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Chapter 1 Introduction

Malnutrition

In most developing countries the majority of the population-the rural population especially-does not receive even the most basic health care or any nutritional advice. Malnutrition usually stems from poverty and from ignorance of what are the right foods to eat. At the same time it increases the problems caused by the lack of health care because it weakens the body's defences against disease. People weakened by malnutrition and disease do not have the energy to overcome poverty and are helpless to improve their own situation. Malnutrition, therefore, is not merely one of the greatest public health problems in the world today, it is also both a result and a cause of social and economic under-development.

The root of the problem is in the home: to solve it, the family must be helped to learn better habits of nutrition and must be served by better health care. In an increasing number of countries, the person responsible for health care at the family level is the community health worker. In a primary health care system, she occupies a key position, being the first point of contact that the family has with the health services. It is she who first treats the members of the family for their illnesses and who gives them advice on health matters. It is essential, therefore, that she should be properly trained to deal with the most prevalent health problem she is likely to meet- namely, malnutrition.

The community health worker's nutrition tasks

There are many tasks she will have to perform to overcome the malnutrition problem. Studies conducted in recent years by the World Health Organization and others have shown that the majority of these tasks are common to community work in most developing countries. They can be grouped into eight main categories-namely:

· Getting to know the community needs
· Measuring and monitoring the growth and nutrition of children
· Promoting breast-feeding
· Giving nutritional advice on feeding infants and young children
· Giving nutritional advice to mothers
· Identifying, managing, and preventing nutritional deficiencies
· Providing nutritional care during common infections
· Conveying nutritional messages to the community.

The need for a change in nutrition training

The training in nutrition that the community health worker receives commonly suffers from three main defects.

First, because nutrition trainers are often professionals from different disciplines (doctors, nutritionists, or nurses, for example), they naturally tend to teach what they themselves learned during their own professional training. This often leads to the training being biased towards the profession of the trainer and being aimed at too high a level of learning. A doctor, for instance, may attempt to make his trainees learn details of the clinical aspects of nutrition that a community health worker does not really need to know and may not be able to understand. Moreover, the training frequently relies too much on learning technical information from textbooks and not enough on learning how to deal with practical problems of nutrition.

Secondly, the training is based mainly on lectures, during which the trainees remain passive listeners. There is no exchange of ideas between them and the lecturer that would help them remember the information he is attempting to pass on. Thus, lecturing is not always the best method of conveying information to the trainees.

Thirdly, there is a lack of simple training material designed specifically to teach community health workers how to perform certain tasks. Most manuals on nutrition concentrate on technical aspects of the subject. They do not specify the tasks the trainees will be expected to perform. They do not explain how the training should be conducted so that the trainees learn the necessary skills. And they do not indicate how to check whether the trainees have in fact learned those skills.

The purpose of these guidelines

The guidelines presented here have been prepared to help trainers overcome these problems. They are designed to train a community health worker to improve nutrition in her area by learning in a practical way the most important things she will need to know and do.

They are based on the following main considerations:

1. The training should be directed to the performance of specific tasks. These are the activities that the community health worker will need to carry out in order to deal with the nutritional problems in her area. The performance of these tasks requires certain skills; and these skills in turn have to be based on a knowledge of certain facts. For instance, if a child has diarrhoea the community health worker needs to know that the loss of water and salts from the body is dangerous and that this loss must be replaced by a special solution of salts and sugar in water. She also needs to be able to prepare the solution and feed it to the child, and to convey to the mother the importance of this task so that the mother can do it herself next time.

2. The community health worker should be trained to perform a limited number of practical tasks for the improvement of health and nutrition. The amount of theoretical information given during the training can be restricted to the minimum necessary for understanding the importance of those tasks.

3. To be fully effective, training requires the maximum participation by the trainees themselves. This can be achieved by what is called the "teaching-learning" method. It differs from conventional teaching in that it is more concerned with stimulating a trainee to acquire the knowledge she needs to perform a task successfully than with simply transferring knowledge from a teacher to a pupil. Using the modules in this book, the trainee will participate actively in her own training.

4. It is very important for the trainees to have a strong motivation to learn their job and to serve the community. This should be taken into account when selecting persons for training as community health workers. During the training period, the trainer should try to increase this motivation, in order to encourage the trainees to learn better and to help them to do their community work effectively.

5. As far as possible, the training should be given near the community in which a trainee will be working later. It is much easier for her to understand the problems she is learning to solve if she can relate them to the actual conditions she will meet in the community.

6. The trainees will have to acquire certain knowledge and skills that may not seem to be directly related to the technical aspects of nutrition. This is because the whole community must participate as much as possible in solving their own problems if activities or programmes to improve nutrition are to be successful. The community health worker will need, for instance, to be able to communicate with the community, to motivate and organize community groups to solve their own problems, to show leadership, and to analyse problems before proposing solutions for them.

7. The duration of the training will depend upon the educational background of the trainees, upon how many tasks they will be expected to perform, and upon how complicated these are.

8. Training is not necessarily completed in a set period of time or at the end of the formal training course. The supervisor will need to judge how effectively a community health worker is doing her job, to see what further training she may need, and to help her to acquire that training. This should be an encouragement to the community health worker to improve the service she can give. Refresher training at regular intervals will increase the effectiveness of community health workers.

How trainers may use these guidelines

Trainers who wish to develop nutrition training plans for community health workers for the first time may do so by following the steps listed in the next chapter. For the training itself they may use the modules given in the second part of this book. Depending on the situation in the local communities and on the qualifications of their trainees, one or more of the modules may need to be adapted to suit local conditions, customs, and resources. The length of the training period can be set when this has been done.

Each of the training modules deals with one topic and describes tasks associated with it. For example, Module 2 is entitled "Measuring and monitoring the growth and nutrition of children". To carry out the tasks described in each module, community health workers will have to learn several subtasks. It should be noted that a community health worker will not necessarily perform all the tasks described in the guidelines every day. Rather, her daily activities will depend upon the type of nutritional problems in the community she is serving. Furthermore, nutritional problems in a community often vary with time.

The subtasks in each module form the learning objectives, which are given at the beginning of each module. For example, the learning objectives of Module 2 are:

· Explain the relationship between growth, development, and nutrition

· Find out the age of a child by using a local-events calendar if the mother is not sure of the age of her child

· Weigh a child accurately to within 100 grams

· Record the weight of a child on a growth chart

· Explain to the mother the features of the growth chart and how it will help her decide whether or not the child is doing well

· Interpret a child's growth pattern from the weight changes recorded.

The learning objectives also indicate what tasks a community health worker will be able to perform after the training is over.

The second section of each training module is entitled Training content. This section contains the basic training information about each module. After learning the training content the trainees should be able to:

· Understand why the task described in the title of the module is important
· Understand what subtasks and skills are required for carrying out that task
· Carry out the subtasks and practice the skills.

In this section, the training material is arranged in the same order as the learning objectives. The training content also describes the skills which must be acquired in order to carry out specific tasks. For example, the training content relating to the task of nutritional monitoring of young children describes in detail what a growth chart looks like, how the chart is to be used, how to weigh a child accurately, how to assess the correct age of the child, how to record the weight on the chart, and so on. In other words, the training material imparts the knowledge necessary to understand the importance of specific tasks, and also describes the skill required for each.

At the end of each section on training material there is a list of training methods suitable for that particular module. Here again, the trainer should remember that these are only examples and that other methods may be used if they are found to be more suitable for the trainees in a particular training situation.

The last section of each module presents practical exercises. These can be used in two ways. The trainees can use them as practical tasks to practice skills. And the trainers can use them as practical tests to assess how well the trainees have learnt the skills. As explained earlier the exercises are based on different training methods. Some involve practical work (for example, weighing a baby) and certain others are based on community survey work. In addition, there are some role-playing exercises for practicing and testing communication skills. It should be noted that the exercises given in this book are only examples. Trainers are advised to devise, if necessary, new exercises that suit local conditions and customs better.