|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)|
|Training needs for nutrition education: Guidelines for in-service training of nutrition educators|
Before launching in-service training programmes for nutrition educators, careful consideration needs to be given to the circumstances for which nutrition education is an appropriate intervention.
What causes of malnutrition can be remedied by nutrition education?
Clarify goals of intervention
Before embarking on nutrition education or training endeavours, the context and rationale for efforts need to be established. The following questions must be asked and answered: What factors contribute to the inappropriate or inadequate nutrition knowledge and food practices? Is the goal of the programme to increase nutritional knowledge, or to provide skills for making healthy dietary decisions to maximise nutritional status, or both of these?
Nutrition education can rarely remedy malnutrition alone
Nutrition education is an appropriate intervention only when a lack of food and nutrition knowledge, attitudes, or skills, harm the health or well-being of the individual or those she or he is responsible for. When factors other than lack of nutrition knowledge cause poor nutritional status, these also need to be addressed. Informational or educational efforts to combat undernutrition are ineffective unless they are culturally relevant and geared to the target groups interests.
What are some other causes of malnutrition and how can they be addressed?
· Multifactorial economic and social inequalities contribute to malnutrition:
Many of the problems related to the ill effects of improper nutrition are due to economic and social inequalities. For example, among the poor in developing countries, undernutrition is a problem that is often due to inadequate food supply, limited purchasing power, poor health conditions, and incomplete nutrition knowledge (Berg, 1987). Problems of poorly nourished populations in developing countries are multifactorial and include disease, lack of education, poor education, other circumstances associated with poverty, and unequal distribution of food resources, not only within society but within families, as well as lack of nutrition knowledge. Abundant research shows that in situations of poverty, where food inadequacy exists, food-assistance programmes must precede educational interventions. Thus, it is especially important in developing countries to integrate nutrition education into broader programmes that encompass agricultural and food availability issues. Nutrition education must also be appropriate for the biological, cultural, economic, social, and cognitive contexts in which the programmes operate.
When undernutrition is present, the causes may sometimes include not only insufficient economic resources to purchase adequate diets, or inappropriate food distribution in the family, but also psychopathology. This is particularly likely in affluent countries. Infants who fail to thrive and adolescents with eating disorders often come from disturbed families. Programmes to address prevention of failure to thrive (Pollitt, 1994) and eating disorders (Nagel & Jones, 1993) must also include both nutrition education and attention to these psychosocial issues.
Status of women
The status of women also has an impact on the effectiveness of nutrition education, especially in developing countries. In developing countries women have multiple social and economic roles, long working hours, and less access to education and nutrition than males (Brown, 1990). Yet it is they who are responsible for the alimentation of their families. The international human rights movement has neither considered nor remedied the low status of women, although it has called for respecting the political rights of people in general (Bunch & Carrillo, 1991). Gender discrimination and violation of womens rights deny many women education, health care, and good nutrition.
Economic and political instability
Developing countries must currently make structural adjustments in the economy, and austerity measures, which have a great social impact on food availability, may be implemented to cope with economic instability (Bradshaw et al., 1993). The latest international statistics on the effect of different social indicators, including level of nutrition, present a bleak picture, especially in poorer countries experiencing economic crisis, such as Mexico, certain other Latin countries, and Eastern Europe. Political conflict and wars increase already existing inequalities. During the Gulf War, there was a dramatic increase in malnutrition that threatened the lives of over 250,000 children under the age of 12 (UNESCO, 1991; Field & Russell, 1992). Violence in Croatia and Bosnia, in several countries in Africa, and in the countries making up the Former Soviet Union have also increased malnutrition. Political strife in Haiti, Somalia, Iraq, Cuba, and Chechnya may have led to food shortages, and under- and malnutrition in vulnerable groups. Education to improve food choices and handling under conditions of war may alleviate some of the impact on nutritional status as limited knowledge may contribute to the undernutrition seen in these circumstances, but undernutrition rarely yields to nutrition education efforts alone.
Environmental influences on nutritional status differ in degree between industrialised and developing countries, but are evident in both (Scrimshaw, 1993). For example, the effects of poverty on child development, links between anaemia and decreased levels of mental and motor development, the positive effects of supplemental nutrition programmes on child development, and the ill effects of poor nutrition and concurrent illness on school performance, are present in both poor and rich countries (Pollitt, 4994).
Ill-effects of malnutrition are well substantiated
Poor early childhood development, low productivity, violations of human rights and womens rights, and abject poverty all combine with lack of nutrition education to cause malnutrition in populations. Evidence for the deleterious effects of inadequate food is substantial. Foster and Rosenzweig (1993) reported that intakes of food energy had adverse effects on productivity in the Philippines, India and Pakistan. Khurana (1992) reported an association between malnutrition and lack of basic literacy skills among children in India. But in many developing countries, in addition to dietary inadequacy, nutrition-related feeding problems exist in early childhood development. The ill effects of improper nutrition early in life are many, and may sometimes be irreversible. Myers (1992), analysing the situation in Latin America, concluded that intellectual development, personality, and social behaviour were all severely impaired by lack of good nutrition. Glewwe and Jacoby (1993) indicated that nutritional deficiencies in early childhood in Ghana were associated with delayed primary school enrolment.
Nutrition education must be included as part of the solution
Prognoses of the nutritional status of populations around the world are not so negative that we should surrender to a future of malnutrition. The late, former-UNICEF Director John Grant (1993), analysed the State of the Worlds Children and found hope in the post-cold-war world. He indicated that now the means were at hand to end mass undernutrition, preventable disease and widespread illiteracy among the worlds children. The estimated cost was only US $25 billion per year in additional aid to developing nations. Experts agree that if we are to address these problems, nutrition education must be included as part of overall development efforts. Risks of malnutrition cannot be addressed by nutrition education alone, but nutrition education is appropriate, and can be effective, in situations where food is available but food practices are inappropriate or uninformed from a nutritional standpoint. Frequently, such lack of knowledge is only part of the problem, and therefore for nutrition education to be most efficient and effective, it should be delivered along with programmes that provide the other components that are lacking.
The 1990 UNESCO Education for All conference (Fordham, 1992) called for enhancing the learning environment through early childhood care and education about health and nutrition. In 1991 in Lisbon, Portugal, education specialists from 51 countries concluded that systematic and continuous social and familial action, beginning in early childhood and continuing until maturity were necessary to tie together pre-school education, health, nutrition, and social service programmes in to effective intentions. Others have also emphasised the need to sustain nutrition education in the context of overall promotion of maternal and child health (Dwyer, 1990; Wallace, 1988).
In highly industrialised countries such as the United States and Western Europe amongst others, efforts to provide information to consumers so that they can make informed choices have been popular. In these countries, chronic degenerative diseases that have been linked to diet are more prevalent than undernutrition as causes of malnutrition (USDHHS, 1990).
Individual choice contributes to malnutrition through chronic disease
In these countries the choices of individuals, rather than insufficient incomes for purchasing adequate diets, make up most of the malnutrition problem. Many long-standing lifestyle factors, in addition to dietary patterns of excess, contribute to ill health and me development of chronic degenerative diseases that are common in those countries. These diseases include coronary artery disease, hypertension, non-insulin dependent diabetes mellitus, obesity and alcoholic liver disease (National Research Council, 1989).
Successful Programmes Focus Both on Lifestyle Factors and Diet
Programmes to decrease risks of these disorders are most effective when they include attention to lifestyle factors in addition to diet, as do programmes such as the National Cholesterol Education Programme (NCEP, 1987) and the National High Blood Pressure Education Programme (NHBPEP, 1988). Innovative, experience-based teaching techniques are also needed. For example, Fletcher and Braner (1994) report that an effective way of teaching children about nutrition is for them to prepare their own foods and to instil awareness of ethnic and cultural influences on food choice.
Institutional arrangements and resources for nutrition education
The institutional arrangements for nutrition education and training already in place within a country vary. Usually it is necessary to build programmes on these bases. Lead responsibility for each aspect of nutrition education should be clear whatever the institutional arrangement.
Both efforts sponsored by international and bilateral organisations (country to country) may be involved, and these may include not only governmental but non-governmental organisations as well. When the government is involved, in some countries, one institution or sector is designated as responsible for training. In other countries, responsibility is shared by several sectors (e.g. health, agriculture and education). The degree of centralisation of control over programmes also varies. Responsibility may lie with a centrally located group or less highly centralised structures may exist. Finally institutional structures may include only a single discipline or multiple disciplines.
Know organisational resources
Those who wish to develop in-service training in nutrition education must be familiar with the organisational resources and channels for communicating within these structures for developing training programmes. Imposition of in-service training in nutrition education by international organisations with little or no involvement by groups within the country is unlikely to succeed. Co-operation at the government level will make some aspects of training easier than efforts relying unilaterally on voluntary groups. Countries where interdisciplinary teams have already been formed with a mutual interest in nutrition (i.e. Thailand, with Ministries of Health, Agriculture and Education working together) may have systems in place for training and delivery of education which can be used. Large government organisations typically have specified procedures for training staff, which may be necessary and useful to incorporate into training plans if funding is to be obtained from the government agency. For example, in the United States, the Nutrition Education and Training (NET) Programme was established to support the training of nutrition educators of school age children (Ullrich, 1992), and training is built into the mission of the Co-operative Extension service organisations at the Federal and State level. These organisations exist to translate research information into practical terms, and to bring it to people in target groups who would otherwise not have access to it. In planning and training, nutrition interventions can be linked to other health and socio-economic development programmes.
Investigate other organisations with and interest in nutrition education
It is also useful to investigate the willingness of other government, industry and volunteer organisations to cooperate in developing in-service training. They may have aims which overlap with or involve nutrition education. Monetary or in-kind assistance may also be available for nutrition education training programmes from these sources if their goals and objectives are consistent with those of these funding organisations.