|Effective Communications for Nutrition in Primary Health Care (UNU, 1988, 208 pages)|
|Country and project reports|
Institute of Nutrition and Food Science, Dhaka University, Dhaka-2, Bangladesh
Mothers and children in rural areas are the main target for nutrition education in Bangladesh. Various strategies have been used to convey nutrition information to different groups. The messages generally given are: (a) identification of malnutrition; (b) environmental factors influencing nutritional status; (c) infection and malnutrition; (d) parasites and malnutrition; (e) infant-feeding practices, including breast-feeding and weaning food; and (f) immunization. Examples of some strategies used are:
Nutrition and related activities are strengthened by short-course training of peripheral-level workers and middle-level officials. Attention is given to cultural practices in dietary food and preparation habits. The mass medium most often used is radio, and, to a rather limited extent, television.
It has been reported that there is a high incidence of malnutrition in children aged between one and three years in deprived localities in Bangladesh. Many nutritional problems could be alleviated by the proper use of available food sources, if the public were exposed sufficiently to nutrition education through effective communication.
A training programme was arranged in conjunction with the Bangladesh Rural Development Board (BRDB). Field-level workers, including female co-operators of the BRDB, were trained to direct the programme using lectures, discussions, and demonstrations. Trainers were grouped into teams of three, one of whom was the leader. Mobile units for education and training were made available with UNICEF assistance. Booklets written in Bengali, posters, slides and photographs presenting nutritional deficiency diseases, and flannelboard demonstrations of the function of food groups were some of the educational aids used in the programme. The contents of the training covered breast-feeding, infant feeding, clean water, environmental hygiene, and immunization.
Pre- and post-tests indicated that the messages did reach the learners. There was no systematic evaluation for long-term impact. However, female co-operators responded positively to follow-up visits and have disseminated the knowledge to their fellow co-operative members. Further evaluation is required to assess the effectiveness of their influence on food behaviours and practices and on the nutritional status of the people.
Nutrition Directorate of Health and Family Welfare Services, Bangalore, India
Recognizing the interdisciplinary nature of nutritional problems, a national programme called the Integrated Child Development Services Scheme has been developed. Package services, including supplementary food, immunization, nutrition and health education, health and referral services, and non-formal education have been formulated and provided.
Currently, the existing primary health-care infrastructure at the block level is making use of nutrition communications. Paramedical workers and female health assistants/health workers play an important role, and are supervised and guided by district-level health officers. Face-toface communications by informal talks, for example among women, are most widely used. Radio, newspaper, and, to a limited extent, television have been utilized.
A unique effort is being made in Karnataka State, where systematic education activities have been developed. A unit was formed consisting of a nutrition officer, a health education expert, and a paramedical worker at the district level. The unit plans the education activities, with particular emphasis on supplementary foods for infants and proper diets during pregnancy and lactation. Training, teaching aids, and all communication activities were identified, and involvement of all health services and various agencies has been encouraged. Small research studies on several little-known communication systems were suggested.
It is recognized that changing food habits is a slow process and proper planning of systematic delivery of information is crucial. As India is a vast country, with different languages, cultural practices, and social values, the communication systems should be developed to suit individual communities.
A systematic, realistic programme of education is required and community involvement and participation must be encouraged. Well-trained personnel, proper supervision, guidance, and reliable documentation are all essential elements for successful nutrition education.
C. de Windt and T.M. Hill
UNICEF Jakarta Office, Jakarta, Indonesia
The Government of Indonesia, in co-operation with UNICEF, has developed and organized an extensive, multi-sectoral nutrition programme, entitled the Family Nutrition Improvement Programme (UPGK) in an attempt to alleviate malnutrition. The emphasis of UPGK is on local co-operation and community self-reliance. The slogan "A healthy child is a growing child" has been popularized. Monthly weighing is carried out and individual growth charts kept at home serve as nutrition surveillance tools. Village volunteers trained and supervised by local health officers play key roles in conducting various nutrition activities, including nutrition education. Government agencies are co-ordinated in the programme at all levels, from central to subdistrict.
UPGK's basic strategy is toward changing behaviour, with the ultimate objective that mothers will be aware of and improve their children's nutrition through better family feeding patterns and nutrition practices. To reach this objective, communication, information, and education efforts are carried out by all sectors involved in this pivotal approach. UNICEF provides technical expertise, scholars, and consultants, and organizes working meetings. All sectors involved are invited to participate from the early stages of the development of materials throughout the communication process.
In developing nutrition education and training materials, the same basic message and content units were included for the programme implementors and villagers. The specific guidelines for implementation are dependent upon the kinds of responsibilities of the field staff. This refers to vertical integrity. Moreover, to assure continuity and a unified interpretation, the same basic guidance is at the core of all training and promotional materials, and can be used cross-sectorally. The difference, for different sectors, is that the information is related to the field-worker's specific role and responsibilities. This is referred to as the horizontal integrity of a nutrition education approach.
To bridge the gap between training manuals and user materials, a "Handbook for Village Nutrition Volunteers" was developed for use by cadres. The presentation of the book in a comic-strip format with many drawings, step-by-step instructions, and simple questions and answers was readily accepted. Field testing confirmed that the book meets the need for "handson" material, reference and continual guidance, and orientation of cadres. It is at present widely used in both government and NGO project areas. The book has become a source for standard content and has been used for further development of training and education materials.
This is an effort at using adult education methods to develop a variety of nutrition education tools, materials, and games that keep reinforcing the basic set of messages. A joint communication strategy for systematic evolution of additional user materials has still to be designed.
Korea Institute for Population and Health, Seoul, Republic of Korea
Fifty-seven per cent of the Korean population lived in urban areas in 1980. A consequence of this is the emergence of urban slum squatters who are unskilled and socio-economically underprivileged, and who often receive inadequate health care.
The Korean Institute for Population and Health has been entrusted by the government to carry out a demonstration project for urban primary health care (1982-1986). The project began in Seoul and will be replicated throughout the major cities if it proves effective.
The nutrition service component of the project, provided by the newly developed community health practitioners, includes nutrition consultation, education, demonstration, and weight/height measurements.
To cite an example, one of several slide packages consists of 41 slides containing messages on (a) balanced diet - meaning, significance, and how to plan; (b) proper cooking methods; and (c) food practices and beliefs of pregnant women and how mothers should feed infants and preschool children. Various signs and symptoms of deficiency diseases are presented and food items to remedy these deficiencies are promoted. Proper infant-feeding practices, such as breast-feeding, supplementary foods, and improved maternal diets during pregnancy, are encouraged.
Department of Health, Seremban, Negeri Sambilan, Malaysia
The primary health-care approach in Malaysia is an integral part of the government community development movement, or Gerakan Pembaharuan (Operation Renewal), launched in 1972. Nutrition communication activities form a major component of the existing basic health services. The activities are channelled through various health and nutrition services.
Group talks, cooking demonstrations with group discussions, individual advice in clinics, and home visits are provided through maternal and child health services. The health education unit is responsible for producing educational materials such as posters and leaflets at both national and state levels. Health education mobile units, fully equipped with audio-visual aids, provide films and slide shows, arrange talks and dialogue sessions, and distribute leaflets. A mass media programme using radio and television was introduced in July 1983 as a joint effort of the ministries of Health and Information. The messages include a wide range of health and nutrition information. Health education materials are used extensively and local radio broadcasts will be utilized to overcome dialect problems.
The applied nutrition programme started in 1969 uses an intersectoral approach towards PHC. Four main ministries are involved, namely, Health, Agriculture and Rural Development, Education, and Information. Health and nutrition education is one of the main tasks. Nutrition surveillance is also used as a channel for nutrition communications. In addition, both formal education, such as that provided in nursing schools, and in-service training for health personnel are being conducted by various training schools.
The present trend of the health service is shifting from a clinic-based to a community-based approach, in which health staff work closely with community leaders. Attempts to encourage more active community participation in health activities are being made through committee meetings on development at the village and district levels.
Tirtha Rana and Nanda M. Sthapit
Health Education Section, Kathmandu, Nepal
Malnutrition is particularly prevalent in the age group from 6 to 36 months in Nepal. Lack of knowledge on how to use available foods, very low literacy and a high workload among women, the maintenance of food taboos, and destructive cultural practices lead to poor weaning and young-child-feeding practices.
A nutrition education programme is being conducted through various peripheral level workers. Emphasis is given to promoting breast-feeding, making weaning foods from locally available and family foods, proper feeding of sick babies, use of oral rehydration for children with diarrhoea, provision of growth charts for monitoring child development, immunization, improvement of personal and environmental hygiene, and teaching what foods are best for pregnant and lactating women.
The media used by these health workers are flash cards, posters, flip charts, and brochures. Various training manuals have been developed for different levels of workers. Growth is monitored by arm-circumference measurement. Food demonstrations and home-visit demonstrations on the preparation of oral rehydration fluid and weaning foods have been conducted. Radio spots, programmes, and film shows, as well as training workshops, have been developed by health and nutrition offices. The Ministry of Agriculture is involved in the local development of food provisions, preparation, processing, and preservation, while the Ministry of Education provides health and nutrition education through the formal education system up to the graduate and postgraduate level. Non-governmental agencies, both national and international, have been actively engaged in strengthening nutrition training and communications.
Areas for future research have been suggested, including evaluation of the ongoing communications programmes, development of simple training materials for large-scale use, strengthening of the communication links at the peripheral levels, and production of appropriate audio-visual aids to support nutrition activities.
M. Ramzan Azhar
UNICEF Islamabad Office, Islamabad, Pakistan
A nationwide nutrition programme, assisted by the World Food Programme, was begun in 1982. Lady health visitors were trained to play a key role in the project through nutrition education and integrated health services. The existing food habits, beliefs, and taboos were surveyed, and these studies revealed that urgent changes are required in child care.
Twenty-four basic messages were identified and used to form the basis of all training and extension materials. Message designs provided different levels of sophistication to suit the target audience: lady health visitors (LHVs) and other health workers, such as traditional birth attendants (TBAs) or child health workers (CHWs), or relatively illiterate mothers. All materials were carefully designed and extensively tested for use as tools to support nutrition education by the peripheral workers.
Posters were developed to illustrate the nutritional needs of pregnant mothers, and to promote breast-feeding, proper child feeding and care, and child growth. Another poster was used to describe food distribution and available integrated health services.
Flip charts giving information on primary health care were developed and are used by TBAs and CHWs after they are trained by LHVs. Another flip chart on breast-feeding was produced to support the LHVs' teaching of mothers, and yet another gives weaning-food recipes to serve as LHV teaching aids. The LHV has a book version as her reference source, while mothers are given recipe charts. Cooking demonstrations have been provided at selected centres. On-the-spot feeding of mothers and preschool children has also been introduced. Growth charts are used as a monitoring tool, on a nationwide scale. Two hundred and fifty food demonstration centres and 20 on-the-spot feeding centres have been established. Weaning food is distributed by LHVs at these centres as well as by other health services, and nutrition education is being imparted by the LHVs.
Currently, 500 fully trained paramedics and LHVs are the frontline workers who provide nutrition education. Teaching and training aids are widely available to primary health-care workers, and the available health facilities have been increasingly utilized. Awareness of the importance of nutrition is gradually being recognized by urban slum dwellers. A total of 360,000 mothers and children are directly benefiting from these projects. An in-depth evaluation is to be carried out soon to assess the impact of the programme on the target population.
Chuan Jia Lin
Beijing Children's Hospital, Beijing, China
After Liberation in 1949, the People's Government formulated a policy according to which maternal and child health-care administrative organizations were set up at all levels above the county level. A basic network for child health care was established, consisting of the Bureau of Maternal and Child Health, district MCH and child health care institutes, and county MCH centres. At the grass-roots level, there is a child health unit in every hospital, clinic, or commune hospital in rural areas, and this is responsible for taking care of 0- to 7-year-old children.
The bureau personnel provide training and supervision as well as supportive materials to district- and country-level professionals. These professionals then train and supervise professionals and paraprofessionals working at the grass-roots level, where the tasks in child health care include dissemination of health and nutrition information, birth registration, morbidity and mortality records, preventive health care including surveillance of deficiency diseases - and immunization and treatment of common diseases.
It is realized that the development of a child health-care service is inseparable from political, economic, and cultural development. Progress is noteworthy in Beijing; however, in other areas many problems still exist and require further efforts to resolve them.
Department of Information, Colombo, Sri Lanka
Sri Lanka is, for the most part, rural. Agriculture is the predominant occupation, and per capita income is relatively low. Although the country has one of the highest literacy and lifeexpectancy rates in the developing world, malnutrition is still prevalent. The improvement of the nutritional status of the population has been made a national policy, with a holistic approach aimed at balancing food needs and supplies. Effective communication is regarded as a necessity for bringing about the integration and coordination of relevant sectors and agencies.
Efforts are being made by the Food and Nutrition Policy Planning Division (FNPPD) and the Ministry of Information and Broadcasting to use the state mass media (newspaper, television, and radio) to promote special nutrition messages. A four-week training course for district-level planners and administrators is being organized. Special sets of training materials will be produced to assist them to plan a nutrition programme on a multi-sectoral basis and to promote community involvement. Monitoring, control, and evaluation will be integral parts of all programmes and will be handled by FNPPD through a steering committee. Effectiveness and the impact on the attitudes and practices of target groups will be assessed.