under three years. Pregnant and nursing mothers.
Sectors and strategies
Health, with the support of the World Bank. The programme was delivered in health centres and households in rural villages.
· Nutrition delivery services: Weighing of all children of six to 36 months at Community Nutrition Centres. Malnourished children were enrolled for short feeding programmes. Pregnant women were also selectively fed.
· Health services: Ante- and post-natal care, focusing on a reduction of infant and child morbidity and mortality.
· Communication: Designed to: (i) make mothers fully aware of the nutritional needs of children, (ii) address better intra-family distribution of food, (iii) enable the community to handle its health and nutrition needs more effectively. Targeting, both for nutrition intervention and communication, was critical. The communication strategy segmented the audience into primary and secondary targets and strategies were carefully planned for both. Two-way communication was used for the primary target group and one-way communication for the secondary audience. The primary target group was mothers, mothers-in-law, and fathers. Counselling was used, linked to weighing and supported by flip charts and flash cards. The secondary target group was the rest of the population. The methods used were films - incorporating popular film tunes, film strips, and slides. Pamphlets were available for the literate. An innovative strategy was the use of popular folk media villupattu. Professional troupes incorporated nutrition messages into villupattu and audio cassettes were produced.
· Social mobilisation: Womens Working Groups (WWGs) were formed. They were trained in communication. Each group adopted a number of families, assisted with counselling mothers and later ran income generation projects, e.g. 200 WWGs produced weaning foods. Childrens Working Groups (CWGs) relayed messages via songs, poems and jingles.
· Training: There was a three-month training for primary health care workers (PHWs), plus a two-week refresher after two years. Community Nutrition Workers (CNWs) - local mothers, were locally trained for three months. Joint training was conducted for the last ten days for PHWs and CNWs to build rapport and understanding. Annual refresher courses were provided. CNWs were supervised and supported. There was strong bureaucratic and political commitment to the project. The communication component was separately managed by a co-ordinator who was assisted by a team including a communication research officer, a librarian and an artist. Management was planned at all levels.
The project began in 1980 and ended in 1987.
Comprehensive but manageable evaluation was integral to the programme. Independent evaluations were conducted of the experimental and control type. Base-line, mid-term, and terminal surveys were conducted. No separate evaluation of the communication strategy was conducted, but it would seem that its main value probably lay in achieving better utilisation of project services.
The programme achieved a 55% decline in malnutrition over 72 months. In areas where the programme was evaluated over four years, the reduction was about 35%. Overall a 40% decline was achieved, with spectacular decreases in clinical deficiency signs. No statistical analyses were applied.
A major contribution of the communication strategy was to increase the communitys use of services. IEC activities should be supported by other services/strategies which make it possible to act on the messages. Target groups were not involved in planning, and it is difficult to assess whether involvement would have improved the programme. It would have been valuable to have had direct monitoring of the communication component and to have had key indicators developed in this area.
A major factor in the success of the programme was the strong bureaucratic and political support. The project was carefully planned, but had flexibility and made modifications as needed. Technical expertise was available from national and international experts. The CNWs were local and credible to the community. Training and community participation through WWGs were other critical factors in success.
As the evaluation was not systematic and supported by statistical analyses, all conclusions should be interpreted carefully. Furthermore, no specific evaluation of the communication component was undertaken, making it impossible to assess its role in achieving nutritional improvements, which could have been mainly due to the feeding component of the programme. Formative evaluation was conducted to determine the most appropriate methods for the target groups, and audience segmentation methods were used. There was no pre-testing of messages or materials, although some modifications occurred during the programme as the result of feedback.
This case history again highlights the importance of training, which was given a high priority, although there is no report of an evaluation of this training. Overall this project is generally regarded as cost effective but the high cost of developing and distributing films, slides, posters, audio cassettes, and posters could be prohibitive for projects without outside funding. A range of communication channels was used, including folk media. In general TINP-1 suggests that interpersonal communication, supported by media, is appropriate for illiterate communities.