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¹ This is the first of two articles on nutrition education. It reviews the consequences of nutrient-based, sender-oriented nutrition education practices while an alternative approach is presented in the second article, to be published in the next issue of Food, Nutrition and Agriculture.

M.T. Cerqueira

A health and nutrition educator, Maria Teresa Cerqueira has worked as a consultant for the Pan American Health Organization, the World Bank and FAO. She is currently a doctoral candidate in the Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA.

Disappointing reports that many nutrition education efforts have brought few changes in nutrition-related behaviour or nutritional status have sparked debate among nutrition educators.² The first issue of controversy involves the effectiveness of current methods of information dissemination as a strategy for nutrition education. The usefulness of nutrition education with “sender versus receiver oriented” messages is a second topic of discussion. A third aspect being examined by nutrition educators is the effect of content that is determined by nutritional science and thus nutrient based rather than community based. These interrelated issues and their influence on the content and methods of nutrition education are examined below.

² Many nutrition education efforts occur in the context of other programmes and were not evaluated; thus, it is difficult to draw empirical conclusions about all programmes.

Information dissemination

While dissemination of information through newspapers, pamphlets, posters, radio and television broadcasts has increased knowledge among target audiences and moderately influenced attitudes, this strategy has had little effect on changing eating patterns (Zeitlin and Formacion, 1981; Hornik, 1985; Johnson and Johnson, 1985). A review of nutrition education projects concluded that changing behaviour, rather than disseminating information, must be the clear intention of a programme if nutrition education is to be effective (Whitehead, 1973). In information dissemination the objective is to send a message, usually formulated for the general public. There is rarely any interaction or dialogue between the sender and receiver or concern with the analysis of problems or with the process of building people’s capacity for making decisions and taking action to solve problems (Rogers, 1983; Stevenson, 1988; Cerqueira and Olson, 1991).

Nutrient-based messages out of context

Nutrient requirements influence the goals, objectives and content of nutrition education activities. Nutrition education messages generally address a nutritional problem (deficiency or excess) which has been identified in the population. The messages aim to change an eating practice that is considered to be the cause of the nutritional problem.

The term “nutrient-based approach” refers to activities or services that are determined by scientific knowledge rather than by the perceived needs of the persons receiving the service. While nutrition education is usually community-oriented, i.e. designed with consideration of the social and cultural context, it is structured in form and content according to the dictates of medical and nutritional science (Gussow and Contento, 1984). Materials are produced to reinforce or divulge the messages in a textual format, illustrated by drawings or pictures, in audiovisual form or in broadcast formats for radio and television.

Information designed (in form and content) by the person sending the message, usually a nutritionist, has been called “sender-oriented” (Dervin, 1981). The information is based on technical and scientific rules and modelled by the social and cultural context of the sender. In contrast, “receiver-oriented” messages are designed (in content and form) to stimulate critical thinking in the receivers and to respond to their information needs.

This issue implies that the concept of audience needs to be critically analysed. Receiver-oriented messages require meticulous audience research in order to have the text, language, graphic style, images, colours, dress, personal appearance, etc. resemble those of the receivers more than those of the senders.

The recognition that food habits and eating patterns are complex multi-dimensional behaviour, not simply biological functions, was an important breakthrough in nutrition education research. Nutrition educators studied the attitudes and beliefs of the audience and the social, economic, cultural and psychological factors that influenced the food habits and nutritional status of the population. Yet the focus of nutrition education on changing individual eating habits remained as they were still seen as the cause of the diet-related disease. In spite of the efforts of public health professionals to understand the economic and cultural conditions and to tailor information to individual situations, the basic message conveyed was still that derived from the biomedical model.³

³ Biomedical model: a system that determines the type of medical or nutritional care that is provided, the structure of the service and the content and method of delivery. In the dominant biomedical model, activities are organized around different disease states and the service is standardized for the group of patients that have a given disease, irrespective of their social and cultural context. The influence of the traditional biomedical model on nutrition education is discussed in Cerqueira (1990).

Face-to-face nutrition education strategies, especially health centre or hospital based, have reached very few people. In addition, health personnel have been inadequately trained and too burdened with curative and administrative duties to implement nutrition education activities. Mass communication greatly increased the audience of nutrition messages, yet the messages continued to focus on individual behaviour change.

Nutrition education based in the community

People’s concepts and beliefs about feeding, health and growth are rooted in their traditions, and the language and conceptual framework for nutrition education needs to have meaning in each cultural context. Development communication studies involving health and nutrition programmes suggest that receiver-oriented messages are more appropriate than sender-oriented messages. Activities should be planned and implemented by a group of community members rather than by technical experts who are not members of the community.

Another breakthrough in nutrition education was the recognition that active involvement of community members is necessary to improve nutritional status because eating patterns are complex phenomena influenced by multiple social, economic and cultural factors. The transformation of social conditions such as improvements in community sanitation, water supply and food availability requires collective awareness,⁴ commitment and participation.

⁴ Collective awareness refers to the process of critical thinking generated by the Freire method (Freire, 1970; 1971; 1973) which assists people to think in their own terms and speak in their own active voices. Consciousness raising is a process in which a group discovers the historical roots and socio-economic and political relationships that affect their lives.

Involving the active participation of the learner is a more comprehensive and effective approach to developing food and nutrition skills. because a critical/ reflexive process trains people to make decisions, to set goals and to initiate action (Drummond, 1975; Praun, 1982). For instance, it is important that mothers know the basic mechanisms of human milk lactation and understand when it is appropriate to introduce other foods to their infants in order to avoid confusion by conflicting opinions. Other nutrition skills, such as washing hands before preparing foods, imply awareness that germs rather than the food itself cause diarrhoea. When children do get diarrhoea it is important that parents know that the body needs fluids and extra nourishing foods. Confidence, self esteem and perseverance are required to act upon this knowledge. The availability of water and sanitary conditions is also implicit.

Women need social support and empowerment to practice nutrition skills. Strength of conviction is needed to resist peer pressures, and it takes exceptional character to adopt new practices. This empowerment can best be achieved by connected teaching rather than by technical and procedural imposition of information that would aggressively challenge the women’s notions and isolate them from their community. The importance of a participatory, community-based approach is that it trusts the participant’s experience and thinking and encourages participants to expand them. How to engage members of the community in an active learning process is a critical question.

Content in nutrition education

The issue of selecting the basis for making choices about foods in various regions remains unresolved. Do we take a nutritional science approach, as in nutrient-based information, or a community-based approach, and work with indigenous knowledge? The content of nutrient-based nutrition education is determined by the nutritive value of foods. Foods are grouped by categories according to the nutrients they provide (especially the essential protein, vitamins and minerals), their presence in food and their functioning in the body. Surveys using anthropometric measures of preschool children and a 24-hour recall of the foods consumed by the family are usually the basis for assessing nutritional status and for identifying the nutrient deficiency problems in a community. If the children are low in weight then energy is the deficient nutrient; if the dietary data show low levels of retinol, then vitamin A becomes the basis of the nutrition education programme; etc.

Diverse food group categories and other teaching tools have been developed to provide consumers with information about food composition, human nutrient requirements and the relationships between nutrients and disease. The definition of “good” nutrition or adequate diet was based on the nutrient content of foods.

Focus and scope of the content in recent nutrition training materials
Orientation et portée de matériel récent de formation nutritionnelle
Orientación y campo de aplicación del contenido de materiales recientes para capacitación en materia de nutrición

Assessment of widely used training materials

A review of the contents of recent nutrition education training materials from three sources (see Table) reflects the concern with the identification of nutritional deficiencies, followed by technical information about high nutritional value foods and adequate eating practices, especially for women during pregnancy and children under two years of age. Another concern that is evident is that of planning nutrition education activities, especially for mothers with young children. The content of both the WHO (1986) and FAO (1983) documents is directed primarily at training community workers to implement activities to improve the nutritional status of these vulnerable groups. Traditional activities such as growth monitoring, preparation of weaning foods, infant feeding and avoiding infection are important topics.

The FAO (1983) training package has a thorough treatment of the collection, processing and use of nutrition information, especially for evaluation purposes. In both the WHO (1986) and the FAO (1983) training materials the content is nutrient based. Nutrition education activities rely mainly on dissemination of sender-oriented messages. The documents include a complete analysis of the social, economic and cultural factors that influence nutritional status, and stress that community workers consider local conditions. However, the topics focus on the change of individual behaviour associated with diet-related diseases.

The Save the Children (Keehn, 1982) monograph emphasizes the planning of training workshops for community workers and incorporating participatory learning approaches. With the group dynamics and participatory approach advocated in this monograph, technical nutritional science information can be integrated with indigenous knowledge. However, it is not clear that community workers will be able to mobilize the resources to plan and implement a nutrition education programme. The series of didactic techniques advocated in this type of training may not be sufficient to develop the skills that community workers need to assist community members in thinking in their own terms and speaking with their own active voices. It is doubtful that this brief exposure to group dynamics will enable the community nutrition workers to develop a participatory, empowerment-based approach in working with community members to improve the health and nutritional status of the population significantly. The question remains whether the community worker will acquire the information, knowledge and skills and have the support (level of discretion) both from the community and from the organization (e.g. health system) to be an effective change agent.

Both WHO (1986) and Save the Children (Keehn, 1982) could be more rigorous in training the community workers to record and use information in a practical but effective way to monitor progress toward community goals and to procure resources both internally and externally that would help to sustain the health and nutrition education programme. The quality of the performance of community health workers is crucial to building credibility with community members and involving them in the development of health and nutrition education activities. If the worker is not adequately prepared, community members may lose interest in participating in the activities that have been planned.

Messages for diverse audiences

Nutrition education in developing countries must address both nutritional deficiencies and chronic diseases. The concern with chronic diseases has yet to be incorporated into the nutrition education materials produced by international organizations for use in developing countries. Community workers need to be prepared to develop many diverse activities and need the tools to work with community members in identifying and determining solutions to both types of problem in order to contribute to the improvement of the health of all community members. With the increase in cardiovascular disease, messages may conflict since foods which have been considered “good” because they contain essential nutrients, such as protein, calcium and iron (meat, dairy and eggs) also present risks for cardiovascular disease because of their high content of saturated fat and cholesterol.

Conclusion

The controversy about the content of nutrition education and its focus on individual behaviour change has spurred a critical/reflexive analysis about the practice of nutrition education. The facts derived from nutritional sciences are not an inappropriate basis for nutrition education, but they are insufficient. It is important for nutrition educators to address dietary habits that are associated with the risk of disease, but nutrient-based information alone is inadequate, and a focus on individual behaviour change is probably insufficient and ineffective.

The issue is not whether sound medical or nutritional knowledge is important in nutrition education or even how much or what part of that knowledge is useful to those doing the eating. The issue is how to work with members of the population in a critical/reflexive and more systematic manner that would stimulate their active participation and commitment in their own learning process.⁵ Nutrition education needs to develop an approach that will empower community members to make the appropriate choices, using both scientific and cultural knowledge.

⁵ Active learning process refers to a method of education which involves the learner in different activities that contribute to the acquisition of skills and knowledge. Active learning involves three aspects: the cognitive, the emotional and the psycho-motor. In this process, the learners are not passive listeners; instead they ask questions, discuss, practice, read and do other activities. This implies that the learner is involved in making decisions regarding the learning process. For more information, refer to the works of Freire (1970, 1971, 1973).

A second article in an upcoming issue of Food, Nutrition and Agriculture will address several questions such as: How could nutrition education be different if nutritional sciences were the basis of knowledge needed to analyse the problems rather than the recipe for the solutions? How would nutrition education change if we focus on the needs of the learner and the community? What is the role of nutrition educators in this emergent practice? Finally, how will the goals, content and methods of nutrition education change for the practitioner?

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